1. Enhancing Occupancy Lisa Bazemore, MBA, MS, CCC-SLP Director of Consulting Services

2. Objectives Today we will talk about the following topics:  Identify market potential based on publicly available data  Analyze operational practices to identify barriers to patient admissions  Identify data points to track and trend for non- admission review  Data entry requirements and reports generated in the referral tracking system of eRehabData  Apply information from referral tracking reports to program marketing

3. Philosophy Goals for Census Development  Serve the patients from the host hospital, in the communities, and surrounding areas where we live.  Extend the reach of case management  Follow through for patients with post acute needs from time of admission  Reduce the burden on the referral source

4. Objectives of Market Sizing Facility data review:  Analyze DRG data from hospital patients to determine appropriate rehabilitation impairment classification codes based on the patient’s discharge diagnosis.  Apply appropriate rehabilitation conversion rates based on actuarial judgment.  Given industry length of stay, determine the optimal number of beds for internal admissions.

5. Objectives of Market Sizing Primary and secondary market data review:  Using industry Medicare data (like American Hospital Directory data), determine the acute care providers in the primary and secondary market, as well, as rehabilitation competitors.  By medical service line determine the approximate number of rehabilitation patients in the market.  Apply appropriate rehabilitation conversion rates based on actuarial judgment.  Given the industry length of stay, determine the optimal number of beds for all patients (internal and external) and residual volume given the number of available beds in the marketplace.

6. Facility Data Review Version One  Example Hospital calendar year 2006 hospital discharge data was analyzed and ICD-9 codes were assigned to the most common rehabilitation impairment classification (RIC).  This patient volume was reduced to reflect your Medicare population percentage-64%.  Patient volume by RIC was further classified by industry conversion percentage to determine the potential patient volume by RIC.  The anticipated number of beds required was calculated from the derived potential patient volume.

7. Facility Data Review RICAcute Patient Volume Medicare Patient Volume Anticipated Rehabilitation Volume 01 Stroke463296104 02 Traumatic Brain Injury795111 03 Non-Traumatic Brain Injury31119929 04 Traumatic Spinal Cord Injury1387 05 Non-Traumatic Spinal Cord Injury1439229 06 Neurology1177540 07 Facture of the LE1086919 08 Replacement of the LE36323223 09 Other Orthopedic3792432 10 Amputation, LE87455949 11 Amputation, Other430 12 Osteoarthritis000

8. Facility Data Review RICAcute Patient Volume Medicare Patient Volume Anticipated Rehabilitation Volume 13 Rheumatoid Arthritis48317 14 Cardiac3519225214 15 Pulmonary4713015 16 Pain1571006 17 Major Multiple Trauma, no brain/SC injury 62403 18 Major Multiple Trauma, with brain/SC injury 1380 19 Guillain Barre000 20 Miscellaneous131083832 21 Burns740 Total84415402381

9. Facility Data Review Represents 381 patients Total revenue of $6,426,084 60% Rule Conditional Compliance of 75.46% Based on national benchmark length of stay of 14.5. Beds needed equals 17 Occupancy rate based on 85% would be 15.1

10. Example Hospital Capture by RIC RICAnticipated Rehabilitation Volume Example Hospital Admissions 01 Stroke10426 02 Traumatic Brain Injury113 03 Non-Traumatic Brain Injury292 04 Traumatic Spinal Cord Injury70 05 Non-Traumatic Spinal Cord Injury294 06 Neurology403 07 Facture of the LE1915 08 Replacement of the LE2335 09 Other Orthopedic21 10 Amputation, LE496 11 Amputation, Other00 12 Osteoarthritis00

11. Example Hospital Capture by RIC RICAnticipated Rehabilitation Volume Example Hospital Admissions 13 Rheumatoid Arthritis70 14 Cardiac140 15 Pulmonary50 16 Pain60 17 Major Multiple Trauma, no brain/SC injury 31 18 Major Multiple Trauma, with brain/SC injury 00 19 Guillain Barre00 20 Miscellaneous321 21 Burns00 Total Discharges38197

12. Primary Market Data Review American Hospital Directory data was analyzed to determine patient volumes for the primary service market excluding Example Hospital, which is defined as a 50 mile radius around your zip code. PatientsPatient DaysBeds Needed 21123062096

13. Primary Market Data Review American Hospital Directory Data  AHD calendar year 2006 hospital discharge data was analyzed and medical service line codes were assigned to the most common rehabilitation impairment classification (RIC).  Frequency of use values were applied to the medical service line totals and then they were assigned to the aforementioned RIC.  Patient volume by RIC was further classified by industry conversion percentage to determine the potential patient volume by RIC.  The anticipated number of beds required was calculated from the derived potential patient volume.

14. Primary Market Data Review RICAcute Patient Volume Anticipated Rehabilitation Volume 01 Stroke582204 02 Traumatic Brain Injury13729 03 Non-Traumatic Brain Injury53178 04 Traumatic Spinal Cord Injury1714 05 Non-Traumatic Spinal Cord Injury20664 06 Neurology223120 07 Facture of the LE394227 08 Replacement of the LE1363463 09 Other Orthopedic1302271 10 Amputation, LE28525 11 Amputation, Other61 12 Osteoarthritis00

15. Primary Market Data Review RICAcute Patient Volume Anticipated Rehabilitation Volume 13 Rheumatoid Arthritis15835 14 Cardiac585783 15 Pulmonary363676 16 Pain47429 17 Major Multiple Trauma, no brain/SC injury 15813 18 Major Multiple Trauma, with brain/SC injury 793 19 Guillain Barre00 20 Miscellaneous6958376 21 Burns80 Total Discharges223742112

16. Primary Market Data Review Represents 2112 patients Total revenue of $19,257,917 Based on national benchmark length of stay of 14.5 Bed need equals 56 Occupancy rate based on 85% would be 49

17. Primary Market Data Review Percent of Population:  4-6% of Medicare patients discharged from the hospital will require inpatient rehabilitation stays.  Patient days and bed need are based on 85% occupancy and an average length of stay of 14.5 days, which is consistent with eRehabData national averages. 4%6% Bed Need 4161 Patient Days 1297719465

18. Primary Market Data Review Residual Table:  Beds and patient counts reported by AHD in 2006  Based on 14.5 average length of stay and 85% occupancy ReportedNeeded Beds 10873 Patient Days 1551723353

19. Secondary Market Review Repeat for secondary and tertiary market as desired and necessary to capture market potential.

20. Analyzing Operational Practices Assess preadmission screening and admissions process  Interview and shadow the preadmission screeners who are likely making the initial determination of the impairment group and admitting and ongoing diagnoses.  Determine how referrals are captured and managed for internal and external sources.  Determine the medical director’s role in monitoring compliance and making admission decisions to ensure compliance with the 2010 IRF PPS Final Rule.  Determine philosophy on case finding versus referral management.

21. Analyzing Operational Practices Conduct a review of referrals not admitted to determine changes since my previous review.  Review pre-admission screenings for 30 referrals at each facility not admitted to determine patterns or trends.

22. Analyzing Operational Practices Observations in an example facility:  Adequate number of beds to accommodate the in-house volume. Should medical necessity be a concern when evaluating these patients, you have the option to fill your excess capacity with non-Medicare patients.  A review of the operational process revealed an attitude of screening in to rehab versus screening out. I believe that patients referred are automatically considered sub-acute patients until proven otherwise, which is determined on diagnosis alone.  You are not working with hospital case managers as team members. Instead of working together to find the appropriate discharge plan, rehab and case management are working independently.  Given the discrepancy between available patients and admitted patients, I recommend increasing the amount of time spent on direct marketing efforts within your facility first.

23. Marketing Plan Observations in the facility:  To do: Visit each case manager to determine what they feel the barriers to rehab referrals and admissions are. Educate case managers on basic IRF concepts and referral methods. Review the hospital census daily. Approach case managers to ask about patients that may have rehab potential. Target Medicare patients with an ALOS of 4 days or more and all patients with a typical rehab diagnosis. Employ the assistance of your medical director in making contacts with the physician referral sources. Manage the referrals received closely for appropriate decision making by the admissions coordinator. Utilize the eRehabData referral tracking system. Log each referral into the system. Those admitted will become active patients and those denied will be stored with the reason for non-admission. Utilize referral outcomes to show who is generating the referrals and reasons for non-admission. Managing physician and case manager trends to enable rapid response to declining referrals.

24. Marketing Plan Observations in the primary and secondary market:  You have ample capacity in the primary and secondary market to meet the demands of Medicare patient population.  According to the patient days needed, there are patients who meet the diagnostic criteria for rehab who are not being admitted. These patients may be receiving services in a SNF or other level of care.  I recommend that you begin marketing within your community and primary market place. Approximately 25% of your marketing efforts should be spent with physician referral sources and external case managers from surrounding hospitals.  Given the volume available in Example Hospital, I do not believe that you require a full-time marketing coordinator. You do, however, need to establish and then maintain a presence in the external market with efforts concentrated on contacts with hospital case managers.  Direct marketing to physicians should be included in the marketing plan, but this should not be the primary focus of the marketing plan in the secondary markets.

25. Marketing Plan Observations from the primary and secondary market:  To do: Rank facilities by discharges, referrals, and admissions Develop call list for external territory coverage within a 50 mile radius of your facility. Develop marketing message and collaterals for your program that reflect the level of service uniquely provided by LMH’s inpatient rehabilitation unit. Employ the assistance of your medical director in making contacts with the physician referral sources. Manage the referrals received closely for appropriate decision making by the admissions coordinator. Utilize the eRehabData referral tracking system. Log each referral into the system. Those admitted will become active patients and those denied will be stored with the reason for non-admission. Utilize referral outcomes to show who is generating the referrals and reasons for non-admission. Managing physician and case manager trends to enable rapid response to declining referrals.

26. Referral Tracking System Trending Information:  Referral source  Referring physician  Zip code where patient resides  Payor source  Basic patient profile (anticipated CMG)  Accepted or denied with reason for denial

27. Referral Tracking System Referrals Outcomes:  Designed to trend referral sources, referring physicians, and conversion rates.  Offers information on reasons for denied admission.  You can filter the information to drill down on physician, referral source, internal vs. external fill, and reason for denied admission.

28. Referral Tracking System Referrals Outcomes:  Use information to determine referral trends by- Referral source Referring physician Internal versus external fill Zip code breakdown Payor source breakdown Conversion rates Reasons for denial  Drill down by RIC, CMG, and Patient Patient reports list patients denied

29. Referral Tracking System Non-admission review: The review of all patients that have not been admitted to rehab unit. This is done by reviewing the pre-admission forms and reviewing the section that notes the reason for not admitting to the rehab unit to help identify trends and changes that occur over a quarter. Common Reasons  Too impaired  Too functional  No bed available  Physician did not agree  Patient or family refused  Insurance did not authorize  Not 60% rule compliant

30. Referral Tracking System Review data entry for tracking referrals Review referral outcomes reports Study facility data for opportunities

31. Questions? Lisa Werner Bazemore Lbazemore@erehabdata.com