Swing Bed More Questions AUGUST 3, 2018 BUILDING LEADERS TRANSFORMING HOSPITALS IMPROVING CARE HTS3 2018

Transcription

1 Swing Bed More Questions AUGUST 3, 2018 BUILDING LEADERS TRANSFORMING HOSPITALS IMPROVING CARE

2 1 Carolyn began her healthcare career as a staff nurse in Intensive Care. She has worked in a variety of staff, administrative and consulting roles and has been in her current position as Regional Chief Clinical Officer with HealthTechS3 for the last fifteen years. Carolyn St.Charles Regional Chief Clinical Officer In her role as Regional Chief Clinical Officer, Carolyn St.Charles conducts mock surveys for Critical Access Hospitals, Acute Care Hospitals, Long Term Care, Rural Health Clinics, Home Health and Hospice. Carolyn also provides assistance in developing strategies for continuous survey readiness and developing plans of correction. Carolyn also has extensive experience in working with rural hospitals to both develop and strengthen Swing Bed programs. carolyn.stcharles@healthtechs3.com

3 45 YEARS OF DELIVERING RESULTS HealthTechS3 is a 45 year old, award-winning healthcare consulting and strategic hospital services firm based in Brentwood, Tennessee with clients across the United States. We are dedicated to the goal of improving performance, achieving compliance, reducing costs, and ultimately improving patient care. Leveraging consultants with deep healthcare industry experience, HealthTechS3 provides actionable insights and guidance that supports informed decision making and drives efficiency in operational performance. Our consultants are former hospital leaders and executives. HealthTechS3 has the right mix of experienced professionals that service hospital clients across the nation. HealthTechS3 offers flexible and affordable services, consulting, and technology as we focus on delivering solutions that can be implemented and provide a positive, measurable impact.

4 STRATEGY SOLUTIONS SUPPORT 3 GOVERNANCE & STRATEGY FINANCE CLINICAL CARE & OPERATIONS RECRUITMENT Affiliation Consulting Executive & Management Leadership Development Strategic Planning & Market share Analysis Community Health Needs Assessment Compliance Consulting Services Performance Optimization / Margin Improvement Revenue Cycle & Business Office Operations Productivity & Staffing Consulting Continuous Survey Readiness Quality Assurance Performance Improvement Lean Culture Customer Experience Clinical Resource Management Care Coordination Primary Care Practice Physician Practice & Clinic Assessment Long Term Care Consulting Swing Bed Consulting Perioperative Services Consulting Executive Recruitment Manager and Clinical Positions Physician / Provider Recruitment Information Technology Professionals Interim Placement

5 SWING BED CONSULTING PACKAGE 4 1. Growth Strategies 2. Skilled Criteria 3. Policy and Procedures Let me know if you would like a proposal, or would like to talk about our services 4. Patient Admission Packet 5. Staff Education 6. Provider Education 7. Multi-disciplinary Assessment / Care Planning Tools 8. Annual Survey on-site 9. Quarterly reviews off-site 10.Unlimited telephone and support

6 5

7 3 RD QUARTER WEBINARS Critical Access Hospitals Just The Questions Please Host: Carolyn St.Charles, RN, BSN, MBA, Regional Chief Clinical Officer July 6, 2018 at 12pm CST 03 Whole Person Care Hosts: Faith M Jones, MSN, RN, NEA-BC, HealthTechS3 Director of Care Coordination and Lean Consulting, and Sara Crow, CrossTx July 12, 2018 at 12pm CST 43 Expert Evidence-Based Assistance Where It Matters Most Host: Diane Bradley, PhD, RN, NEA-BC, CPHQ, FACHE, FACHCA, Regional Chief Clinical Officer July 18, 2018 at 12pm CST 87 Swing Bed More Questions Please Host: Carolyn St.Charles, RN, BSN, MBA, Regional Chief Clinical Officer August 3, 2018 at 12pm CST The Good, Bad and Ugly of Interim Leadership What You Need To Know But Were Afraid To Ask Host: Mike Lieb, FACHE, Vice President, HealthTechS3 August 9, 2018 at 12pm CST The Power of Observation The Foundation Of your Lean Culture Host: Faith M Jones, MSN, RN, NEA-BC, HealthTechS3 Director of Care Coordination and Lean Consulting August 16, 2018 at 12pm CST

8 3 RD QUARTER WEBINARS Cybersecurity The Challenges Health Care Is Facing Hosts: Diane Bradley, PhD, RN, NEA-BC, CPHQ, FACHE, FACHCA, Regional Chief Clinical Officer Johnathan Buice, MBA, MIS, Chief Information Officer, Upson Regional Medical Center August 17, 2018 at 12pm CST 9 Community Health Needs Assessment: Strategies for Engaging The Community Host: Carolyn St.Charles, RN, BSN, MBA, Regional Chief Clinical Officer September 7, 2018 at 12pm CST 1 Expert Evidence-Based Assistance Where It Matters Most Host: Diane Bradley, PhD, RN, NEA-BC, CPHQ, FACHE, FACHCA, Regional Chief Clinical Officer September 19, 2018 at 12pm CST 3 Incorporating Community Resources In To Your Care Coordination Program Host: Faith M Jones, MSN, RN, NEA-BC, HealthTechS3 Director of Care Coordination and Lean Consulting September 20, 2018 at 12pm CST 9 Questions & Answers On Executive Placement Host: Peter Goodspeed, HealthTechS3, Vice President of Executive Search September 28, 2018 at 12pm CST 9 ALL WEBINARS ARE RECORDED 7

9 OTHER SWING BED WEBINARS 8 Swing Bed Just the Questions Please June 1, Uncomplicating Swing Beds Is it really possible? Nov 3, Swing Bed What you really need to know June 16,

10 INSTRUCTIONS FOR TODAY S WEBINAR 9 You may type a question in the text box if you have a question during the presentation We will try to cover all of your questions but if we don t get to them during the webinar we will follow-up with you by You may also send questions after the webinar to our team (contact information is included at the end of the presentation) The webinar will be recorded and the recording will be available on the HealthTechS3 web site: HealthTechS3 hopes that the information contained herein will be informative and helpful on industry topics. However, please note that this information is not intended to be definitive. HealthTechS3 and its affiliates expressly disclaim any and all liability, whatsoever, for any such information and for any use made thereof. HealthTechS3 does not and shall not have any authority to develop substantive billing or coding policies for any hospital, clinic or their respective personnel, and any such final responsibility remains exclusively with the hospital, clinic or their respective personnel. HealthTechS3 recommends that hospitals, clinics, their respective personnel, and all other third party recipients of this information consult original source materials and qualified healthcare regulatory counsel for specific guidance in healthcare reimbursement and regulatory matters.

11 RESOURCES 10 State Operations Manual (Rev. 165, ) Appendix W - Survey Protocol, Regulations and Interpretive Guidelines for Critical Access Hospitals (CAHs) and Swing-Beds in CAHs State Operations Manual (Rev. 137, ) Appendix T - Regulations and Interpretive Guidelines for Swing Beds in Hospitals (paid under PPS) State Operations Manual (Rev. 168, ) Appendix PP - Guidance to Surveyors for Long Term Care Facilities Medicare Claims Processing Manual Chapter 4 - Physician Certification and Recertification of Services (Rev. 3685, ) Chapter 6 - SNF Inpatient Part A Billing and SNF Consolidated Billing (Rev. 3612, ) Medicare Benefit Policy Manual (Rev. 228, ) Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance

12 IMPORTANT IMPORTANT IMPORTANT 11 We are going to talk primarily about Medicare Swing Bed Different payors, including Medicaid and Medicare Advantage plans have different rules including admission criteria length of stay copays And as you know --- Distinct part swing bed units in a Hospital have different regulations than CAH Swing

13 BACKGROUND 12 The Social Security Act (the Act) permits certain small, rural hospitals to enter into a swing bed agreement, under which the hospital can use its beds, as needed, to provide either acute or SNF care. As defined in the regulations, a swing bed hospital is a hospital or critical access hospital (CAH) participating in Medicare that has CMS approval to provide post-hospital SNF care and meets certain requirements. Source:

14 BACKGROUND - SUBSTANTIAL COMPLIANCE 13 C (d) SNF Services A (b) Skilled Nursing Facility Services The CAH is substantially in compliance with the following SNF requirements contained in subpart B of part 483 of this chapter: (1) Resident rights ( (b)(3) through (b)(6), (d), (e), (h), (i), (j)(1)(vii) and (viii), (1), and (m) of this chapter). (2) Admission, transfer, and discharge rights ( (a) of this chapter). (3) Resident behavior and facility practices ( of this chapter). (4) Patient activities ( (f) of this chapter), except that the services may be directed either by a qualified professional meeting the requirements of (f)(2), or by an individual on the facility staff who is designated as the activities director and who serves in consultation with a therapeutic recreation specialist, occupational therapist, or other professional with experience or education in recreational therapy. (5) Social services ( (g) of this chapter). (6) Comprehensive assessment, comprehensive care plan, and discharge planning ( (b), (k), and (l) of this chapter, except that the CAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under (b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in (b) of this chapter). (7) Specialized rehabilitative services ( of this chapter). (8) Dental services ( of this chapter). (9) Nutrition ( (i) of this chapter). The facility is substantially in compliance with the following skilled nursing facility requirements contained in subpart B of part 483 of this chapter. (1) Resident rights ( (b)(3), (b)(4), (b)(5), (b)(6), (d), (e), (h), (i), (j)(1)(vii), (j)(1)(viii), (l), and (m)); (2) Admission, transfer, and discharge rights (a)(1), (a)(2), (a)(3), (a)(4), (a)(5), (a)(6), and (a)(7); (3) Resident behavior and facility practices ( ); (4) Patient activities ( (f)); (5) Social services ( (g)); (6) Discharge planning ( (l)); (7) Specialized rehabilitative services ( ); (8) Dental services ( ).

15 QUESTIONS 14

16 HOW DO YOU HELP STAFF UNDERSTAND THE DIFFERENCE BETWEEN ACUTE AND SWING? 15 Do everything possible to make sure EVERYONE INCLUDING THE PATIENT knows they are now in another level of care and it s DIFFERENT! 1. Move the patient to a new room even if it s down the hall 2. Put a sign on the door or by the patient s bed SKILLED CARE 3. Put a big note on the front of the paper chart SKILLED CARE 4. Make sure the patient is dressed in their own clothes every day (no hospital gowns) 5. Post the Care Plan Goals for EACH DAY in the patient s room 6. Post the Discharge Plan ---- When (By November 15) and Where (Home) in the patient s room

17 AND A FEW MORE Establish a team 2. Educate each team member about their roles and responsibilities 3. Develop swing bed competency for ALL staff who care for swing bed patients (RN LPN CNA Pharmacist Dietitian Social Work Discharge Planning Rehab, etc.) 4. Distinguish Swing Bed patients at shift report rounds etc. 5. Lots and lots and lots of feedback

18 CAN WE ACCEPT A SWING BED PATIENT IF THERE ARE AVAILABLE SNF BEDS IN THE COMMUNITY? YES 17 There is no Medicare requirement to place a swing-bed patient in a nursing home and there are no requirements for transfer agreements between CAHs and nursing homes. There is no Medicare requirement to place a swing-bed patient in a nursing home and there are no requirements for transfer agreements between hospitals and nursing homes. Source: C Special Requirements for CAH Providers of Long-Term Care Services ( Swing-Beds ) Source: A Special Requirements for Hospital Providers of Long-Term Care Services ( Swing-Beds )

19 CAN WE REFUSE (NOT ACCEPT) A PATIENT? 18 Identify the types of patients you are not able to accept Pediatrics Mentally ill Suicide risk Ventilator dependent Morbidly obese Identify any circumstances where you would limit number of swing patients Above defined percentage of beds filled by inpatients Staff availability cannot meet patient needs i.e. NO speech therapist Important: Ensure your admission criteria is in policy form reviewed by medical staff and approved by the governing board

20 CAN WE TRANSFER A PATIENT (AFTER THEY ARE ADMITTED) IF THEY NEED SPECIALIZED REHABILITATIVE SERVICES? 19 A Specialized Rehabilitative Services (a) Provision of Services If specialized rehabilitative services such as, but not limited to, physical therapy, speech-language pathology, occupational therapy, and mental health rehabilitative services for mental illness and intellectual disability, are required in the resident s comprehensive plan of care, the facility must (1) Provide the required services; or (2) Obtain the required services from an outside resource (in accordance with (h) of this part) from a provider of specialized rehabilitative services. The intent of this regulation is to assure that residents receive necessary specialized rehabilitative services as determined by the comprehensive assessment and care plan, to prevent avoidable physical and mental deterioration and to assist them in obtaining or maintaining their highest practicable level of functional and psychosocial well being. Specialized rehabilitative services are considered a facility service and are included within the scope of facility services. They must be provided to residents who need them even when the services are not specifically enumerated in the State plan. No fee can be charged a Medicaid recipient for specialized rehabilitative services because they are covered facility services. A facility is not obligated to provide specialized rehabilitative services if it does not have residents who require these services. If a resident develops a need for these services after admission, the facility must either provide the services, or, where appropriate, obtain the service from an outside resource.

21 CAN WE TRANSFER A PATIENT FROM A SWING BED TO A SNF (SAME LEVEL OF CARE)? C (a) Transfer and Discharge (1) Definition: Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. Interpretive Guidelines (a)(1) The intent of the regulation on transfer and discharge provisions is to significantly restrict a facility s ability to transfer or discharge a resident once that resident has been admitted to the facility to prevent dumping of high care or difficult residents. This requirement applies to transfer or discharges that are initiated by the facility, not by the resident. Source: Appendix W A (a) Transfer and Discharge (1) Definition: Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. Interpretive Guidelines (a)(1) The intent of the regulation on transfer and discharge provisions is to significantly restrict a facility s ability to transfer or discharge a resident once that resident has been admitted to the facility to prevent dumping of high care or difficult residents. This requirement applies to transfer or discharges that are initiated by the facility, not by the resident (7) Transfer From One SNF to Another There is no presumption of coverage in cases involving the transfer of a beneficiary from one SNF to another or from SNF-level care in a swing bed to a SNF. The presumption only applies to the SNF stay that immediately follows the qualifying hospital stay when the beneficiary is correctly assigned one of the case-mix classifiers that CMS designates for this purpose as representing the required level of care. Therefore, in cases involving transfer of a beneficiary from a swing-bed hospital to a SNF, the presumption only applies if the beneficiary was receiving acute care (rather than SNF-level care) immediately prior to discharge from the swing-bed hospital. Source: Medicare Benefits Manual, Chapter 8 Guidance/Guidance/Transmittals/2018Downloads/R242BP.pdf 20.

22 DO WE REALLY HAVE TO DISCHARGE THE PATIENT FROM ACUTE AND ADMIT THEM TO SWING? 21 There must be discharge orders from acute care services, appropriate progress notes, discharge summary, and subsequent admission orders to swing-bed status regardless of whether the patient stays in the same facility or transfers to another facility. If the patient does not change facilities, the same chart can be utilized but the swing-bed section of the chart must be separate with appropriate admission orders, progress notes, and supporting documents. Source: C Special Requirements for CAH Providers of Long-Term Care Services ( Swing-Beds ) There must be discharge orders changing status from acute care services, appropriate progress notes, discharge summary, and subsequent admission orders to swing-bed status regardless of whether the patient stays in the same hospital or transfers to another hospital with swing bed approval. If the patient remains within the hospital, the same chart can be utilized but the swing-bed section of the chart must be separate, with appropriate admission orders, progress notes, and supporting documents. Source: A Special Requirements for Hospital Providers of Long- Term Care Services ( Swing-Beds )

23 DOES A PATIENT HAVE TO MEET SKILLED CRITERIA TO BE ADMITTED TO A SWING BED? Skilled Services Defined (Rev. 179, Issued: , Effective: , Implementation: ) Skilled nursing and/or skilled rehabilitation services are those services, furnished pursuant to physician orders, that: Require the skills of qualified technical or professional health personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech-language pathologists or audiologists; and Must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result. NOTE: General supervision requires initial direction and periodic inspection of the actual activity. However, the supervisor need not always be physically present or on the premises when the assistant is performing services. Skilled care may be necessary to improve a patient s current condition, to maintain the patient s current condition, or to prevent or slow further deterioration of the patient s condition. Source:

24 CAN A PATIENT STAY IN A SWING BED IF THEY ARE NOT IMPROVING? 23 Jimmo v. Sebelius Settlement Agreement Program Manual Clarifications Fact Sheet No Improvement Standard is to be applied in determining Medicare coverage for maintenance claims in which skilled care is required. There are situations in which the patient s potential for improvement would be a reasonable criterion to consider, such as when the goal of treatment is to restore function. We note that this would always be the goal of treatment in the inpatient rehabilitation facility (IRF) setting, where skilled therapy must be reasonably expected to improve the patient s functional capacity or adaptation to impairments in order to be covered. However, Medicare has long recognized that there may be situations in the SNF, home health, and outpatient therapy settings where, even though no improvement is expected, skilled nursing and/or therapy services to prevent or slow a decline in condition are necessary because of the particular patient s special medical complications or the complexity of the needed services. The manual revisions clarify that a beneficiary s lack of restoration potential cannot, in itself, serve as the basis for denying coverage in this context, without regard to an individualized assessment of the beneficiary s medical condition and the reasonableness and necessity of the treatment, care, or services in question. Conversely, such coverage would not be available in a situation where the beneficiary s maintenance care needs can be addressed safely and effectively through the use of nonskilled personnel. Medicare has never supported the imposition of an Improvement Standard rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient s condition. Thus, such coverage depends not on the beneficiary s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves. The manual revisions serve to reflect and articulate this basic principle more clearly. Therefore, denial notices for claims involving maintenance care in the SNF, HH, and OPT settings should contain an accurate summary of the reason for the determination, which should always be based on whether the beneficiary has a need for skilled care rather than on a lack of improvement.

25 CAN A PATIENT STAY IN A SWING BED IF THEY ARE NOT IMPROVING? 24 Jimmo v. Sebelius Settlement Agreement Program Manual Clarifications Fact Sheet Care must be taken to assure that documentation justifies the necessity of the skilled services provided. Justification for treatment would include, for example, objective evidence or a clinically supportable statement of expectation that: In the case of rehabilitative therapy, the patient s condition has the potential to improve or is improving in response to therapy; maximum improvement is yet to be attained; and, there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time. In the case of maintenance therapy, the skills of a therapist are necessary to maintain, prevent, or slow further deterioration of the patient s functional status, and the services cannot be safely and effectively carried out by the beneficiary personally, or with the assistance of non-therapists, including unskilled caregivers.

26 HOW OFTEN DOES A PHYSICIAN (PROVIDER) NEED TO SEE A PATIENT IN SWING BED? 25 At a minimum At admission H&P Dependent on 1 your policy and medical staff bylaws Admission Orders Certification 2 needs of the patient 14 Days Recertificaiton Every 30 days thereafter

27 PHYSICIAN CERTIFICATION AT ADMISSION SPECIFIC FORM IS NOT REQUIRED 26 Patient Name: Admission Date: Health Insurance: Reason for Admission: Goals for Admission: Expected Length of Stay: Admission to swing bed is for the same condition(s) for which the Patient received inpatient hospital services c YES c NO (if no, please explain) CERTIFICATION Required at time of admission I certify that services are required to be given on a daily basis which, as a practical matter, can be only be provided in a swing bed or skilled nursing facility. Physician Signature Date and Time

28 RECERTIFICATION- EAMPLE 27 Within 14 days and every 30 days thereafter (Progress Notes are OK) Patient Name: RECERTIFICATION of continued swing bed inpatient care. To be completed on or before the 14th day after admission to swing bed. Admission Date: I certify that continued swing bed inpatient care is necessary for the following reason(s): I estimate that the additional period of swing bed Care will be days or weeks. Plan for post-swing bed care: Home Home Health Care Office / Physician Follow-up Long Term Care Other Physician Signature Date and Time

29 ASSESSMENT The facility must conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident s functional capacity.

30 COMPREHENSIVE ASSESSMENT C ELEMENTS 29 The facility must conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident s functional capacity (vii) Psychosocial well-being (viii) Physical functioning and structural problems (ix) Continence (x) Disease diagnoses and health conditions (xi) Dental and nutritional status The assessment must include at least the following: (i) Identification and demographic information (ii) Customary routine (iii) Cognitive patterns (iv) Communication (v) Vision (vi) Mood and behavior patterns (xii) Skin condition (xiii) Activity pursuit (xiv) Medications Hospital Distinct Part Complete RAI (xv) Special treatments and procedures (xvi) Discharge potential (xvii) Documentation of summary information regarding the additional assessment performed through the resident assessment protocols (xviii) Documentation of participation in assessment

31 IDENTIFY PRIMARY RESPONSIBILITY VERY IMPORTANT Identification & Demographic Info Customary Routine Cognitive Patterns Communication Vision Mood and behavior patterns Psychosocial well being Physical functioning and structural problems Continence Disease diagnoses and health conditions Dental status Nutritional status Skin condition Activity pursuit Medications Special treatments and procedures Discharge potential Physician Nursing Social Work Pharmacy Rehab Dietitian Activities Hospital Swing USE RAI 30

32 COMPREHENSIVE ASSESSMENT 31 C The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts. Interpretive Guidelines (b)(1) The intent of this regulation is to provide the facility with ongoing assessment information necessary to develop a care plan, to provide the appropriate care and services for each resident, and to modify the care plan and care/services based on the resident s status. The facility is expected to use resident observation and communication as the primary source of information when completing the assessment. In addition to direct observation and communication with the resident, the facility should use a variety of other sources, including communication with licensed and non-licensed staff members on all shifts and may include discussions with the resident s MD/DO, family members, or outside consultants and review of the resident s record.

33 DOES NURSING HAVE TO ASSESS THE PATIENT? IS THE ASSESSMENT THE SAME AS ACUTE? 32 Identification & Demographic Info Customary Routine Cognitive Patterns Communication Vision Mood and behavior patterns Psychosocial well being Physical functioning and structural problems Continence Disease diagnoses and health conditions Dental Oral status Nutritional status Skin condition Activity pursuit Medications Special treatments and procedures Discharge potential Physician Nursing Social Work Pharmacy Rehab Dietitian Activities Don t Forget: comprehensive, accurate, standardized, reproducible assessment of each resident s functional capacity

34 DOES PT/OT/SPEECH HAVE TO ASSESS THE PATIENT EVEN IF THERE ISN T A REHAB NEED? 33 Identification & Demographic Info Customary Routine Cognitive Patterns Communication Vision Mood and behavior patterns Psychosocial well being Physical functioning and structural problems Continence Disease diagnoses and health conditions Dental status Nutritional status Skin condition Activity pursuit Medications Special treatments and procedures Discharge potential Physician Nursing Social Work Pharmacy Rehab Dietitian Activities

35 DOES A DIETITIAN HAVE TO ASSESS THE PATIENT? 34 Assessment C (xi) Dental and nutritional status C (i) Nutrition Based on a resident s comprehensive assessment, the facility must ensure that a resident: (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident s clinical condition demonstrates that this is not possible; and Interpretive Guidelines (i)(1) Parameters of nutritional status that are unacceptable include unplanned weight loss as well as other indices such as peripheral edema, cachexia and laboratory tests indicating malnourishment (e.g., serum albumin levels). Weight: Since ideal body weight charts have not yet been validated for the institutionalized elderly, weight loss (or gain) is a guide in determining nutritional status. An analysis of weight loss or gain should consider the loss or gain in light of the individual s former life style as well as the current diagnosis. C (i)(2) Receives a therapeutic diet when there is a nutritional problem.

36 DOES A DIETITIAN HAVE TO ASSESS THE PATIENT IF THE INITIAL NURSE SCREENING SHOWS NO NUTRITIONAL RISK? 35 Assessment C (xi) Dental and nutritional status C (i) Nutrition Based on a resident s comprehensive assessment, the facility must ensure that a resident: (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident s clinical condition demonstrates that this is not possible; and Interpretive Guidelines (i)(1) Parameters of nutritional status that are unacceptable include unplanned weight loss as well as other indices such as peripheral edema, cachexia and laboratory tests indicating malnourishment (e.g., serum albumin levels). Weight: Since ideal body weight charts have not yet been validated for the institutionalized elderly, weight loss (or gain) is a guide in determining nutritional status. An analysis of weight loss or gain should consider the loss or gain in light of the individual s former life style as well as the current diagnosis. C (i)(2) Receives a therapeutic diet when there is a nutritional problem.

37 DOES A SOCIAL WORKER HAVE TO ASSESS THE PATIENT? 36 Identification & Demographic Info Customary Routine Cognitive Patterns Communication Vision Mood and behavior patterns Psychosocial well being Physical functioning and structural problems Continence Physician Nursing Social Work Pharmacy Rehab Dietitian Activities Disease diagnoses and health conditions Dental status Nutritional status Skin condition Activity pursuit Medications Special treatments and procedures Discharge potential

38 DOES A SOCIAL WORKER HAVE TO ASSESS THE PATIENT? 37 C (g) Social Services (1) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. (2) A facility with more than 120 beds must employ a qualified social worker on a full-time basis. (3) Qualifications of social worker. A qualified social worker is an individual with-- (i) A bachelor s degree in social work or a bachelor s degree in a human services field including but not limited to sociology, special education, rehabilitation counseling, and psychology; and (ii) One year of supervised social work experience in a health care setting working directly with individuals. Interpretive Guidelines (g) The intent of this regulation is to assure that all facilities provide for the medically-related social services needs of each resident. This requirement specifies that facilities aggressively identify the need for medically-related social services, and pursue the provision of these services. A qualified social worker need not personally provide all of these services. It is the responsibility of the facility to identify the medically-related social service needs of the resident and assure that the needs are met by the appropriate discipline. A (g) Social Services (1) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. (2) A facility with more than 120 beds must employ a qualified social worker on a full-time basis. (3) Qualifications of social worker. A qualified social worker is an individual with-- (i) A bachelor s degree in social work or a bachelor s degree in a human services field including but not limited to sociology, special education, rehabilitation counseling, and psychology; and (ii) One year of supervised social work experience in a health care setting working directly with individuals. Interpretive Guidelines (g) The intent of this regulation is to assure that all facilities provide for the medically-related social services needs of each resident. This requirement specifies that facilities aggressively identify the need for medically-related social services, and pursue the provision of these services. A qualified social worker need not personally provide all of these services. It is the responsibility of the facility to identify the medically-related social service needs of the resident and assure that the needs are met by the appropriate discipline.

39 MEDICALLY-RELATED SOCIAL SERVICES 38 Medically-related social services means services provided by the facility s staff to assist residents in maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needs. These services could include: Making arrangements for obtaining needed adaptive equipment, clothing, and personal items; Maintaining contact with family (with resident s permission) to report on changes in health, current goals, discharge planning, and encouragement to participate in care planning; Assisting staff to inform residents and those they designate about the resident s health status and health care choices; Making referrals and obtaining services from outside entities (e.g., talking books, absentee ballots, community wheelchair transportation); Assisting residents with financial and legal matters (e.g., applying for pensions, referrals to lawyers, referrals to funeral homes for preplanning arrangements); Discharge planning services (e.g., helping to place a resident on a waiting list for community congregate living, arranging intake for home care services for residents returning home, assisting with transfer arrangements to other facilities); Providing or arranging provision of needed counseling services; Assisting residents to determine how they would like to make decisions about their health care, and whether or not they would like anyone else to be involved in those decisions; Finding options that meet the physical and emotional needs of each resident; Meeting the needs of residents who are grieving; and Assisting residents with dental/denture care, podiatric care; eye care; hearing services, and obtaining equipment for mobility or assistive eating devices. Where

40 DOES A PHARMACIST HAVE TO ASSESS THE PATIENT? 39 Identification & Demographic Info Customary Routine Cognitive Patterns Communication Vision Mood and behavior patterns Psychosocial well being Physical functioning and structural problems Continence Disease diagnoses and health conditions Dental status Nutritional status Skin condition Activity pursuit Medications Special treatments and procedures Discharge potential Physician Nursing Social Work Pharmacy Rehab Dietitian Activities

41 DOES THE ACTIVITIES COORDINATOR HAVE TO ASSESS THE PATIENT? 40 C (xiii) Activity pursuit C (f) Activities (1) The facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. (2) The activities program must be directed by a qualified professional who-- (i) Is a qualified therapeutic recreation specialist or an activities professional who-- (A) Is licensed or registered, if applicable, by the State in which practicing; and (B) Is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or (ii) Has 2 years of experience in a social or recreational program within the last 5 years, 1 of which was full-time in a patient activities program in a health care setting; or (iii) Is a qualified occupational therapist or occupational therapy assistant; or iv) Has completed a training course approved by the State. In a Critical Access Hospital, the services at (f) may be directed either by a qualified professional meeting the requirements of (f)(2), or by an individual on the facility staff who is designated as the activities director and who serves in consultation with a therapeutic recreation specialist, occupational therapist, or other professional with experience or education in recreational therapy. A (f) Activities (1) The facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. (2) The activities program must be directed by a qualified professional who-- (i) Is a qualified therapeutic recreation specialist or an activities professional who-- (A) Is licensed or registered, if applicable, by the State in which practicing; and (B) Is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or (ii) Has 2 years of experience in a social or recreational program within the last 5 years, 1 of which was full-time in a patient activities program in a health care setting; or (iii) Is a qualified occupational therapist or occupational therapy assistant; or (iv) Has completed a training course approved by the State. Interpretive Guidelines (f) A recognized accrediting body refers to those organizations or associations recognized as such by certified therapeutic recreation specialists or certified activity professionals or registered occupational therapists. The activities program should be multi-faceted and reflect individual resident s needs on their care plan. Activities can occur at anytime and are not limited to formal activities being provided by activity staff. Others involved may be any facility staff, volunteers, and visitors.

42 DOES THE ACTIVITIES COORDINATOR HAVE TO DEVELOP AN ACTIVITIES PLAN? 41 C (f) Activities Interpretive Guidelines The activities program should be multi-faceted and reflect individual resident s needs on their care plan. Activities can occur at anytime and are not limited to formal activities being provided by activity staff. Others involved may be any facility staff, volunteers, and visitors. A (f) Activities Interpretive Guidelines The activities program should be multi-faceted and reflect individual resident s needs on their care plan. Activities can occur at anytime and are not limited to formal activities being provided by activity staff. Others involved may be any facility staff, volunteers, and visitors. Important: It s not JUST AN ASSESSMENT it s also a PLAN Important: Activities must be documented based on the PLAN

43 DOES A DENTIST HAVE TO ASSESS THE PATIENT? NO BUT THERE MUST BE A DENTAL / ORAL ASSESSMENT 42 Identification & Demographic Info Customary Routine Cognitive Patterns Communication Vision Mood and behavior patterns Psychosocial well being Physical functioning and structural problems Continence Disease diagnoses and health conditions Dental status Nutritional status Skin condition Activity pursuit Medications Special treatments and procedures Discharge potential Physician Nursing Social Work Pharmacy Rehab Dietitian Activities IF NURSING is responsible for the dental / oral assessment there must be education/training

44 COMPREHENSIVE CARE PLAN 43

45 COMPREHENSIVE CARE PLAN C (K) 44 (1) The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following-- (i) The services that are to be furnished to attain or maintain the resident s highest practicable physical, mental, and psychosocial well-being as required under ; and (ii) Any services that would otherwise be required under but are not provided due to the resident s exercise of rights under , including the right to refuse treatment under (b)(4).

46 COMPREHENSIVE CARE PLAN C (K) 45 An interdisciplinary team, in conjunction with the resident, resident s family, surrogate, or representative, as appropriate, should develop quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on the comprehensive assessment. The care plan must reflect intermediate steps for each outcome objective if identification of those steps will enhance the resident s ability to meet his/her objectives. Facility staff will use these objectives to follow resident progress. Facilities may, for some residents, need to prioritize needed care. This should be noted in the clinical record or on the plan of care. The requirements reflect the facility s responsibility to provide necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well being, in accordance with the comprehensive assessment and plan of care. However, in some cases, a resident may wish to refuse

47 COMPREHENSIVE CARE PLAN C (K)(2) 46 Interdisciplinary means that professional disciplines, as appropriate, will work together to provide the greatest benefit to the resident. It does not mean that every goal must have an interdisciplinary approach. The mechanics of how the interdisciplinary team meets its responsibilities in developing an interdisciplinary care plan (e.g., a face-to-face meeting, teleconference, written communication) are at the discretion of the facility. The MD/DO must participate as part of the interdisciplinary team, and may arrange with the facility for alternative methods, other than attendance at care planning conferences, of providing his/her input, such as one-to-one discussions and conference calls. The resident has the right to refuse specific treatments and to select among treatment options before the care plan is instituted. The facility should encourage residents, surrogates, and representatives to participate in care planning, including encouraging attendance at care planning conferences if they so desire.

48 COMPREHENSIVE CARE PLAN C (K)(2) 47 A comprehensive care plan must be-- (i) Developed within 7 days after the completion of the comprehensive assessment; (Note: 7 days is too long for Swing Bed) (ii) Prepared by an interdisciplinary team, that includes the attending MD/DO, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident s needs, and, to the extent practicable, the participation of the resident, the resident s family or the resident s legal representative; and (iii) Periodically reviewed and revised by a team of qualified persons after each assessment.

49 SO HOW DO WE GET THERE? START WITH THE ASSESSMENT Ensure that assessment templates are consistent 2. Ensure that EVERY discipline knows what they are assigned to assess and the timeline to have assessments completed 3. Ensure that there is a designated place for each discipline to document assessment and that all disciplines know how to find it 4. Assign someone to talk to patient and/or family about their goals (usually social work, utilization review or discharge planning) May be done as part of admission process and obtaining signatures on required documents

50 SO HOW DO WE GET THERE? SCHEDULE MULTI-DISCIPLINARY MEETING Assign a facilitator usually Swing Bed Coordinator 2. Include ALL disciplines including provider if at all possible (don t forget Activities) 3. Invite the patient 4. Identify BIG GOALS for SWING BED STAY first and make sure everyone agrees 5. For each BIG GOAL identify measurable objectives and timelines. Identify specific responsibilities by discipline 6. Document the Plan IDEALLY on a single form 7. Make sure someone takes minutes and documents the meeting

51 GOAL EAMPLES 50 Goal: Mrs. Jones will be independent in medication management within 10 days of admission to swing bed Intermediate Goal: Mrs. Jones will correctly identify each medication and why it has been prescribed within 3 days of admission Responsibility: Pharmacist Other Disciplines: Nursing will ask patient to identify medications and reason for medication, at the time of each medication administration Goal: Mr. Smith will dress himself, including shoes, without assistance each morning by 8:00 AM within 5 days of admission Intermediate Goal: Mr. Smith will dress himself, except for shoes, without assistance each morning by 8:00 AM within 3 days of admission Responsibility: Occupational Therapy Other disciplines: Nursing Assistants will assist patient to dress each morning but will not dress patient (will allow patient to dress themselves)

52 GOAL EAMPLES 51 Goal: Mrs. Jones will walk independently with a walker feet within 7 days Intermediate Goal: Mrs. Jones will walk with walker to the end of the hall with stand-by assist within 3 days of admission Responsibility: Physical Therapy Other Disciplines: Goal: Mr. Smith will be at 165 pounds within 14 days of admission. Intermediate Goal: Mr. Smith will be at least 160 pounds within 7 days of admission. Responsibility: Dietitian Other disciplines: Nursing Assistants will assist Mr. Smith to table for all meals Nursing Assistants will weigh Mr. Smith daily Nursing Assistants will document food intake Nursing Assistants will provide mid-morning, afternoon and evening snacks

53 WHITE BOARD IN ROOM 52

54 SWING BED PROGRAM --- PROTECT IT 53 YOUR SWING BED PROGRAM IS A BENEFIT TO YOUR FACILITY IS A BENEFIT TO YOUR COMMUNITY IS A BENEFIT TO YOUR PATIENTS

55 SWING BED CONSULTING PACKAGE Growth Strategies 2. Skilled Criteria 3. Policy and Procedures Let me know if you would like a proposal, or would like to talk about our services 4. Patient Admission Packet 5. Staff Education 6. Provider Education 7. Multi-disciplinary Assessment / Care Planning Tools 8. Annual Survey on-site 9. Quarterly reviews off-site 10.Unlimited telephone and support

56 QUESTIONS 55

57 56 PLEASE CONTACT ME IF YOU WOULD LIKE TO SCHEDULE A MOCK SURVEY OR IF YOU HAVE QUESTIONS CAROLYN ST.CHARLES CAROLYN.STCHARLES@HEALTHTECHS3.COM OFFICE: CELL:

58 ADDITIONAL INFORMATION SKILLED CRITERIA 57

59 EAMPLE 1 MEDICARE BENEFITS MANUAL MANAGEMENT AND EVALUATION OF A PATIENT CARE PLAN 58 An aged patient with a history of diabetes mellitus and angina pectoris is recovering from an open reduction of the neck of the femur. He requires, among other services, careful skin care, appropriate oral medications, a diabetic diet, a therapeutic exercise program to preserve muscle tone and body condition, and observation to notice signs of deterioration in his condition or complications resulting from his restricted (but increasing) mobility. Although any of the required services could be performed by a properly instructed person, that person would not have the capability to understand the relationship among the services and their effect on each other. Since the nature of the patient s condition, his age and his immobility create a high potential for serious complications, such an understanding is essential to assure the patient s recovery and safety. The management of this plan of care requires skilled nursing personnel until such time as skilled care is no longer required in coordinating the patient s treatment regimen, even though the individual services involved are supportive in nature and do not require skilled nursing personnel. The documentation in the medical record as a whole is essential for this determination and must illustrate the complexity of the unskilled services that are a necessary part of the medical treatment and which require the involvement of skilled nursing personnel to promote the stabilization of the patient's medical condition and safety.

60 EAMPLE 2 MEDICARE BENEFITS MANUAL MANAGEMENT AND EVALUATION OF A PATIENT CARE PLAN 59 An aged patient is recovering from pneumonia, is lethargic, is disoriented, has residual chest congestion, is confined to bed as a result of his debilitated condition, and requires restraints at times. To decrease the chest congestion, the physician has prescribed frequent changes in position, coughing, and deep breathing. While the residual chest congestion alone would not represent a high risk factor, the patient s immobility and confusion represent complicating factors which, when coupled with the chest congestion, could create high probability of a relapse. In this situation, skilled overseeing of the nonskilled services would be reasonable and necessary, pending the elimination of the chest congestion, to assure the patient s medical safety. The documentation in the medical record as a whole is essential for this determination and must illustrate the complexity of the unskilled services that are a necessary part of the medical treatment and which require the involvement of skilled nursing personnel to promote the patient's recovery and medical safety in view of the patient's overall condition.