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Written by: Darlene D'Altorio-Jones (1959-2015) on Monday, September 16, 2013 Posted in: Inpatient Rehab

Day passes obliterated from practice in IRFs? Not so fast!!

Several months back, I was pulled into a discussion with a southeastern hospital system that suddenly found RAC denials for patients under ‘lack of medical necessity’ because they participated in a practice that most rehabilitation facilities do as a matter of business; that practice is best known as community outings. Whether outings are with staff or family, rehabilitation passes are a normal process for those of us working with severe disability. We must be certain the patient has a true experience with a flavor similar to discharge, so that the final steps leading to discharge are not met with problematic delays or failed plans.

Practice makes perfect, right? We have all learned that to be true. Well, everyone except perhaps someone attempting to deny payment…because obviously, if a patient can endure a ‘pass’ they are certainly ready for discharge. That’s their theory at least. Rehab professionals know that in that instance of practice on the pass, the real (not the perceived) challenges suddenly face that patient and their caregiver and instantly, you have their undivided attention to work through every type of challenge to help ease the real discharge plan. Sometimes without this physician ordered and very specifically needed challenge, you would be more apt to discharge failure.

Having worked in an IRF as far back as 1986, the practice of passes (even overnight at that time), were an important part of the relearning process for patients. Entire businesses spawned from the crucial need to reenact exactly the expectations you had for the patient who was expected to re-enter life in the community with challenges that require special skill sets and considerations. Hospitals created unit apartments and/or savvy small towns by a company called Easy Street® and/or created ad hoc versions to resemble the necessary elements a patient would need to be challenged and trained to achieve to return to the community through practiced interventions and skilled recommendations.

As healthcare professionals, we understand that people who have never experienced the devastating challenges our inpatient rehabilitation patients experience will not understand the unique treatment protocols we employ to improve success at discharge. It is fair to say that anytime our unique practices are challenged or ‘denied’ as reasonable and necessary we must advocate at the highest level to be sure excellent care is not obliterated with faulty unknowing judgement.

I applaud the east coast health system that shared their denial story with me and the steps they took to be sure this doesn’t happen to others like you! They specifically queried CMS for clarification when several of their claims were questioned for denial based on the fact that the patient was permitted to test the waters of independence during a day pass. By seeking clarification at the highest level (CMS directly), they were assured that this is beyond standard practice but sometimes ordered and necessary by the rehabilitation physician.

They discussed with the health system how to decide whether those day-pass minutes would count toward the 3 Hour Rule. In the absence of the skilled healthcare caregiver, minutes would not count. If therapy personnel were present, they would count toward rehabilitation intensity. In light of improved preparedness for home-going and reducing return to acute care admissions, CMS also agreed the practice itself is NOT a reason for denial and CMS asked for the name of the  audit contractor to educate them on the matter.

If you too have experienced denials for practicing the essence of rehabilitation in the form of a day pass, perhaps you too should prepare appropriate rebuttals. The unique practices of IRFs to prepare patients for successful discharge, specifically given very shortened length of stays, is extremely necessary for a handful of patients and families that must ‘test the waters’ before accepting the full blown daily routine they will soon inherit.

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Outcomes that include all cause 30-day readmission is on the IRF horizon. IRFs have enjoyed a reduced level of return to acute care. We feel this is mostly due to education and training collaboratively provided by the interdisciplinary team for the patient and caregivers. The practices of rehab are best employed and supported by those who know these values. Don’t let  the value of day pass and/or any other unique practices that enable patient success to be swept away in misunderstanding. Stand up for the rights of patients and advocate whenever you can!