Eli's Rehab Report

Published on Thu Sep 24, 2009 PDF

Key ingredient: rock-solid training.

If you aren't watching your hospital readmissions, the Feds are.

Post-acute care venues, including inpatient rehab facilities, long-term acute care hospitals, home health agencies, and skilled nursing facilities may soon face bundled payments with acute hospitals 30 days after discharge. So any readmissions would cost extra. (See the last issue of Physical Medicine & Rehab Coding Alert for more information on post-acute payment bundling.)

Although Congress hasn't passed anything yet, the writing's on the wall. "Any post-acute provider with a readmission rate over 18 percent will automatically be on the high review screen," says Fran Fowler, FAAHC, managing director of Health Dimensions Group in Atlanta. "Congress thinks the rate should be more around 5 percent," Fowler continues.

The good news: There's plenty you can do to lower your readmission rates now. This month, we'll focus on rehab management techniques Aegis Therapies uses in its chain of SNFs, Golden LivingCenters. And keep in mind that many of the following tips can apply to HHA, IRF,and LTACH settings too.

Rehab is only one part of a large team responsible for patient care in a SNF setting. However, therapy staff must be able to spot early signs of exacerbations that could eventually result in a return to hospital, stresses Mark Besch, PT, VP of clinical services for Aegis. "These include cardiac impairments such as congestive heart failure, pulmonary conditions such as COPD or emphysema, and more."

Problem: "In SNFs, you don't routinely see therapists monitoring things like pulse oximetry, blood pressure, and before and after exercise physiological signs, etc.," observes Martha Schram, PT, president of Aegis Therapies. "Yet therapists should be held accountable to that level of training and should be partnering with the facility to monitor these fragile patients."

But it's not an overnight training process. Golden LivingCenters doesn't try to cram it all into a new therapist's orientation. "But at the appropriate period in their employment, we do have therapists undergo a rather extensive training that includes understanding pulse oximetry and monitoring blood pressure, etc., to the depths that we think is necessary," Besch says. "We also have the training available in an e-learning format where therapists can review it on-demand and repeat it as often as needed."

Good idea: Golden LivingCenters also created a peer-to-peer pool of experts therapists can contact for clinical support, Schram says. "And our therapists really value that."

Therapists should report to nursing any changes in their patients' performance. That could be more swelling in a limb, more shortness of breath than the prior day, etc., Besch says. "The patients can't tolerate much decline or exacerbation until it really becomes a medical issue, and if we don't recognize and respond, we're in a situation where there's no choice but to return the patient to the hospital."

Rule of thumb: At the very minimum, therapy should be communicating with other staff on a weekly basis, Besch says. "But keep in mind that depending on the profile of your facility's admissions, you may need daily communication."

Tip: Your SNF's entire staff needs to realize it runs a 24-7 program and know how to handle many smaller issues internally. "Don't just call the doctor for any little sign of decline," Besch says. "The oncall doctor doesn't know the patient, and he's probably going to say, 'it's hard for me to tell over the phone, why don't you just send him to the hospital?' And then you have a readmission."

Every SNF should analyze its readmissions experience in collaboration with therapy, Schram insists. "Then the facility can design a riskmanagement and intervention strategy that includes not just nursing and rehab, but far more departments than that in the facility."

Example: Besch recently visited one of the Golden LivingCenters that had analyzed when their highest return to hospital rate was occuring.

"They found out that in fact, it wasn't weekends, to our surprise; their highest return to hospitals was Wednesdays between 10 a.m. and noon," he recalls. "That's important to know. So the next question is why would that be? And that's where they are in the process -- figuring that out."