Eli's Rehab Report

Published on Fri Aug 08, 2008 PDF

Try these stellar staff education tips from this acute care facility.

Word is out that inappropriate rehab referrals in acute care are happening everywhere -- and a lot more than they used to.

If you read the May edition of Eli's Rehab Report with the latest scoop on this topic and are dying to hear more, your wish has come true. In this article, Mary J. Kroohs, PT, CWS, supervisor of acute rehab services for Forsyth Medical Center in Winston-Salem, N.C., describes some solutions her facility has implemented to fix the problem.

Even if you can implement only one of these strategies, you're well on your way to a more ideal situation in your rehab department.

1. Educate Hospitalists, Case Managers About PT and OT

Be careful what you assume your referral sources know about PT and OT. "It's shocking how many hospitalists think that it's a PT's job to walk patients and an OT's job to feed patients," Kroohs says. So the best starting point is to create a basic list of what PTs and OTs really do.

On the flip side: Also spell out situations that don't call for a PT or OT consult. For example, Kroohs listed reasons such as "unstable vital signs, new onset & untreated DVT, unable to follow commands or have carryover, patient not getting out of bed, etc." as inappropriate reasons for PT and OT referrals. "We also explained the difference between PT and OT because so many physicians would request, 'PT/OT consult' -- which could result in a tremendous waste of resources for a discipline that really wasn't needed."

Tip: Spread the word to your case managers as well, because they might at times request hospitalists to order therapy for the wrong reasons, Kroohs suggested.

Also be sure to explain the therapist's role and decision-making say in an eval. "This was a revelation for some," Kroohs says. Many physicians and case managers don't know that the therapist determines whether a patient needs skilled therapy, as well as the frequency of therapy.

Good idea: "We created laminated cheat sheets with this information that we distributed to hospitalists and posted around the hospital," Kroohs says. Hospitalists also downloaded the information onto their PDAs.

If you're in a teaching hospital, extend this education to your residents as well. Now's a good time since July is when new rounds of residents come on board, Kroohs points out.

2. Educate Your PTs and OTs

Although your PTs and OTs know their roles better than anyone else, they'll occasionally face some gray areas. To streamline these situations, a team of PTs & OTs at Forsyth developed a decision tree for her therapists to use on all referrals. For example, one question in the tree is, "Are there any medical contraindications for a PT or OT to get involved at this point?" If the answer is yes, the decision tree tells the clinician to check back later to determine if the person has become medically stable.

Another question is, "Are discharge orders written for nursing home placement that same day?" If the answer is yes, the decision tree instructs the therapist to check with case management to see why the eval was ordered and if it was required by the insurance company or the long-term care facility.

Plan ahead: Guiding your therapists through the gray areas with an algorithm will have them well-positioned for objective decisions, but you'll also want to equip them with some subjective decision-making skills too -- particularly in the realm of people skills. "We did role playing to act out what to do when a physician gets very irritated because you said the person didn't need skilled therapy," Kroohs says. "This helped the therapists develop concrete ideas for difficult confrontations they may face."

3. Get Your Administration's Blessing

You can make all the algorithms and info sheets you want, but until the bigwigs have your back, you don't have much to stand on. And it's a good idea to be armed with solid research before you plead your case with upper management. "We did a large literature search before we got going on this," Kroohs tells TCI.

Strategy: Discuss your case and your findings with both hospitalists and nursing administration. "We gathered about 30 hospitalists and had them express their frustrations about patients not getting out of bed," Kroohs says. "It's also important to get the support of nursing administration -- explain that this isn't something we're trying to push on nursing, but PTs and OTs can't ethically perform nursing tasks and get paid for skilled therapy."

Be thorough when you inform hospitalists and other hospital staff where you're coming from. "We even met with all our PT and OT staff for two hours on two separate occasions," Kroohs recalls.

Seal the deal: Forsyth Medical Center made the decision tree for therapy referrals a policy to ensure support from hospital staff.

Note: For a more detailed overview of Kroohs' method, join her for a live TCI-sponsored audioconference this October. Sign up at http://www.audioeducator.com.