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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 Plan Lisa Werner, MBA, MS, CCC-SLP Overall Plan of Care Overall Plan of Care What is the Overall Plan of Care? – PowerPoint PPT presentation

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


1
Using Team Conference to Drive Your Rehab
PlanLisa Werner, MBA, MS, CCC-SLP
2
Overall Plan of Care
3
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.

4
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.

5
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

6
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)

7
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.

8
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.

9
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.

10
Team Conference
11
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

12
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.

13
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.

14
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.

15
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.

16
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.

17
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.

18
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

19
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

20
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

21
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

22
Patient Care Conference Notes
23
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

24
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

25
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

26
Review your Patient Care Conference Note
27
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?

28
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

29
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

30
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

31
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

32
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

33
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.

34
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.

35
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

36
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?

37
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.

38
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

39
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

40
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

41
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

42
Questions?
  • Lisa Werner, MBA, MS, CCC-SLP
  • Director of Consulting Service
  • Lwerner_at_erehabdata.com
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