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Written by: Darlene D'Altorio-Jones (1959-2015) on Wednesday, July 13, 2011 Posted in: Inpatient Rehab

If you feel you still have to convince MACs and RACs, we know exactly what documentation is required to defend medically necessary care at the IRF rehabilitation level, listen up; the documentation stated in the pre-admission screen should without a doubt hold that defense.

Here is how I see it.

In April, I blogged about the listed criteria stated within the regulations in the post titled, “Pinning the Tail on the Pre-Admission Screen.” Now, let’s look past the standard list and discuss how to build the rationale that meets the intended population we serve, still using regulations and data for that discussion.

All details are important in the rule; specifically content items included in pre-admission information and timeliness.  The most important, yet often forgotten element is to demonstrate that the patient requires an inpatient stay, an interdisciplinary team and complexity of patient’s nursing and medical management in addition to therapy that warrants a rehabilitation level of care over what may be available at a SNF or lesser level of care.

Often, we ignore the element of time that it takes to produce the intense yet brief encounter that enables a patient to safely,  successfully and reasonably benefit from an interdisciplinary team approach that leads to community discharge.

What do I mean by that statement?  We ignore the element of time that it takes to produce the results for brief intense interdisciplinary success.

I believe, as an industry, we often recall the 3 Hour Rule for intensity but often neglect the other 21 hours of medical and functional management to enable a lesser burden of care. Furthermore, we don’t state what amount of time is expected to care for the patient in the pre-admission screen so that we define up front the level of hours per patient day required to attend to the full plan of care required immediately upon discharge from the acute setting for the care and training of a patient’s particular needs.

Yet, we know that information, it’s in the pre-admission screen.  A comprehensive needs assessment with full disclosure of risk and required hands on clinical care has been outlined.

If we defended admission to an IRF based on the time it takes to fulfill the required plan of care at discharge from acute, hands down we could dispel the doubt for “medically necessary” defense after the fact to MACs and RACs.

When the  physician reviews the pre-admission screen, there are four items that equate to hours per patient day contact time to fulfill the patients plan of care.  Review those items to make a medical judgement of total time to meet the needs each day based on the facts of the screen.

These areas are:

  • Risk for clinical complications (surveillance and prophylaxis)
  • Conditions that caused the need for rehabilitation (impairments that must be managed, retrained)
  • Combinations of treatments needed in the IRF (hands-on clinical care or interventions to meet all risks, conditions, impairments, instructions and education to understand and pass responsibility specifically if it can be re-trained at the patient and caregiver level)
  • Expected frequency and duration of treatments in the IRF (how much and how often to succeed in reducing the burden of care by a clinical provider)

Although some of that time may be transferable to lesser skilled individuals; it is expected that in a rehabilitation level of care that the contact is continuously at a teaching level (rehab nursing 24-7), expecting return on learning even for ADL that a patient cannot perform on their own. Coaching, cuing and carrying forward the plans of care established within the interdisciplinary team and not being done for the patient just to get it done.    Rehab Nursing is practiced specifically and intensely at an IRF level of care.  That integration is not passive.  All contact is an opportunity for teaching, training and carry-over with demonstration.  Validate the time required in the pre-admission screen to provide that care on a daily basis.  These contact hours defend 24/7 rehabilitation nursing. All too often, only the medical/surgical care is thought of because that is most often what is charted.

Total the amount of time expected (similar to relative value units) for medication management, clinical risk surveillance, continuous coaching for movement the patient cannot yet perform safely on an independent level and all the various elements that enable all the areas we functionally assess and retrain.  Start with the 18 functional items and how much time it takes to complete those daily.  The rehab plan of care is time intensive;  especially to encourage the patient to be the predominant facilitator to lessen the burden and regain the greatest level of self sufficiency.

Time that, in total, may far outweigh time available at a lesser level of care. Hours per patient day practiced in a skilled settings within your zip code area is published at the CMS Compare website.  These values are broken down to licensed and non-licensed hours of patient care.  Do you know the standard hands on hours provided in your area?   Review those standards and discern very carefully if your pre-admission information defends a level of care that requires more than two to three  hours of clinical contact care outside of the 3 Hour Rule therapy.  What portion of that time is required by licensed and non-licensed staff?  Often state regulations hold the definition and are published by the Department of Health and Human Services from state to state.

Would it shock you to know that in Ohio, for example, the state regulations require a minimum daily average of two and three fourths hours of direct patient care services per resident, per day and that a minimum of two-tenths of an hour per resident day must be provided by an RN? That is 12 minutes!*  Healthcare Compare publishes each SNF’s actual reported averages.  Since there is a minimum level and averages aren’t often far off, somewhere in that intelligence lies the rationale to defend the correct level of care that your patient needs.  In addition, therapy time is permissible to count in the two hour average in Ohio.  MDS therapy frequencies at the various RUG levels are also published. Build your case – you have the data!

If the patient contact hours reviewed for admission is in line with the needs of a skilled level of care and not with a rehabilitation level,  then directing the care based on the pre-admission screen should be simple.  The complexity of the nursing and medical management portion of medical necessity cannot be defended. If they are beyond the expected norm of skilled care for your area, state the projected contact hours required so there is no question that the patient appropriately requires the intensity of care only you can provide.   With physician concurrence for admit, based on these projections of care, there is more solid defense for how you reached an appropriate decision. State facts – leave no holes.

If the patient requires medical and functional physician plan of care management no less than  three times a week,  multidisciplinary hands-on care in total that is above your state SNF published norms for contact care; you have solid defense to admit the patient.

I think somehow MACs and RACs will see it the same way too.  Stop ignoring the time required to defend 24/7 vigilance and retraining of both medical and functional patient potential.   The purpose of the pre-admission screen and post admission evaluation defends credibility toward a medically necessary admission to your IRF.   This intensity compared to standard lesser levels of care set IRF/IRU apart.  Build that case when necessary.   So many patients are slipping through the cracks because we have neglected to make these comparisons.

Review your state SNF practice standards and share those links here at our blog.  Can we get a response to represent each state?  Let’s try!  If you cannot find a standard, let us know that too.

OHIO:   * http://codes.ohio.gov/oac/3701-17-08 updated 05/2011