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Written by: Darlene D'Altorio-Jones (1959-2015) on Monday, July 18, 2011 Posted in: Inpatient Rehab

The 2010 Rule has no doubt changed many practices within a rehabilitation facility. Oddly enough, much of what was published was known and practiced similarly before 2010, but the regulations and very specific clarification seemed to bring about one thing; accountability without a doubt.

Can we be accountable to very specific interpretations of a rule and hold to those standards without question? For the areas that are time-driven or require specific information, it seems fairly simple to figure out. Having everyone work on the same page for “measureable improvement” is quite another story.

Section 1: 110.3 of the Medicare Benefit Policy Manual for inpatient rehabilitation practice is the final section of the 2010 IRF regulations. I realize it is 2011 and we are still discussing old news, but this last section should be read and discussed at a theoretical level with staff. It leads a harsh realism in my grasp of expectations as a therapist and in my guidance as a teacher to manage rehabilitation facility practices.

This section says what it means and will challenge healthcare reform to the fullest extent in several ways. Read Section 1:110.3 carefully!

This section challenges the basic premise of what we do every day in the value of care we provide and implores us as clinicians that our practice will generally shift from “traditional, patient-centered therapeutic services to patient/caregiver education, durable medical equipment training, and other similar therapies that prepare the patient for a safe discharge to the home or a community-based environment.” Furthermore, the same section states that our patients are not “expected to achieve complete independence in the domain of self-care.”

The specific role of an inpatient rehabilitation facility is to resolve barriers that result in return to the community. Therefore, from the moment of admission you must seek the specific level required to prepare a patient for safe discharge. We tend to say “at the highest possible level of independence,” but this is not exactly what this section implores. In contrary, it acknowledges that as a specialty we have a specific highly specialized expectation to act as an interdisciplinary team that cannot easily be replicated (because of its interdisciplinary nature) by any other level of care to reasonably and predictably improve function in a “reasonable amount of time.” Whoa, what does that mean? We have guideline standards for the average length of stay for each CMG but each patient is unique so we are asked not to consider those numbers. What?

But those are the resource allocations for what it should cost to care for this type of individual so how can I separate from the expectations those numbers suggest is my reasonable average?

It’s a tall order for my yester-year NDT perfectionist nature in building a firm and stable foundation for all other normal movement to be practiced from. This regulatory description of “measurable improvement” has shattered my previous ideals of goal attainment as I used to define it. It’s not all about perfecting the skills but to accommodate enough skill that my patient or caregiver can manage safely, given education and devices to swiftly move onto the next appropriate (least costly) level of care.

Every burden has a price tag; expedient movement through a costly interdisciplinary model must be done more expeditiously or we’ll cost ourselves right out of the future of health care reform. Our patients deserve better and we need to strike a balance that works towards demonstrating cost effective and efficient management of their care.

Read section 1:110.3, internalize what this final section means to you and post your thoughts/comments. How will you define “measurable improvement” and how will you be accountable in obtaining it at an IRF level of care?

If you read and interpret this section differently, please post a comment to dialogue on this topic. We are struggling as an industry to grasp meaning on this topic.

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