Understanding Levels of Rehab for Effective Discharge Planning Rose M. Turner, RN, BSN, ACM Thursday, January 22 nd, 2015 The information provided in AHC Media Webinars does not, and is not intended to constitute medical or legal advice. Opinions, references and links provided by our speakers are provided for your convenience and do not represent our endorsement of such opinions, products or services.
Speaker Rose M. Turner, RN, BSN, ACM, is President of Rose M. Turner Consulting, a hospital case management consulting firm where she uses over 20 years of expertise to design programs that are patient focused and easy to operationalize. She has worked in hospital case management for over 20 years managing the most complex cases on the front lines and designing programs and processes for difficult patient populations as a special projects case manager. Her hospital work also includes developing policy, astute knowledge of government regulations affecting case management, and implementing case management education & orientation programs. 2
Objectives 1. Review how to read and use hospital therapy notes to identify ideal rehab options. 2. Recall the various rehab options available and what occurs with each. 3. Identify rehab options for specific disease groups. 4. Explain new and revised case management standards, regulations, and laws put forth by CMS, TJC and the federal government. 5. Evaluate case management protocols and penalties.
Types of Rehab for your hospital patient Outpatient Home Health Skilled Nursing Facility (SNF) Sub-acute Acute Rehab Long Term Acute Care Hospital (LTACH) *Nomenclature may be different in various parts of the country.
Which one is the right one? Baseline functional ability can we get back there? Current rehab function Potential functional ability (rehab therapists are the experts) Social/home support Patient s ability to meet the goals Is it the safest and least restrictive? You may need more than one one is a precursor to the next
If nursing can ambulate the patient Consider home with out rehab Previously a household ambulator? Is this base line? Consider home with home health for PT safety eval Recommendations on loose rugs Moving furniture Where to put grab bars Navigating the bathroom May still need DME walker, crutches, cane
Safe to Go Home (how to phrase it to a patient) Be able to get in & out of bed w/o assistance Be able to get in & out of a chair w/o assistance Be able to get up & down off a toilet w/o assistance Be able to walk 50-75 ft down the hallway (even with a FWW) w/o anyone touching you for assistance Choose the shorter distance if they really need some placement rehab
Need a PT/OT or Speech eval Requires a physician order (rehab actually bills to hospital account) Initiate assessment Will recommend type of rehab for discharge Sees patient daily or twice a day in house Level of treatment depends on location of patient and ability of patient to participate Assessment will cover previous function and needed equipment You can request specific assessment like stairs
How to read the eval - PT Endurance poor, fair, good, excellent Ability - narrative Assistance needed SBA - Stand by assistance CGA contact guard assistance min, max, X1, X2 (persons) Equipment needed various DME Look for specialized equipment for trauma/ortho patients Distance usually measured in feet Know the distance of your unit hallways Time of treatment generally 30-40 min. Cognitive does the patient need cues
OT eval definitions Focus on ADL s Upper body dressing, hair brushing, oral care Lower body dressing, shoes and socks Endurance strength required, unable to finish Amount of assistance set up, SBA, min or max assist Cognitive patient needs cues ; will look at sequencing of tasks Ability - narrative
Speech Therapy Often related to neurological diagnosis Limited availability in Home Health Home program practice Best in outpatient or SNF & higher facilities If only therapy needed perform in outpatient rehab Cognitive/cues Endurance of treatment time
Outpatient Rehab PT/OT/Speech/Lymphedema therapy Wound care wound vacs At discharging hospital, outpatient rehab clinic or private PT office Patient has social support and ride Safe in home environment while receiving outpatient care Ability to transport (not home bound) Can be daily or intermittent Needs a physician order Assessment done first, then insurance contacted for number of treatments needed
Home Health PT/OT/Speech Must be home bound (exceptions) MD appts Church Hair Salon Safe home environment Social support Intermittent rare to get therapies more than 2x/week Will develop home program for patient to follow through Requires physician order
Skilled Nursing Facility PT/OT/Speech Therapy is twice a day M-F Can play Wii (available in most SNF s) Not able to ambulate independently Short term (1 week to 3 months) When discharged home consider HH or outpt therapy to continue working on goals Patient may have other clinical needs MD visits once per month
Sub-acute Patient has more complex medical needs besides rehab Therapy is twice a day M-Sat MD visits once a week At least 3 of the following: IV infusions TPN Complex wound care Therapies (PT/OT/Speech) Trach care/suctioning Ventilator
Acute Rehab Complex needs Requires daily physician oversight Aggressive therapy PT/OT/Speech Average LOS 14-21 days Criteria: Be able to do 3 hours of therapy/day Have a home plan (home with live in support or AL) A payor Diagnosis meets criteria
Long Term Acute Hospital Chronic acute hospital care Daily physician oversight Complex needs (anything you would see in a hospital) Can provide ICU care PT/OT/Speech aggressive Average LOS 25-35 days Limited options if Medicaid or Contracted HMO Consider HH or outpatient care to continue therapy goals after discharge
Making the decision Patient & family will look to the hospital CM for guidance What makes the most sense for each patient Therapy may make a recommendation may not meet the needs of the patient Use more intense therapy options first as a stepping stone The needs may change over the hospital stay Be prepared to change the discharge plan Some physicians will only go with what the therapist recommends It s about what meets the needs of the patient and what they want
Educate the patient As part of developing the discharge plan, offer options of rehab Explain how each one works; how much rehab the patient will receive If possible, give family the opportunity to tour facilities tell them to visit the rehab departments Educate family to advocate for patient at next facility ask for Home Health or out patient rehab
Educate yourself Spend a day as a ride along with HH Physical Therapist Visit outpatient rehab department at your hospital Visit: SNF, Sub-acute, acute rehab, LTACH facilities Check out the rehab departments Can the patient continue out patient therapy there? What s the difference in available services? What are the specialties of different facilities? Acute rehabs may have driving programs or special neuro programs find out what is in your service area
Put the rehab needs together with the discharge plan Include the rehab needs and options when devising the discharge plan and discussing with patient & family Follow all CMS regulations on offering choice Patient needs endurance training before acute rehab? Have acute rehab do assessment in hospital before transfer to SNF/subacute the acute rehab will follow up Teach the family and patient to be proactive in getting the rehab care needed Advocate for your patient some insurances limit benefits
Jimmo vs. Sebelius Settlement 2013 Settlement Medicare contractors inappropriately applying an Improvement Standard Center for Medicare Advocacy represented Ms. Jimmo who was denied home health services based on lack of restorative potential She won there is no Improvement Standard If patient needs skilled care to prevent or slow further deterioration in clinical condition they qualify for rehab 42 CFR 409.32(c) - restoration of a patient is not the deciding factor whether skilled services are needed. This ruling also applies to all MCARE Managed Care pts.
Which rehab option is the right one? Use clinical chart review & patient interview What does the patient want? Advocate for a SAFE discharge Suggest use of community programs: Yoga, water aerobics, walking programs with physician OK are great ways to continue rehab More than one may be necessary
This presentation is intended solely to provide general information and does not constitute legal advice. Attendance at the presentation or later review of these printed materials does not create an attorney-client relationship with the presenter(s). You should not take any action based upon any information in this presentation without first consulting legal counsel familiar with your particular circumstances.
Thank you! Questions? Feel free to contact me at: 858-414-2903 Rose@RoseMTurnerConsulting.com