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Lets Cure the Referral Free-for-All; Once-and-for-All

Written by: Darlene D'Altorio-Jones (1959-2015) on Thursday, December 26, 2013 Posted in: Acute Care Rehab

No matter where I visit, I hear very similar complaints about the rationale for why a patient may be referred to various levels of post-acute care following the acute care stay. The most common force to discharge a patient is to reduce the overall acute care LOS statistic. A medically necessary acute stay is often challeged by Medicare and third party payers alike. Without thought, we are pushing people out of an acute bed for alternative reasons that may not provide for the most thorough decisions in the patients’ best interest.   When will the madness end if we as clinicians don’t take the first rational step to stop and do the right thing for the patients’ sake?

The care management and social work departments have their work cut out for them to find speedy discharge alternatives given the array of leftover medical/functional needs of patients discharged today. Having Medicare Part A may make this an even trickier proposition. How you may ask?

Let’s be honest, ours is a busy society and when care needs exceed a reasonable home health or outpatient alternative, there is little understood about the appropriateness for what venue of care best meets the patient’s left over needs.

The screening process has not been simplified to a decision tree. Usually, the appropriate rationale and alternatives are not always presented to the Medicare patient to disclose the BEST alternatives to consider within the guidelines of the Medicare Policy Benefit Manual.   This is not to offend the practices; this is to make a posture for the need for an improved process and understanding.

Are the rules too complex? Well yes, they are complex, but they do not make it impossible to develop appropriate rationale and recommendations, rather than set up a free-for-all by ordering or referring two to three levels of care. How often do you see referrals for SNF and IRF in the orders of a patients chart being discharged? Are they interchangeable? Not generally.

Each level provides therapy rehabilitation but what is most important are the MEDICAL and FUNCTIONAL aspects of recovery along with a more intense level of nursing hours.  Patients with multiple medications and their possible interactions especially when newly prescribed need more intense skilled resources to monitor these risks and potential side effects while increasing their physical demands.    Increased education, medical interventions and patient stability requires the guidance of a more accessible physician to guide the plan of care and generally a more intense level of RN surveillance. If nursing intervention/resources are greater than 2.5 – 3 hours of care per day, it must be acknowledged that this is a level rarely provided at a SNF level of nursing.  CMS’s Skilled Compare website will demonstrate this to be true.

Patients with newly acquired medical issues often involving greater than six – eight medications, require skillful 24 hour vigilence.  Patients unable to manage self care tasks who need continuous coaching to reincorporate to independent skills along with their caregivers need professional TIME to educate, train and observe carry over so that individual patient is capable of managing a very complex array of functional and medical oversight before they are discharged and left to fend for themselves.   A certain level of assuredness in self care and medical management improves a patients self care capacity and may reduce readmission statistics.

It’s time to demonsrate real learning and problem management – not just passively overlooking the risks all lurking to occur.  When you see a complex patient,  ask yourself clinically what is the right level of nursing managment.

Now lets ask again. Why do discharge plans go awry? Was the appropriate time spent in providing an adequate discharge referral to meet the unique needs of each patient? I can say that greater than 50 percent of the time most likely not.

That’s a pretty bold statement.  I believe I can make that statement because repeatedly inpatient rehabilitation facilities/units that require screening for admission often have a less than 50 percent refer to admission statistic.  ‘Ethis is because there are inappropriate referrals and or mulitiple orders were received for varying levels of care.  If an IRF screen takes longer than a skilled approval, a patient can be directed perhaps inappropriately. Don’t pretend this doesn’t happen. It does.

What are your statistics? Are they similar? If they are, there is a broken referral collaboration that needs mending fast. Even facilities that have a full continuum of post-acute care levels are ‘fighting’ for the same patients. It shouldn’t happen too often if the clinicians directing the care of the patient better understood the need for clinical resource matching and guidelines specific to levels of required medical necessity. 

There are more than 15,314 licensed skilled facilities and approximately 1,300 IRFs either freestanding or unit-based. Given these odds and a 3 day qualifying stay, it’s understandable why some might automatically place a SNF on the list to refer to. But when you have the option, be certain you educate the best access for the patient. Doing the right thing for the patient should improve the ability to match the resources needed at discharge and eventually improve the best outcomes for that patient.

Provide a pretest of knowledge needed in referring based on regulatory statutes; provide education and then post test to see if you can improve the discharge process in your facility. Create an atmosphere of correct referrals rather than ‘free-for-all’ orders.

No matter where I visit, I hear very similar complaints about the rationale for why a patient may be referred to various levels of post-acute care following an acute care stay. The most common force to discharge a patient is to reduce the overall acute care LOS statistic. Often, a medically necessary acute stay is often challeged by Medicare and third party payers alike. Without thought, we are pushing people out of the bed as soon as we can for alternative reasons that may not provide for the most thorough decisions to be made. When will the madness end if we as clinicians don’t take the first rational step to stop and do the right thing for the patients’ sake?

The care management and social work departments often have their work cut out for them to find speedy discharge alternatives given the array of leftover medical/functional needs of the patients discharged today. Having Medicare Part A may make this an even trickier proposition. How you may ask?

Let’s be honest, ours is a busy society and when care needs exceed a reasonable home health or outpatient alternative, there is little understood about the appropriateness for what venue of care best meets the patient’s left over needs. The screening process has not been simplified to a decision tree. Usually, the appropriate rationale and alternatives are not always presented to the Medicare Part A patient to disclose the BEST alternatives this person should consider within the guidelines of the Medicare Policy Benefit Manual and or Medicare Processing Manual directives. This is not to offend; this is posture improved process.

Why is this? Are the rules too complex? Well yes, they are complex, but they do not make it impossible to develop appropriate rationale and recommendations, rather than set up a free-for-all by ordering or referring two to three levels of care. How often do you see referrals for SNF and IRF? Are they interchangeable? Not generally.

Each provide a level of therapy rehabilitation. However, what is most important are the MEDICAL and FUNCTIONAL aspects of recovery along with a more intense level of nursing hours to manage the resources of the risks/medical interventions and patient stability under the guidance of an onsite accessible physician to guide the plan of care. More intense is generally greater than 2.5 – 3 hours of RN care per day which is rarely provided at a SNF level of nursing.

Patients with newly acquired medical issues often involving greater than six medications, require a skillful 24 hour vigilence. Patients unable to manage self care tasks who need coaching to reincorporate to independent skills, along with their caregivers and TIME to educate, train and observe carry over so that individual patient is capable of managing a very complex array of functional and medical oversight in often less than two weeks time. This is what keeps patients from re-occurring admissions. It’s time to demonsrate real learning and problem management – not just passively overlooking the risks all lurking to occur.

Now lets ask again. Why do discharge plans go awry? Was the appropriate time spent in providing an adequate discharge referral to meet the unique needs of each patient? I can say that greater than 50 percent of the time most likely not.

That statement is a pretty bold statement.   I repeatedly see that inpatient rehabilitation facilities/units that require screening for admission often have a less than 50 percent refer to admission statistic.    Reasons range from inappropriate level of care referrals and mulitiple orders to different levels of care have been ordered and the first one to respond may get the patient.  Even if a patient is more appropriate for a rehabilitation level of care, if the pre-admission assessment took longer than a skilled approval the patient may never get the chance to receive the more intense IRF services.   Don’t pretend this doesn’t happen. It does.

What are your statistics? Are they similar? If they are, there is a broken referral collaboration that needs mending fast.  Even facilities that have a full continuum of post-acute care levels are ‘fighting’ for the same patients.  It shouldn’t happen too often if the clinicians directing the care of the patient better understood the need for clinical resource matching and guidelines specific to the levels of required medical necessity are being followed.  

There are more than 15,314 licensed skilled facilities and approximately 1,300 IRFs either freestanding or unit-based. Given these odds and a 3 day qualifying stay, it’s understandable why some might automatically place a SNF on the list to refer to.   When you have the option, be certain you educate the best access for the patients resource needs.  Doing the right thing for the patient should improve the ability to match the resources needed and eventually improve the best outcomes for that patient.

Provide a pretest of knowledge needed in referring based on regulatory statutes; provide education and then post test to see if you can improve the discharge process in your facility. Create an atmosphere of correct referrals rather than ‘free-for-all’ orders.  When you experience a readmission within 30 days, look at discharge orders and matched resource alignment to be certain the interim step didn’t create the outcome failure.

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