Using Team Conference to Drive Your Rehab PlanLisa Werner, MBA, MS, CCC-SLP Overall Plan of Care 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. 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. 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 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) 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. 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. The Interpretation CMS Q&As:
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. Team Conference 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 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. 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. 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. 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. 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. The Interpretation CMS Q&As:
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. 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 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 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 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 H&P 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 Patient Care Conference Notes 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 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 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 Review your Patient Care Conference Note 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? 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 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 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 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 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 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. 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. 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 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? 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. Analyze the Facility Report
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 Analyze the Facility Report
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 Analyze the Facility Report
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 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 Questions? Lisa Werner, MBA, MS, CCC-SLP
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