by Jackie Birmingham, RN, MS
A new federal rule that took effect Jan.1 will make it more difficult for discharge planners to transfer patients to acute rehab. CMS-1538-F governs admission requirements to inpatient rehabilitation facilities (IRFs) where payments are higher than for other levels of care. The evolution of hair-splitting reimbursement systems combined with the growth in different-but-related post-acute care options continues to shift to the post-acute provider the decision of where to place a patient.
I have three predictions about the impact of CMS-1538-F, which will be wide-ranging: It will be more difficult to place patients in IRFs, thereby driving up hospital length of stay (LOS) and placements in non-acute-care settings.
Prediction No. 1: Transition of Care Gets Tougher. (Crystal Ball Required.)
Discharge planners will now need to predict earlier in a patient’s hospital stay whether he might be eligible for and benefit from an IRF referral. At that point, pre-admission screening by the staff in the IRF will need to start. This preadmission screener will need more information including a review of prior level of functioning (before admission to short-term acute care), expected level of improvement, estimated LOS, risk for complications, the specific condition that necessitates an IRF stay and anticipated discharge destination. In other words, the discharge plan from the IRF will need to be set up prior to admission to the IRF. That’s right: Plan for a potential patient’s discharge from the facility before admitting him.
Also plan to communicate more with IRF staff for preadmission screening, and not just collaborate with hospital physicians. While some IRFs have on-site liaisons which could make this easier, many do not. So, for discharge planners already challenged to understand all possible discharge levels of care and choose the right one, their workload will grow with increased communication requirements. Knowing the difference between SNF for rehab, and IRF for rehab, or outpatient, or home rehab, or just keeping the patient in the hospital for rehab, (yes, hospitals do provide rehabilitation services) just got more important.
Prediction No. 2: Length of Stay for Patients Headed for IRFs Will Increase.
Acute facilities without a streamlined exchange of complete patient records will not be able to work within the timeframe mandated by the new coverage requirement. Additionally, with the hospital, not the IRF, making preadmission decisions, hospital staff faced with an IRF denial may have to start the transition-planning process all over again.
The preadmission screening by IRF staff must be done by a review of clinical records sent to the IRF no more than 48 hours before a patient’s anticipated discharge. Conveying information over the phone is no longer enough. So, any missing clinical note can hold up acceptance of the patient, and may even close the 48-hour window, forcing the process – and the clock – to restart. Then add to LOS calculations the time spent explaining to patients any delays or changes in their discharge plans.
Here’s another contributor to increased LOS that comes with the rule’s 48-hour window: a lack of staff. Those facilities without discharge planning services 7x24 – including holidays – will have to keep patients longer since they’re unable to work within the 48-hour window over weekends and on holidays.
Prediction No. 3: More Patients Will Get Care in Non-Acute Care Settings.
With greater scrutiny of the admission process, fewer patients will be transferred to IRFs - causing a backup elsewhere. More patients will be transferred to other settings where similar rehab services are offered: skilled nursing facilities (SNFs), home-health agencies and outpatient clinics. With the shortage of physical therapists, these post-acute providers will be stretched to accommodate more patients – patients who previous to CMS-1538-F would have been sent to an IRF.
The impact of this extends back to the physician’s office where the elective admission was initially booked. Doctors’ offices that tell patients they will go to a specific place after discharge for acute rehabilitation will need to rethink that approach. Or face the wrath of patients and their families.
Get Help from HIT to Navigate the New Terrain.
Health-care IT can help discharge planners and case managers work with the new rule. With that 48-hour clock running, the secure, automated transmission of clinical records to the IRF will relieve some of the new communication burden placed on health-care professionals. Additionally, having automatically generated, time-stamped documentation that an IRF is the only reasonable and necessary setting for a patient’s rehab needs will help when decisions are challenged.
Lastly, clinical workflow redesign coupled with technology can ensure that hospital staff identifies early those patients who could potentially benefit from transfer to an IRF while in parallel developing a plan B for those who might not be accepted. Setting up a "rule-out" IRF early in the patient’s stay can make transitions better for patients and staff.
Jackie Birmingham, RN, MS is vice president of regulatory monitoring and clinical leadership at Curaspan Health Group.
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