As I speak to more and more clinical staff members, it is apparent that we struggle, as a profession, to understand the guidelines that were written in the IRF 2010 Federal Regulations. There are four separate clarification documents (found online at http://www.cms.gov/InpatientRehabFacPPS/04_Coverage.asp#TopOfPage ) that attempt to redefine success in more deliberate coaching terms. However, defining team goals, and how to communicate those in a way that we can all act upon, carryover and meet the required patient needs, isn’t necessarily easy.
We have been taught to write discipline short and long term goals, but IRF medical necessity requires more. It requires that we have a unified plan of care each discipline can impact together to meet success to align a safe discharge to home or community whenever possible. Discern the true barriers to discharge, develop the measurable level the patient/caregiver must meet to be discharged safely, and write the goal that, as a team, all must meet to make it happen.