Healthcare IT Squad

Part 5 – Interdisciplinary Documentation – Plan of Care & Team Meetings

Part 7 – PT, OT, SLP, Orthotics/Prosthetics Documentation

Inpatient Rehab Facility (IRF) – Part 9: The 3 Hour Rule is a post from: Healthcare IT Squad

Inpatient Rehab Facility (IRF) – Part 8: Other Services Documentation

Jared Houck — Mon, 22 Mar 2010 11:30:21 +0000

While CMS does recognize the value of psychological, neuropsychological, recreational therapy, music therapy, and/or respiratory therapy services on a patient-by-patient basis; these services should only be used adjunct to the primary IRF therapies (PT, OT, SLP, Orthotics/Prosthetics) and are not included in the IRF-PPS payment. These services can be covered by Medicare if medical necessity is well documented by the rehabilitation physician and is ordered as part of the overall plan of care for the patient. The documentation design for these groups should meet individual practice guidelines, but does not have specific requirements in relation to IRF guidelines.

The Inpatient Rehabilitation Series continues here:

Part 1 – Inpatient Rehab Facility (IRF) – EMR Documentation Design Series Introduction

Part 2 – Pre-Admission Screen

Part 3 - Inpatient Rehabilitation Facility – Patient Assessment Instrument (IRF-PAI)

Part 5 – Interdisciplinary Documentation – Plan of Care & Team Meetings

Part 7 – PT, OT, SLP, Orthotics/Prosthetics Documentation

Part 9 – The 3 Hour Rule

Inpatient Rehab Facility (IRF) – Part 8: Other Services Documentation is a post from: Healthcare IT Squad

Inpatient Rehab Facility (IRF) – Part 7: PT, OT, SLP, & Orthotics/Prosthetics

Jared Houck — Mon, 15 Mar 2010 11:19:05 +0000

To meet IRF admission requirements, the patient must require therapy from at least two of the four core therapies: Occupational Therapy (OT), Physical Therapy (PT), Speech-Language Pathology (SLP), and/or Orthotics/Prosthetics. One of the two necessary therapies must be PT or OT.

Initial Eval

Upon admission to the IRF, one of the core therapies must conduct an initial evaluation and provide intensive therapy within 36 hours from midnight on the day of the patient’s admission. For example, if the patient is admitted at 3pm on Friday, the patient must be evaluated and intensive therapy provided before noon on Sunday. In the initial evaluation, therapists need to document the referral mechanism by which their services were initiated, an examination of pertinent patient information, a thorough discipline-specific assessment, the therapist’s professional diagnosis and prognosis, and a comprehensive plan of care. The plan of care must include patient or family goals, therapy defined goals, planned therapeutic interventions, proposed therapy regimen, and discharge plans.

PTAs / OTAs

Many PT and OT departments employ certified therapy assistants that can provide therapeutic interventions to patients post-evaluation by a licensed therapist. Therapy assistants cannot evaluate patients or establish, modify, or revise a plan of care. The licensed therapist and certified therapy assistant roles are clearly defined in their respective state practice acts. The informatician and individual therapy disciplines should review these practice acts to ensure that the documentation design supports the inherent role distinctions.

Progress Notes

Ongoing therapy documentation, in the form of a daily note or progress note, must allow the therapist to document measurable progress toward established goals, specific interventions, the patient’s reaction to the treatment provided, and the therapist’s evaluation of the care event. Many therapies use the SOAP (Subject, Objective, Assessment, and Planning) model to guide documentation design. The ability to populate data items from the initial evaluation into the daily progress note (e.g. goals and plan of care) and the ability to continually edit this information; allows the documentation to accurately demonstrate the historic provision of planned care, the patient’s progress, and the assessment of need for continued therapy services. The documentation should also allow the therapist to indicate the inability to provide treatment secondary to patient refusal or medical instability.

Billing

Therapies document the time spent providing treatment to patients in discrete 15 minute intervals called units. CMS permits rehabilitation providers to bill a single 15 minute unit for each treatment that lasts 8-15 minutes. Most rehabilitation facilities hold therapists to a 75-80% productivity standard. For example, every 8 hours of work should have at least 6 hours (or 24 units) of billable activities. This does not include time spend on documentation. The ability to embed treatment, modality, procedure, and/or diagnosis codes within the day-to-day charting can reduce the amount of time therapists spend on clerical work and vastly improve the accuracy of billing information.

Discharge

Upon discharge, or just prior to discharge of the patient, therapists must finalize their documentation with specific information about the current physical and functional status of the patient. The documentation should allow the therapist to address goals that were achieved and justification for goals that were not achieved. Any continuation of care requirements including home programs, additional services or follow-up referrals, family/caregiver education and or training, and durable medical equipment provided; should also be clearly documented at this time.

The Inpatient Rehabilitation Series continues here:

Part 1 – Inpatient Rehab Facility (IRF) – EMR Documentation Design Series Introduction

Part 2 – Pre-Admission Screen

Part 3 - Inpatient Rehabilitation Facility – Patient Assessment Instrument (IRF-PAI)

Part 5 – Interdisciplinary Documentation – Plan of Care & Team Meetings

Part 9 – The 3 Hour Rule

Inpatient Rehab Facility (IRF) – Part 7: PT, OT, SLP, & Orthotics/Prosthetics is a post from: Healthcare IT Squad

Inpatient Rehab Facility (IRF) – Part 6: Physician & Nursing Documentation

Jared Houck — Mon, 08 Mar 2010 11:27:06 +0000

Rehab facilities must clearly demonstrate an interdisciplinary approach in the provision care. According to the CMS, IRF services must “be ordered by a rehabilitation physician with specialized training and experience in rehabilitation services and be coordinated by an interdisciplinary team, including at least a registered nurse 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.” It is imperative for the informatician to understand the documentation requirements of each specialty and subsequently analyze group workflows during the electronic documentation design stages.

Physician

A rehabilitation physician must review and sign the preadmission screening prior to the IRF admission. The rehabilitation physician must complete a post admission evaluation for all patients within 24 hours of IRF admission. The evaluation must identify any significant changes that have occurred since the preadmission screening. The evaluation must also include a history and physical examination of the patient, co-morbidities, medical justification for the necessity of rehabilitative care, functional limitations, and goals for each deficit (i.e. all 18 FIM items). At least three days per week, the rehabilitation physician must document patient progress. The physician must also assess and evaluate the patient’s medical conditions altering orders and treatment plan as necessary. Upon discharge of the patient, the rehabilitation physicians must provide documentation that summarizes the patient’s stay. This discharge document should cover the patient’s rehabilitation needs, the care provided, medical and functional gains, patient/family discussions and education, as well as a post-discharge follow-up plan.

Nursing

The interdisciplinary team must include a registered nurse with specialized training or experience in rehabilitation. Standards of nursing care for any acute inpatient facility serving Medicare beneficiaries is established in the CMS Hospital Conditions of Participation – Basic Hospital Functions. While rehabilitation patients do have specialized needs, the documentation of nursing care provided to these patients should follow hospital-wide standards.

The Inpatient Rehabilitation Series continues here:

Part 1 – Inpatient Rehab Facility (IRF) – EMR Documentation Design Series Introduction

Part 2 – Pre-Admission Screen

Part 3 - Inpatient Rehabilitation Facility – Patient Assessment Instrument (IRF-PAI)

Part 5 – Interdisciplinary Documentation – Plan of Care & Team Meetings

Part 7 – PT, OT, SLP, Orthotics/Prosthetics Documentation

Part 9 – The 3 Hour Rule

Inpatient Rehab Facility (IRF) – Part 6: Physician & Nursing Documentation is a post from: Healthcare IT Squad

Inpatient Rehab Facility (IRF) – Part 5: Interdisciplinary Plan of Care & Team Meetings

Jared Houck — Mon, 01 Mar 2010 11:18:43 +0000

Rehab facilities must clearly demonstrate an interdisciplinary approach in the provision care. According to the CMS, IRF services must “be ordered by a rehabilitation physician with specialized training and experience in rehabilitation services and be coordinated by an interdisciplinary team, including at least a registered nurse 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.”12 It is imperative for the informatician to understand the documentation requirements of each specialty and subsequently analyze group workflows during the electronic documentation design stages.

Overall Plan of Care

The overall plan care provides a general direction for the patient’s care in the IRF using broad goals for the patient’s treatment.

The plan of care document must contain:
• Estimate Length of IRF Stay
• Medical Prognosis
• Anticipated Medical and Therapeutic interventions to be provided
• Functional outcomes
• Expected therapy – number of hours per day, number of days per week, and total number of therapy days for the entire stay
• Discharge destination

Depending on the organizational structure of the IRF, the rehabilitation physician may personally devise the entire plan of care or synthesize the individual plans of care from different treating disciplines. The overall plan of care must be completed by the end of the 4th day after the IRF admission. Part of the synthesis model can be achieved by embedding the required plan of care information within each specialty’s initial evaluation. Once these initial evaluations are documented and signed by the respective disciplines, the data can then be used to populate the patient’s overall care plan for review, refinement, and signature approval by the rehabilitation physician.

Team Meetings

Interdisciplinary team meetings, led by the rehabilitation physician, are to be held at least once per week throughout the patient’s stay.

The primary purpose of the meeting is to assess patient progress since admission (or the last team meeting) and address any impediments. This meeting also provides an opportunity to reassess and/or revise any previously established treatment plan goals. All disciplines actively treating the patient are required to attend and provide report. The rehabilitation physician must then review, approve, and sign the team meeting notes for inclusion in the patient’s medical record.

Designing a single interdisciplinary electronic document to meet this complex need is a challenge. A single paper document can easily be passed around to the various participants for updates, review, and signature. However, many EMRs date and time stamp individual documents based on the login of the current user. Having each user individually login, document their findings, and provide an electronic signature is both time consuming and difficult logistically. The overall plan of care synthesis model mentioned previously contains many of the same components and can be re-used to meet several of the team meeting requirements. The team meeting document must additionally establish the participants for each discipline in attendance.

The Inpatient Rehabilitation Series continues here:

Part 1 – Inpatient Rehab Facility (IRF) – EMR Documentation Design Series Introduction

Part 2 – Pre-Admission Screen

Part 3 - Inpatient Rehabilitation Facility – Patient Assessment Instrument (IRF-PAI)

Part 7 – PT, OT, SLP, Orthotics/Prosthetics Documentation

Part 9 – The 3 Hour Rule

Inpatient Rehab Facility (IRF) – Part 5: Interdisciplinary Plan of Care & Team Meetings is a post from: Healthcare IT Squad

Why the iPad will not be used for Health Care IT

Jared Houck — Fri, 29 Jan 2010 15:49:13 +0000

With the much-hyped release of the iPad, Apple has their sights set on the Amazon Kindle’s market share; and I’m sure they will do well. However, some health care IT industry heavyweights have gone so far as to suggest that the iPad will be greatly utilized in the health care setting and revolutionize the way we do business.

While I do think the iPad is incredibly shiny and is great computer replacement for your grandma, I think it’s a bit of an exaggeration to suggest that it will ever be fully adopted by Healthcare IT shops. Here’s why:

1. It’s a Tablet.

We have this on-going love affair with the idea of the tablet based computer. We can imagine the freedom to roam about, simplified interaction, minimal commitment, and the pride of knowing that we have something no one else has. In practice, however, tablet computers have always been an awkward lot. Too big to put in your pocket, too small to see enough data on the screen, too heavy to carry around for very long, and too expensive to set down any where. I don’t want to even think about how much MRSA/ORSA could be cultured from the screens.

2. Windows OS.

Most Healthcare IT shops are PC based (or for you old schoolers – IBM compatible). The infrastructure to support a PC is already in place. Yes, there are MacBooks and iPhones scattered throughout the hospital staff, but 99% of the devices deployed in the facility are running a Windows-based OS. Not that Apple’s OS X isn’t a capable operating system, it absolutely is. Unfortunately, the iPad doesn’t harness the full* power of OS X; it actually runs a modified and backwards compatible version of the iPhone OS (a derivative of OS X stemming from Apple’s Darwin code*).

*corrections

3. iTunes.

I won’t tread too far into my personal loathing of this application. Let’s just say, it would be incredibly complex to support the software needs of an array of iPads related to their vampiric tethering to this application. Apple does provide business grade solutions for software deployment, but at some point, someone will plug this baby into their home computer to sync their music, and your hospital help desk will immediately place a large bounty on the head of the manager that approved this venture. Also, there are ~~very few~~ no CCHIT certified health care software products that offer interfaced iPhone/iPod Touch apps. And no Epic, Haiku doesn’t count yet.

4. Price.

For the 16GB, 32GB and 64GB Wi-Fi only models, you will shell out $499, $599, and $699. Or add $130 for Wi-Fi-plus-3G models and you’re looking at $629, $729, and $829; plus the $30/month 3G service fee from AT&T. Basically, you could buy 2-3 fairly capable PC-based netbooks for the price of 1 iPad.

5. Multitasking.

PCs have it. The iPad does not (at least until OS4).

6. Expansion ports.

There are no included USB ports of any sort. Instead, you have to purchase a $29 Camera Connection Kit that includes two dongles: one for USB and one for SD cards. The 30-pin docking connector used to sync and charge doesn’t officially count.

7. WiFi + AT&T 3G = still not connected.

Most hospitals have a pretty solid WiFi network. It’s too bad your IT security guys are reluctant to authenticate your device allowing you to connect to it. Considering AT&T’s nose-thumbing at actually improving their coverage, it is also likely that you won’t be able to connect to the web via your cellular connection within the walls of your facility anyway.

8. Safari web browser.

The web browser built into the iPad / iPhone OS is based on the Safari rendering engine. Many applications do not properly support the Safari browser as most healthcare software vendors still use Internet Explorer as the gold standard.

*Update – As of April 14th, you can download the Opera Mini web browser from the Apple App Store. Unfortunately, actually using Opera Mini to view medical records could be a teensy weensy HIPAA violation.

9. HP Slate – the idea (but really the bulletproof Lenovo version).

This little gem from Hewlett Packard could quite possibly be the game changer for tablet PC use in the healthcare setting. Windows OS (XP, Vista, or Win7), check. Deploy-able with current infrastructure, check. Price below <$600. Multitasking, check. USB expansion ports, check. WiFi, check. Hundreds of gigabytes of hard drive storage that I can directly access, check. Internet Explorer, yawn…but check. Touch screen, check.

10. Other silly bemoanings.

No wireless synchronization. No Adobe Flash support in the web browser, 4:3 screen aspect ratio, relative lack of storage space, kludgy copy and paste, projected 10 hour battery life (which really means 6-8 hours of use), and no on-board camera.

Is Lenovo down in the lab making a battle-ready version? Dear Lord, we hope so.

Why the iPad will not be used for Health Care IT is a post from: Healthcare IT Squad

Inpatient Rehab Facility (IRF) – Part 4: The Functional Independence Measure (FIM)

Jared Houck — Fri, 22 Jan 2010 11:18:06 +0000

Established in 2001 as the common instrument to assess rehabilitation patients9, the FIM tool consists of 18 functional assessments (13 motor and 5 cognitive). This non-discipline specific tool is used to objectively measure the type and amount of assistance required for a disabled person to perform basic life activities safely and effectively (i.e. their burden of care). FIM is a seven-level scale ranging from a score of 1 (complete dependence) to a score of 7 (complete independence). A score of zero can be used to indicate that the assessment or particular activity did not occur. CMS requires that the FIM tool is administered over the entire 24 hour period on each of the first three calendar days following the patient’s admission and over a single 24 hour period in one of the last three calendar days prior to discharge. The lowest, or most dependent, score for each of the 18 items is recorded on the IRF-PAI. Some facilities provide on-going FIM assessments to better meet the CMS requirement and to establish a more accurate view of patient progress across the entire length of stay. IRFs must maintain certification to use the FIM instrument. Prior to using the FIM tool, clinicians must pass a FIM mastery exam.

FIM Tool Design

CMS does provide guidelines for collecting FIM data. However, they do not provide a mandatory standardized template. Each facility has the flexibility to design a customized FIM documentation tool. The most basic and expedient FIM tool design allows the clinician to simply type in an appropriate score for each of the 18 items. This FIM model relies heavily on user training and advanced understanding of the FIM assessments. Some facilities use a decision tree structure to guide clinicians through a series of questions arriving at the appropriate score for each item. This approach, while a powerful teaching tool, significantly increases the amount of time needed to complete the assessment.

The Inpatient Rehabilitation Series continues here:

Part 1 – Inpatient Rehab Facility (IRF) – EMR Documentation Design Series Introduction

Part 2 – Pre-Admission Screen

Part 3 - Inpatient Rehabilitation Facility – Patient Assessment Instrument (IRF-PAI)

Part 5 – Interdisciplinary Documentation – Plan of Care & Team Meetings

Part 7 – PT, OT, SLP, Orthotics/Prosthetics Documentation

Part 9 – The 3 Hour Rule

Inpatient Rehab Facility (IRF) – Part 4: The Functional Independence Measure (FIM) is a post from: Healthcare IT Squad

Inpatient Rehab Facility (IRF) – Part 3: The Patient Assessment Instrument (IRF-PAI)

Jared Houck — Fri, 15 Jan 2010 11:15:01 +0000

Implemented in 2002, the IRF-PAI is a patient-specific set of clerical and clinical assessment data collected at both admission and discharge⁷. CMS regulations require completion of the IRF-PAI only for patients admitted to IRFs who are covered under Medicare Part A fee-for-service for the inpatient rehabilitation stay. While commercially available options do exist for the automated submission of the IRF-PAI, many IRFs hire PPS coordinators to thoroughly examine clinical documentation, provide variance education, and ensure compliance with CMS guidelines prior to submission. Uniform Data System for Medical Rehabilitation (UDSMR) offers several web-based and/or locally installed software IRF-PAI submission tools. The UDS-PRO software from UDSMR has an optional Health Level 7 (HL7) interface that allows direct porting of patient specific EMR data into the IRF-PAI. Upon completion of the IRF-PAI record, the patient data is automatically transmitted to the UDS-PRO system database and the necessary text file is created for submission to the CMS national assessment collection database. The UDSMR data warehouse contains IRF-PAI information from over 900 IRFs and is the most widely researched database of clinical rehabilitation data.

The Inpatient Rehabilitation Series continues here:

Part 1 – Inpatient Rehab Facility (IRF) – EMR Documentation Design Series Introduction

Part 2 – Pre-Admission Screen

Part 5 – Interdisciplinary Documentation – Plan of Care & Team Meetings

Part 7 – PT, OT, SLP, Orthotics/Prosthetics Documentation

Part 9 – The 3 Hour Rule

Inpatient Rehab Facility (IRF) – Part 3: The Patient Assessment Instrument (IRF-PAI) is a post from: Healthcare IT Squad

Inpatient Rehab Facility (IRF) – Part 2: The Pre-Admission Screen

Jared Houck — Fri, 08 Jan 2010 11:17:10 +0000

Conducted within the 48 hours immediately preceding IRF admission, the preadmission screen can only be performed by “a licensed or certified clinician (or group of clinicians).…A licensed or certified clinician is an individual who is appropriately trained and qualified to assess the patient’s medical and functional status, assess the risk for clinical and rehabilitation complications, and assess other aspects of the patient’s condition both medically and functionally.” The preadmission screening also serves as the initial determination of whether or not the patient’s admission to the IRF is considered reasonable and necessary by CMS. Registered Nurses (RNs) serving as IRF Intake Coordinators, often provide the initial screening to potential patients.

CMS Requirements

While CMS does not provide strict guidelines for the design of the preadmission screening document, they do require that the form specifically contain:

• Prior level of function
• Expected level of improvement and length of time to achieve that improvement
• Risk for clinical complications
• Conditions that caused the need for rehabilitation
• Combinations of treatments needed
• Expected frequency and duration of treatment in the IRF
• Anticipated discharge destination
• Any anticipated post-discharge treatments

CMS also requires that the preadmission screening contain some narrative information (i.e. cannot be made up entirely of checkboxes or drop-down lists). If an IRF receives a high percentage of patients from its own acute inpatient hospital population, the rehabilitation therapies should engage the acute inpatient therapies (e.g. OT, PT, and SLP) to establish standardized assessment and documentation methods. This standardization can improve IRF pre-admission screening and the continuum of patient care, but may impose CMS documentation requirements on acute inpatient therapies.

The Inpatient Rehabilitation Series continues here:

Part 1 – Inpatient Rehab Facility (IRF) – EMR Documentation Design Series Introduction

Part 3 - Inpatient Rehabilitation Facility – Patient Assessment Instrument (IRF-PAI)

Part 5 – Interdisciplinary Documentation – Plan of Care & Team Meetings

Part 7 – PT, OT, SLP, Orthotics/Prosthetics Documentation

Part 9 – The 3 Hour Rule

Inpatient Rehab Facility (IRF) – Part 2: The Pre-Admission Screen is a post from: Healthcare IT Squad

Inpatient Rehab Facility (IRF) – EMR Documentation Design Series

Jared Houck — Fri, 01 Jan 2010 10:59:16 +0000

Beyond the inherent hurdles of change management and adopting electronic medical records (EMRs), Inpatient Rehabilitation Facilities (IRFs) also have many unique documentation needs. Although stand alone rehabilitation-specific electronic documentation systems are available, their overall cost and lack of integration capabilities make many products poor candidates for inpatient health care facilities with an existing EMR. Many IRFs must leverage the flexibility of their specific EMR to meet their documentation needs.

In this series, we’ll discuss some of the strict IRF regulatory guidelines set by Centers for Medicare and Medicaid Services (CMS) and ways to leverage the flexibility of an existing EMR to effectually address these challenges.

History

Medicare was created by the Social Security Act of 1965. This law established payments to hospitals for the reasonable costs incurred in the provision of care to Medicare beneficiaries. The Social Security Amendments in 1983 established a prospective payment system (PPS) to reimburse the costs of Medicare inpatient hospital stays based on the patient’s diagnosis or DRG. To account for diagnoses that resulted in extended or more costly lengths of stay, a small number of specific care facilities were exempted from the DRG requirement including children’s hospitals, psychiatric facilities, long term care facilities, and rehabilitation facilities.

IRF Admissions

Rehabilitation facilities that meet strict CMS requirements can earn the IRF designation, maintain their Diagnosis Related Group (DRG) exemption, and receive higher reimbursement for services provided under the Inpatient Rehabilitation Facility – Prospective Payment System (IRF-PPS). At least 60% of patients admitted into the IRF must have one of the following as a primary or secondary diagnosis that would benefit from IRF care:

active polyarticular rheumatoid arthritis
amputation
brain injury
burns
congenital deformity
femur fracture (hip fracture)
hip or knee replacement
major multiple trauma
neurologic disorders
osteoarthritis or degenerative joint disease
spinal cord injury
stroke
systemic vasculidities with joint inflammation

CMS also requires that the patient be: (a) medically stable, (b) require the services of at least two acute rehabilitative therapies – physical, occupational, or speech, (c) able to tolerate at least three hours of intensive rehabilitative therapies per 24 hour period for at least five days per week, and (d) able to make measurable improvement to the patient’s functional capacity or adaption to impairments.

The Inpatient Rehabilitation Series continues here:

Part 2 – Pre-Admission Screen

Part 3 - Inpatient Rehabilitation Facility – Patient Assessment Instrument (IRF-PAI)

Part 5 – Interdisciplinary Documentation – Plan of Care & Team Meetings

Part 7 – PT, OT, SLP, Orthotics/Prosthetics Documentation