The Case Managers Dilemma Who Should You Refer Medicare vs Commercial Medicare Must be reasonable and necessary Does not say that if the patient can be treated in SNF they cannot be seen in an IRF ID: 727817
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Slide1
The Anatomy of a Rehab Patient
The Case Manager’s Dilemma:
Who Should You Refer?Slide2
Medicare vs Commercial
Medicare:
Must be “reasonable and necessary”
Does not say that “if the patient can be treated in SNF, they cannot be seen in an IRF”Commercial:Totally up to the payerThe only MC rule that applies to the commercial patient is that we must count them in our CMS-13 calculationsSo, if functional loss and belief that IRF is the best discharge disposition, refer and we will attempt to get prior authorizationWorker’s Comp will often approve rehab in spite of patient’s inability to participate at the high level of therapy intensity that Medicare requires
This presentation prepared for client use by Images & Associates. 2014 All Rights Reserved.
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Medicare: Reasonable and Necessary
Significant functional loss
Needs assist in several one or areas of function
Gait, transfers, bowel and bladder, dressing, eatingPotential for gain (as assessed by the IRF and IRF physician)Need for intensive therapy2 therapies
3 hrs. per day, 5 days per week or 15 hours per week
Includes activities of daily living (feeding, grooming, bathing, dressing)
Not
all about time in the gymlet the IRU decide if patient can tolerateRehab Nursing 24/7To reinforce skills from therapy and to teach and coachTo address medical issues and treatment as well as functional issuesInterdisciplinary CareRehab nursing to reinforce skills from therapy and to teach and coachSocial work/Case Management to address discharge planning and resource needsTherapy servicesRehab physicianRehab physician supervisionTo coordinate the entire teamTo work with consulting medical staffTo lead the team in addressing function in spite of or along with medical management
This presentation prepared for client use by Images & Associates. 2014 All Rights Reserved.
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Commercial Insurance Issues
Not governed by Medicare requirements
except
that the CMS-13 diagnostic compliance is calculated on the entire populationEach payer may have their own pre-cert requirementsAdmissions Coordinator will facilitate this stepSignificant push to send patients to SNFLess expensive on the surface; not necessarily soMay need to have physician advocate for patient with insurer’s Medical Director; but…..Commercial Payers can and do approve cases that would not meet MC payment requirements; andIt is appropriate for us to take those patients
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Commercial Patients
Does the patient have an IRF benefit?
Does the patient have functional loss?
Do you believe the patient would benefit from an interdisciplinary treatment plan to help them achieve higher levels of independence?If yes, refer to IRF. Let our clinical assessment staff review the case and make a recommendation.This presentation prepared for client use by Images & Associates. 2014 All Rights Reserved.5Slide6
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Reasonable Criteria for Admission
The CMS-13 Diagnostic Categories (to some extent)
Prior Level of Community ActivitySignificant Functional Loss
Potential for Significant Practical ImprovementIntensive Therapy Services
Rehab Nursing Requirements
Requirement for Medical Supervision
Comorbid ConditionsFace-to-face physician visit 3 x per weekRequirement for Coordination of CareApproved funding (yes, this is legal)This presentation prepared for client use by Images & Associates. 2014 All Rights Reserved.Slide7
GeNERAL GUIdelines
Who should be referred to IRF?
This presentation prepared for client use by Images & Associates. 2014 All Rights Reserved.
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What’s in a Diagnosis?
Medicare requires that the IRF accept 60% of it’s patients from certain diagnostic categories.
This is a certification requirement, not a coverage requirement
Patients outside these diagnoses are often good candidates for IRFDon’t deny a patient access just because of a diagnosis; but…If they have one of these diagnoses and they have functional loss, it’s likely they will qualifyThis presentation prepared for client use by Images & Associates. 2014 All Rights Reserved.
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CMS DIAGNOSTIC CATEGORIES
Stroke
Fracture FemurSpinal cord injuryBrain injuryBurns Congenital Deformity
AmputationMajor Multiple Trauma
Neurological disorders
Polyarthritis
Active polyarticular RASystemic vasculidities with joint inflammationSevere or advanced osteo – 2 or more JointsTotal Joint Replacement if one or more:BilateralObesity (BMI > 50)Patient age 85 or overThis presentation prepared for client use by Images & Associates. 2014 All Rights Reserved.Slide10
Diagnosis
%
Stroke
20.5Hip Fracture14.4Major Joint Replacement
11.2Debility
9.9
Neurological
9.7Brain Injury7.3Other Ortho6.5Cardiac5.0Spinal Cord Injury4.3Other11.3And, just to prove that diagnosis alone doesn’t drive rehab,The Most Common Diagnoses - 2010
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Much overlap with SNFs, but hospital-based units have easy access to patients and physiatrist Medical Directors on hospital staff who can complete pre-admission consultations in the hospital. Freestanding IRFs have sophisticated and aggressive referral development programs
.Slide11
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Elements
of
“Reasonableness”Rehabilitation NeedsClose Medical Supervision24 Hour Rehabilitation NursingRelatively Intense Level of Rehab ServicesMultidisciplinary Team ApproachCoordinated Program of Care
Significant Practical ImprovementReasonable GoalsAppropriate Length of Stay
This presentation prepared for client use by Images & Associates. 2014 All Rights Reserved.Slide12
Rehabilitation Needs
Does the patient have functional losses that are new or that are exacerbated by this new event?
What was the patient’s prior level of function?
Active in the community (or in the case of a nursing home resident, within the nursing home community)?How do the new functional losses impact the patient’s ability to return to home/community?Does the patient need therapy interventions to regain that function in a reasonable period of time?This presentation prepared for client use by Images & Associates. 2014 All Rights Reserved.
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Rehabilitation Needs
Prior Level of Function
Specific detail of functional level Physical FunctionInclude how much help in detail
Include devices Community Activity
Specific detail
Driving, shopping, Church, other activities
Current Functional LossToiletingToilet TransfersBed to/from Chair TransfersLower Extremity DressingAmbulationStairsBathing
Greatest weighting for payment
Key areas for development of
protocols
Community Activity must be well documented.
This presentation prepared for client use by Images & Associates. 2014 All Rights Reserved.
If patient has minimal to moderate assistance requirements in several of these areas, they should be referred.Slide14
Close Medical Supervision
Need for
rehab physician visits
to manage functional rehab program and coordinate medical issues Patient requires and receives management of the rehabilitation program BY THE REHAB PHYSICIAN no less than three times per weekFace to Face Visits with the Rehab PhysicianNotes address functional issues as well as medical onesNotes address progress to date and continued needs and potential for functional gains
There are orders from the rehabilitation physician written at the time of admissionInclude rehab nursing, therapy, etc
.
Rehabilitation physician synthesizes the interdisciplinary plan of care and specifies the reason for rehab
There is evidence in the record that the rehab physician attends and leads the team conferenceThe documentation in the record must be legible!This presentation prepared for client use by Images & Associates. 2014 All Rights Reserved.14Slide15
24 Hour Rehabilitation Nursing
Must be specific orders for
rehabilitation nursing
proceduresNursing plan and daily notes address the patient’s needs related to rehabilitationRehab nursing staff addresses educational needsDisease informationMedication managementBowel and BladderSelf-CareCarryover of the skills learned in therapy to the tasks completed with nursing staff
Education about medication and equipment use
This presentation prepared for client use by Images & Associates. 2014 All Rights Reserved.
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Relatively Intense Level of Rehabilitation Services
Must have multiple therapies
One of which is
PT or OTIntensive level of therapy servicesAt least 3 hrs. of therapy 5 of 7 daysOr, 15 hours per week
Once again, not all of the exercise is “gym” timeLet the IRF decideBrief exceptions policy allows some leeway
Not more than 3 days
Clear documentation of why requirement not met
Should see discussion in team notesIf problematic, consider if patient appropriate for 15 hours per weekStandard of care is 1:1 therapyIf group therapy better meets patient needs, must clearly document rationaleShould be a transition from patient-centered therapy to patient/caregiver education, DME training and home needs as patient approaches discharge.Different than the acute hospital interventions that are focused on moving the patient to the next level of careCommercial Payers may have their own interpretation16This presentation prepared for client use by Images & Associates. 2014 All Rights Reserved.Slide17
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Interdisciplinary / Coordinated Delivery of Care
Patient Focused, Individualized Plan of Care
Interdisciplinary Approach Team goals and objectivesTeam communicationCoordination of care
ITM at least every weekStanding team meeting once per week sufficesMay be state specific issues requiring more frequent meetings, different documentation
Documentation includes key elements
Assessing the individual's progress towards the rehabilitation goals;
Considering possible resolutions to any problems that could impede progress towards the goals; Reassessing the validity of the rehabilitation goals previously established; and Monitoring and revising the treatment plan, as needed. Attended by professionals involved in the rehab planMust include at least:The rehab physician (not an extender)RN w/ training and experience in rehab (Not an LVN) and who is familiar with the patientSocial worker or case managerLicensed therapist from each discipline involved in treating the patient (Not an assistant) and who is familiar with the patientThis presentation prepared for client use by Images & Associates. 2014 All Rights Reserved.Slide18
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Significant Practical Improvement
Goal of IRF treatment is to enable the patient’s safe return to the home or community-based environment
Generally, goal is community discharge; there are exceptionsDoes the medical record demonstrate measurable deficits that are likely to improve significantly with an intensive rehabilitation programDetailed measurements at least weekly in key areas
FIM Scores are not enough, need formal measurements of ROM, strength and detail of progressIn the absence of potential for independence, does documentation describe what level of functional improvement can be expected from the plan of care?
MYTH: Potential SNF Placement does
not
preclude IRF admission and does not require immediate discharge!This presentation prepared for client use by Images & Associates. 2014 All Rights Reserved.Slide19
Functional Loss & Potential
for Improvement
What is significant, measurable, reasonable?
MEDICARE‘S RESPONSE:
Clarification
of the terms “significant benefit,” “measurable improvement,”
“predetermined and reasonable period of time,” and “nature and degree of expected improvement.”
We believe that rehabilitation physicians are typically able to determine from examining a patient what represents “significant benefit” for that patient, what represents “measurable improvement” for that patient, what is a “reasonable period of time” to achieve the expected level of improvement, and what the “nature and degree” of that expected improvement would be. We also expect that the rehabilitation physicians will be able to clearly explain their reasoning in the patient’s overall plan of care, which must be documented in the patient’s medical record at the IRF.This presentation prepared for client use by Images & Associates. 2014 All Rights Reserved.19What this means to us:Medicare accepts that the rehab physician is the best qualified to make a decision about whether a patient is appropriate for IRFIf the patient has functional loss that would not be expected to return simply with increased activity, they could and should be referred to the IRF.Slide20
Should I refer?
This presentation prepared for client use by Images & Associates. 2014 All Rights Reserved.
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