Using Team Conference to Drive Your Rehab Plan Lisa Werner, MBA, MS, CCC-SLP

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Using Team Conference to Drive Your Rehab
PlanLisa Werner, MBA, MS, CCC-SLP
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Overall Plan of Care
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Overall Plan of Care

• What is the Overall Plan of Care?
• Document required since January 1, 2010.
• Purpose is to create a single document that all
  team members use to direct the care of the
  patient throughout the stay.
• Should be used throughout the stay to ensure that
  the patient is staying on the ideal course of
  treatment to enable him/her to meet goals in a
  reasonable amount of time.

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The Rule

• Requirement for an Individualized Overall Plan of
  Care
• Essential to providing high-quality care in IRFs,
  since comprehensive planning of the patients
  course of treatment early on leads to a more
  coordinated delivery of services to the patient.
  Such coordinated care is a critical aspect of the
  care provided in IRFs.
• Requires that an individualized overall plan of
  care be developed for each IRF admission by a
  rehabilitation physician with input from the
  interdisciplinary team by the end of the fourth
  day following the patients admission to the IRF.
• Must support the determination that the IRF
  admission is reasonable and necessary.
• Must be maintained in the medical record.

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The Rule

• Requirement for an Individualized Overall Plan of
  Care
• Synthesized by a rehabilitation physician from
• Pre-admission screening
• Post-admission physician evaluation
• Information garnered from the assessments of all
  therapy disciplines
• Information from the assessments of other
  pertinent clinicians

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The Rule

• Requirement for an Individualized Overall Plan of
  Care
• Purpose is to support a documented overall plan
  of care. The overall plan of care must detail
• Estimated length of stay
• Patients medical prognosis
• Anticipated functional outcomes
• Anticipated discharge destination from the IRF
  stay
• Anticipated interventions that support the
  medical necessity of the admission
• Based on patients impairments, functional
  status, complicating conditions, and any other
  contributing factors. Should include these
  details about the PT, OT, SLP, P/O therapies
  expected
• Intensity ( of hours/day)
• Frequency ( of days/week)
• Duration (total of days during IRF stay)

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The Rule

• Requirement for an Individualized Overall Plan of
  Care
• Individual clinicians will contribute, but it is
  the sole responsibility of a rehabilitation
  physician to integrate the information that is
  required in the overall plan of care and to
  document it in the patients medical record.
• If the overall plan of care differs from the
  actual length of stay and/or expected intensity,
  frequency and duration, then the reasons for the
  discrepancies must be documented in detail in the
  patients medical record.
• Good practice to conduct the first
  interdisciplinary team meeting within 4 days of
  admission to develop the overall individualized
  plan of care. It is the IRFs choice to develop
  the internal process.

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The Interpretation

• CMS Provider Education call stated
• The physician is responsible for documenting the
  information that pulls the overall plan of care
  together.
• Signing the plan of care is not equivalent to
  synthesizing a plan of care completed by the
  clinicians.

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The Interpretation

• CMS QAs
• Rehab physician has to synthesize the plans of
  care, but he does not have to write it out
  himself.
• The purpose of the overall plan of care is to
  provide general direction for the team and to
  establish broad goals for the patients
  treatment. The team members are responsible for
  setting their specific plan.
• The intensity of therapy should be stated, but
  since treatment is adjusted for the patients
  individual need consider adding a statement that
  reflects the times stated are an average that
  will be varied based on the patients daily
  needs.
• Physician extenders can complete and sign the
  form.

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Team Conference
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Weekly Team Conference

• Purpose
• Weekly meeting attended by a member of each
  treating discipline.
• The purpose of the conference is to problem solve
  the most effective way to meet the patients
  needs.
• Assess the individuals progress or the problems
  impeding progress
• Consider possible resolutions to problems
• Reassess the validity of the rehabilitation goals
  initially established

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The Rule

• Requirement for Evaluating the Appropriateness of
  an IRF Admission / Inpatient Rehabilitation
  Facility Medical Necessity Criteria
• The patient must require an intensive and
  coordinated interdisciplinary approach to
  providing rehabilitation.
• IRF documentation indicates a reasonable
  expectation that the complexity of the patients
  nursing, medical management and rehab needs
  requires an inpatient stay and interdisciplinary
  team approach.
• The complexity of the condition must be such that
  the rehab goals indicated in the pre-admit
  screening, post admission evaluation and overall
  plan of care can only be achieved through weekly
  team conferences by an interdisciplinary team of
  medical professionals.
• Each individual team member will work within
  their own scope of practice, but is also expected
  to coordinate his or her efforts with team
  members of other specialties, as well as with the
  patient and the patients significant others and
  caregivers.

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The Rule

• Requirement for Evaluating the Appropriateness of
  an IRF Admission / Inpatient Rehabilitation
  Facility Medical Necessity Criteria
• Purpose of the interdisciplinary team is to
  foster frequent, structured, and documented
  communication among disciplines to establish,
  prioritize and achieve treatment goals.
• At a minimum the team must document participation
  by professionals from each of the following
  disciplines (each of whom must have current
  knowledge of the patient as documented in the
  medical record at the IRF)
• Rehab physician with special training and
  experience in rehab services
• RN with specialized training or experience in
  rehabilitation
• A social worker or case manager (or both) and
• A licensed or certified therapist from each
  therapy discipline involved in treating the
  patient.

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The Rule

• Requirement for Evaluating the Appropriateness of
  an IRF Admission / Inpatient Rehabilitation
  Facility Medical Necessity Criteria
• Team should be led by a rehab physician who is
  responsible for making the final decision
  regarding the patients treatment in the IRF.
  The rehab physician must document concurrence
  with all decisions made by the interdisciplinary
  team at each meeting.
• Periodic team conference held at least once per
  week must focus on
• Assessing the individuals progress towards the
  rehabilitation goals
• Considering possible resolutions to any problems
  that could impede progress towards the goals
• Reassessing the validity of the rehabilitation
  goals previously established and
• Monitoring and revising the treatment plan as
  needed.

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The Rule

• Requirement for Evaluating the Appropriateness of
  an IRF Admission / Inpatient Rehabilitation
  Facility Medical Necessity Criteria
• May be formal or informal however, a review of
  notes is not a conference.
• All treating professionals from the required
  disciplines are expected to attend every meeting
  or, in the infrequent case of an absence, be
  represented by another person of the same
  discipline who has current knowledge of the
  patient. Documentation must include the names
  and professional designations for the
  participants in the team conference.
• The occurrence of the team conferences and the
  decisions made during such conferences, such as
  those concerning discharge planning and the need
  for any adjustment to goals or the prescribed
  treatment program, must be recorded in the
  patients IRF medical record.
• Review of this requirement will focus on the
  accuracy and quality of the information and
  decision-making, not the internal process used by
  the IRF.

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The Interpretation

• CMS Provider Education call stated
• The definition of a licensed or certified
  therapist from each therapy discipline involved
  in treating the patient means PT, OT or ST, but
  not therapy assistants.
• As with the requirement of a registered nurse,
  the intent is that the individuals present at the
  team meeting have the proper credentials to
  collaborate on and adjust the patients plan of
  care.

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The Interpretation

• CMS QAs
• Patient care conferences should be held weekly,
  which was defined as once every 7 days.
• If you move care conferences, you should hold an
  interim conference to discuss the patient should
  the new day be outside the 7 day window.
• The rehab physician can participate in conference
  by phone if it is absolutely necessary. The
  physicians participation by phone should be
  clearly documented.
• The participant does not have to be the primary
  clinician, but participant needs to have enough
  knowledge of the patient to be able to actively
  participate in the evaluation of the patients
  progress toward his or her goals and the
  modification of the treatment plan so that it
  best contributes to future progress.

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Patient Care Conference Notes

• Barriers to getting the information that CMS
  asked for
• Status reporting
• Not understanding what a barrier to discharge is
  (problems that impede progress)
• Plan of care is not a working document
• Lack of knowledge of the patient
• Time limits

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Patient Care Conference Notes

• What do you report?
• Statement on progress relative to goals
• Problems impeding progress and aspects that are
  facilitating progress
• Focus for next week
• Things that need to be changed on the plan of
  care
• Items that the team needs to know such as
  compensatory strategies that have been working

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Patient Care Conference Notes

• Overcoming barriers
• Status reporting
• Provide that information on paper (or a screen)
  beforehand
• Allow a only general statement by each discipline
• Have a physician leader coach the rehab
  physicians on what to say
• Not understanding what a barrier to discharge is
  (problems that impede progress)
• Provide team with a list of common barriers
• Include the list in your note and check off what
  applies
• Provide education on what a barrier is and have
  an enforcer in conference

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Patient Care Conference Notes

• Overcoming barriers
• Plan of care is not a working document
• Bring the plan of care to conference
• Review the plan of care
• Have a place to document updates
• Review each functional and medical problem.
  Determine if plan of care addresses it adequately
  (like an HP problem list)
• Lack of knowledge of the patient
• Pull notes from prior treatments rather than
  passing off summaries
• Time limits
• Have a time keeper who is the problem solver for
  what requires follow-up at another time
• Make sure the time keeper is assertive
• Enforce reviewing the plan of care and all
  supporting elements. Do not move on to another
  patient if you are not done
• Give every attendee a chance to report as a
  procedure of care conference

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Patient Care Conference Notes
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Patient Care Conference Notes

• Problems that Could Impede Progress
• ADLs
• Balance
• Behavior
• Bladder management
• Bowel management
• Caregiver education
• Cognition
• Communication
• Community resources
• Disposition issues
• Equipment
• Medical management
• Medication management

• Mobility
• Motivation/initiation
• Nutrition/hydration
• Pain management
• Patient education
• Safety
• Skin/wound care
• Support system
• Swallowing
• Tone/spasticity
• Weakness/endurance
• Weight bearing restrictions
• Other

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Patient Care Conference Notes

• Plan of Care Revisions Based on Problems
• Bowel program
• Caregiver identification
• Consult equipment vendors
• Consult orthotist/prosthetist
• Consult psychology
• Consult PT for wound care
• Consult respiratory therapy
• Consult seating clinic
• Consult wound care nurse
• Dietary changes
• Disposition planning
• Education BI support group (family)
• Education Caregiver

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Patient Care Conference Notes

• Plan of Care Revisions Based on Problems
• Education Patient
• Education SCI Ed
• Education Stroke Ed
• Equipment assessment
• FEES
• Funding source assessment
• ICP
• Initiate behavior plan
• IV fluids
• MBS
• Medication change
• NMES for swallowing
• Serial casting
• Splinting
• Timed voids
• Other

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Review your Patient Care Conference Note
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Audit

• Evaluate the scope of the patient care conference
  notes for the following components
• Assessing the individuals progress towards the
  rehabilitation goals
• Considering possible resolutions to any problems
  that could impede progress towards the goals
• Reassessing the validity of the rehabilitation
  goals previously established and
• Monitoring and revising the treatment plan as
  needed.
• Were all team members present at the patient care
  conference?
• Did the team conference occur every 7 days?

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Weekly Team Conference

• Using the team to drive the plan of care
• 1st step Have the plan of care in team
  conference.
• Case Manager report-
• First conference goals as written on the team
  plan of care or overall plan of care
• Subsequent conferences-goals as stated or revised
  during the last meeting
• Medical Director report-
• Medical needs that were addressed
• Ongoing needs

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Weekly Team Conference

• What to do next
• Discuss current situation strengths, barriers,
  and plan for next week including reports from
• Physician
• Therapists
• Nurses
• Social worker/case manager
• Identify strategies for removing the barriers to
  discharge
• Update plan of care by adjusting goals for
  addressing identified barriers to discharge
• Specifically state why the patient needs to stay
  in the hospital for another week

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Weekly Team Conference

• What to do next
• Recap the list of ICD-9 codes. Add codes to the
  list from information conveyed during the meeting
• Ensure that the physician documentation matches
  the report given during the conference to ensure
  proper coding
• Set a discharge plan

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Weekly Team Conference

• What NOT to do
• Fill out the functional portions of the form
  during the conference.
• Come to the meeting with the form mostly
  completed
• Fill in only new information gathered during the
  meeting
• Review each functional item
• Instead focus on progress and barriers
• You should be reporting the level of assistance
  with each task on the FIM scoring form

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Weekly Team Conference

• What NOT to do
• Plan the discharge based on the Medicare expected
  length of stay
• This indicator is meant to be an average not a
  guideline

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Weekly Team Conference

• Rules
• What every good team should do.
• Be knowledgeable of the patient so you can adjust
  the plan of care appropriately.
• Aim for 8-10 minutes per patient.
• Be solutions based.
• Seek contributions from all team members.
• Assure that documentation supports continued
  physician, nursing, and therapy involvement.

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Weekly Team Conference

• Success Elements
• How the good team measures their success.
• You came prepared and everyone could knowledgably
  discuss the patients care.
• Each patients case took 10 minutes or less to
  complete.
• The weekly conference form is completed
  sufficiently to justify the continued stay of the
  patient.
• Significant goals from the previous weeks
  conference are discussed and updated.
• You developed collaborative solutions to
  eliminate or minimize remaining barriers to
  discharge.

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Length of Stay Management

• How do you establish a length of stay?
• Specific patient needs
• Pathways or protocols
• eRehabData facility averages
• National and regional benchmarks
• Medicare CMG length of stay

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Length of Stay Management

• Review your goals
• Keep your patients discharge goal in mind
• How much time will it take to achieve the goals?
• Medical
• Nursing
• Rehabilitation therapy
• When will family teaching be initiated and how
  long will that take?

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Length of Stay Management

• How does this measure up?
• Does your clinical plan fall within benchmarks?
• If yes, good job.
• If no, evaluate treatment plan, discharge plan,
  coding and scoring.

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Do You Have a Problem?

• Analyze the Facility Report
• Transfer Patients
• Percentage of patients that are discharged to
  another Medicare bed
• Acute care
• SNF
• LTACH
• Another IRF
• Discharge Destination
• Breakdown of discharge locations for the
  patients served

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Do You Have a Problem

• Analyze the Facility Report
• Averages
• Two benchmarks Weighted and unweighted
• Onset days Different instructions by RIC
• Length of stay considerations
• FIM scoring data-
• Admission Totals
• Discharge Totals
• FIM Change
• Motor subscale at admission

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Do You Have a Problem

• Analyze the Facility Report
• Individual FIM Items
• Admission, discharge, change, and follow-up
• Explains difference between facility totals and
  benchmark totals
• First glance at isolating FIM scoring errors

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Team Conference

• Documentation of Team Conference
• Level of function at admission
• Discharge goals
• Medical needs
• Nursing needs
• Functional status by major functional areas
  representing function across 24 hours
• Include multiple weeks on a team conference form
  to allow you reflect progress
• Include barriers to discharge
• Update plan of care / team goals
• Identify strategies for attaining the goals
• State discharge plan and estimated length of stay

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Questions?

• Lisa Werner, MBA, MS, CCC-SLP
• Director of Consulting Service
• Lwerner_at_erehabdata.com