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

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 4 – Functional Independence Measure (FIM)

Part 6 – Physician & Nursing Documentation

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

Part 8 – Other Services Documentation

Part 9 – The 3 Hour Rule