Overview of Rehabilitation Legislative Issues, Rehab Nursing Beth Hudson MS, RN, CRRN, Chief Nurse Executive for BIR JV What is the role of rehabilitation nursing within the regulatory environment The history of legislation and the role of rehabilitation nursing The regulatory environment in which we live The economics of healthcare Rehabilitation Nursing and Legislative Issues Early History Early 20 th century identified need for specialty licensure in rehabilitation 1935 Social Security Act defined rehabilitation to assist the disabled return to function 1938 AAPMR established to set standards for rehabilitation 1943 Vocational Rehabilitation Act made funds for training available 1
World War II Rusk & Kessler demonstrated improved lives of veterans and other disabled individuals 1951 1 st book on rehabilitation nursing 1962 Medicare legislation increased demand for rehabilitation services and insurance nurses 1965 Workman s compensation and rehabilitation law focusing on the workplace 1966 CARF established to consult with rehab community 1960-1989 increase recognition of specialty of rehabilitation nursing Legislative Milestones in Rehab Rehabilitation Act of 1973 encouraged efforts to hire people with disabilities and prohibited unfair treatment of people with disabilities in activities supported in any way by federal funds 2
Legislative & Historical Milestones in Rehab 1975 The Education for All Handicapped Children Act required states to provide education free of cost to any school aged child. 1974 ARN established under Susan Novak 1976 ARN journal 1984 CRRN credential established Landmark Legislation! 1990 American s with Disability Act required that public buildings and transportation be made accessible to all. This act also prohibits discrimination against people with disabilities in the workplace. The role of rehabilitation nursing in the historical development of legislation Advocacy Intermediary between where the legislators and the reality of disability Organizational power of the ARN Credentials for the specialty Partnering with other advocacy groups to protect the rights of the disabled to care 3
The regulations for acute rehabilitation Each post acute venue is unique Acute rehabilitation is NOT the same thing as sub-acute rehabilitation which is an unregulated version of a SNF From the federal government s perspective, the definitions of each level is blurry What are the regulations that govern acute rehabilitation today 1 st -Acute Rehabilitation Units/Hospitals are licensed- 75/60% rule -3 hr rule -24-7 specialized rehab nursing 2 nd -Patient must meet medical necessity criteria (can t be treated at lower level of care) 3 rd -Payment is based on PPS System derived based on diagnostic groups and FIM score The 75% rule in a nutshell Established in 1983 to differentiate rehab hospitals from acute hospitals (arbitrary decision) Never challenged until after PPS enacted in 2002 CMS used rule to deny patients after rehab had been completed Focus was the total hip/knee patients not defined as polyarthritis by CMS Challenged resulted in roll-back to 60% rule using the same criteria Not used to deny individual patients, used to measure if you meet the requirements of rehab hospital loss of licensure possibility 4
Post Acute Care Funding from Medicare PPS Began in 2002, Jan 1, in response to the Balanced Budget Act of 1997 Acute rehabilitation is one venue (LTC, home care, LTACH) of post acute care with special method of funding Post Acute care is focus of budget cutting because it grew when DRGs were enacted in acute care Acronyms Related to Regulations IRF-PAI Inpatient Rehabilitation Facility Patient Assessment Instrument FIM is part of this instrument FIM begins at Item #29 of the IRF-PAI CMS Centers for Medicare and Medicaid Services Require the IRF-PAI PPS Prospective Payment System This payment system uses the IRF-PAI to assist with determining reimbursement Functional Independence Measure 18 Activities are Scored Motor-13 Cognitive-5 Function Modifiers Bladder and Bowel Level of Assistance Frequency of Accidents Tub or Shower Transfers Locomotion (Walk/ Wheelchair) and distance traveled 5
Functional Independence Measure Evaluate over a 72-hour period from admission- Burden of Care score (lowest) Attempt to score based on actual observation If not observed, speak with the other staff; family members; read transfer chart; and/or use clinical judgment Record lowest level of functioning (burden of care) Function varies by: Discipline Time of day Record the lowest level of functioning at both Admission and Discharge Each item scored 1-7 scale Based on several factors Patient s ability to perform the task(s) Level of assistance required including physical and cueing And/or specific instructions on each item Admission FIM scores combine to. Determine the CMG for the pt Suggest an average length of stay Determine the total payment FIM Scoring is FUN!! 6
FIM (functional independence measure) Sensitive to motor limitations Less sensitive to cognitive limitations 18 items 12=motor, 6=cognitive Score of 1-7 roughly equally the amount of assistance needed 7=independent, 6=modified independent, 5=supervision, 4=minimal assistance, 3=moderate assistance, 2=maximal assistance, 1=dependent Developed based on Barthel Index, a scale measuring ADLs FIM scoring is an essential competency for the rehabilitation nurse Scoring must hold up to inter-rater reliability comparisons Drives payment for CMS so it is an issue of compliance Other PAC providers use other systems MDS-LTC Oasis-Home Care Rehab is unique, using an outcome system to drive payment more similar to the DRGs of acute care hospitals From the Patient s Perspective Advocacy is critical to moving both legislative and regulatory processes Rehabilitation is an ity bity part of the healthcare pie The philosophical goals are Back to work/school Reduced lifetime costs Functional recovery is good for the patient and good for society Rehab nurses are a trusted and valued voice in the ongoing dialogue to do what is best for our patients 7
Rehabilitation Terms & Goals World Health Organization provides framework Impairment loss of structure function Disability restriction/absence of performing function Handicap disadvantage limiting role Quality of Life is the ultimate goal Rehabilitation is contingent on team approach Rehab Team Models Medical model traditional symptomdiagnosis-treatment not rehab Multidisciplinary Pyramid with MD at top Interdisciplinary matrix with group decisions Transdisciplinary primary team member linked with patient at the center Models are Client centered OR setting centered OR provider centered Case management is a central model for life time management of care Rehabilitation Nursing Holistic focus Embraces ANA Social Policy Statement (1995) Humans manifest unity of mind/body/spirit Humans experience contextually and culturally Health and illness are human experiences Health does not preclude illness and illness does not preclude health Goal is to assist individuals towards maximal health through collaboration with the client/family 8
Specialty of Rehab Nursing Rehab Nursing Foundation linked to the Assoc of Rehab Nurses define specialty and research Rehab Nurses Use theory and research in care delivery Design, manage, coordinate Advocate and lifetime learning through professional associations RNF defines competencies and CRRN First offered in 1984 12,500 CRRNs Defines competency in rehab nursing The Economics of Health Care Funding continues to have a significant impact on access and utilization of services. Medicare A federally funded program for persons who have worked and paid taxes for at least 10 years, are over 65 and are a citizen of the U.S. are eligible. Those with permanent disability also qualify if they have met the work requirements The Economics of Health Care Medicare must be over the age of 65, have end stage renal disease or have been disabled for 2 years. 9
The Economics of Healthcare Medicaid is a state funded program, jointly funded by the state and federal government. Income and healthcare needs determine coverage. This may include Children s Health Insurance Program (CHIP) Workers Compensation Plans initiated by federal law and managed by agencies at the state level Private Insurance Plans The Economics of Healthcare Social Security Disability Income is available to workers with medically determinable limitations that prevent them from working or participating in substantial gainful activity. The disability must last longer than a year or be predicted to result in death. In order to qualify, a worker will need to have worked 5 of the last 10 years, paying FICA taxes during that time Test Question Which piece of legislation is believed to be the most far-reaching civil rights law ever enacted? A) Rehabilitation Act of 1973 B) Surface Transportation Act C)Americans with Disabilities Act D) Individuals with Disabilities Education Act 10
Answer The Americans with Disabilities Act is a landmark piece of legislation providing all Americans with disabilities equal opportunity and access in employment and services to that offered to the general public. The Rehabilitation Act of 1973 and subsequent amendments impacted both social and health-related areas of life. The Surface Transportation Act provided tax incentives for the removal of barriers and the Individuals with Disabilities Education Act established education as a right for all children 5 to 17 years. Test Question Which piece of legislation defined handicapped children and was the first recognition of a separate category for people with learning disabilities? A) 1970 Education of the Handicapped Act B) 1975 Education for all Handicapped Children Act C) 1975 Developmental Disabilities Act and Bills of Rights D) 1990 Individuals with Disabilities Education Act Answer The 1970 Education for all Handicapped Children Act (PL 91-230) defined handicapped children and established a separate category for children with learning disabilities. The 1975 Education for all Handicapped Children Act was a series of amendments to the Education of the Handicapped Act and provided appropriate public education and protection for the rights of children receiving educational services. The Developmental Disabilities Act and Bills of Rights provided funds for developmental disabilities programs and special projects. The Individuals with Disabilities Education Act added transition, assistive technology, rehabilitation counseling and social work to the services provided. 11
Which of the following is true regarding Medicare Part A A. It is a compulsory hospital insurance program for workers over the age of 65 B. It is managed by the states but is federally funded C. It replaces income of retirees by 2/3 the working salary rate D. It is a voluntary hospital insurance program for citizens over age 65 What FIM score is given if a patient is able to complete an activity in a timely manner with an assistive device? A. 5 B. 4 C. 6 D. 7 Which of the following is a definition of an impairment? A. A loss or abnormality B. A restriction in the ability to perform activities in a normal manner C. A disadvantage which limits fulfillment of normal roles D. A pathological alteration in function 12
Which person under the age of 65, is eligible for Medicare Part A coverage without collecting Social Security disability benefits for 2 years A. Those with chronic renal disease requiring dialysis or transplant B. A person injured on the job who has only worked 1 year C. Infants with disability born to mothers receiving Medicaid D. Those who have served in the miltary 13