Discharging to rehab facilities just got harder

New rules mean more communication earlier

A new rule from the Centers for Medicare & Medicaid Services (CMS) makes it imperative that case managers and/or discharge planners be familiar with new coverage requirements for inpatient rehabilitation facilities and that they begin discharge planning earlier with inpatient stay, says Jackie Birmingham, RN, MSN, MS, vice president of regulatory monitoring and clinical leadership at Curaspan Health Group.

The rule, CMS-1538-F, sets out requirements for preadmission screening of potential patients who are candidates for inpatient rehabilitation and requires the receiving facility to document that a patient is eligible for, willing to actively participate in, and is likely to benefit from intensive rehabilitation services.

Under the new inpatient rehabilitation facility coverage requirements, a licensed or certified clinician from the inpatient rehabilitation facility staff must conduct a comprehensive pre-admission screening to identify patients who are eligible for acute inpatient rehabilitation within 48 hours of admission to the rehabilitation facility.

The rule, which took effect Jan. 1, governs admission requirements for only inpatient rehabilitation facilities, either free-standing facilities or inpatient rehab units in acute care hospitals.

Impact 'wide-ranging'

"The impact of the new rule will be wide-ranging and will make it more difficult for hospitals to place patients in an inpatient rehabilitation facility, and will increase hospital length of stay as well as placements to nonacute care settings. Discharge planners will need to work more closely with the clinical staff at inpatient rehab facilities to determine if a patient may be eligible for an inpatient rehab referral earlier in the hospital stay," Birmingham says.

Inpatient rehabilitation facilities and rehabilitation units in acute care hospitals are paid under the Inpatient Rehabilitation Facility Prospective Payment System. The payment rates are higher than those paid for services in other settings, such as skilled nursing facilities or in the home health setting, because the patients have more severe and more complex medical conditions that need intensive and coordinated rehabilitation services, she says.

Under the CMS coverage criteria, patients who are eligible for admission to an inpatient rehabilitation facility must need an intensive level of therapy from multiple disciplines and at least one must be physical therapy or occupational therapy. Other disciplines include speech pathology and orthotics/prosthetics. They must be able to participate in three hours of therapy five days a week.

Patients who can't participate in or can't benefit from an intensive rehabilitation therapy program do not qualify for treatment in an inpatient rehabilitation facility.

This means that discharge planners must be knowledgeable about all the possible discharge levels of care and patient eligibility for each in order to choose the right discharge destination, Birmingham says.

"Knowing the difference between sending a patient who needs rehab to a skilled nursing facility or an inpatient rehab facility, referring patients for outpatient rehab or rehab at home, or keeping them in the hospital for rehab just got more important," Birmingham says.

More data on patients needed

Under the new procedures set out by CMS, the preadmission screener will need more information on the patient than in the past in order to decide if the patient meets inpatient rehabilitation criteria, she adds.

Information includes a review of the patient's level of function before admission to the acute care hospital, expected level of improvement, estimated length of stay, risk for complications, the specific condition that necessitates a stay in an inpatient rehabilitation facility, and the patient's anticipated discharge destination after rehab.

"In other words, the discharge plan from the inpatient rehabilitation facility will have to be set up before the facility admits the patient. That's right — the rehab facility will have to plan a potential patient's discharge before admitting him or her," she says.

The rule means that hospital case managers and/or discharge planners will have to communicate more extensively with the staff at the inpatient rehab facility, she adds.

If the inpatient rehab facility has an on-site liaison, the communications piece will be easier, but many don't have staff on site at hospitals, Birmingham points out.

This means that hospitals must have technology in place to facilitate streamlined exchange of patient records to meet the timetable for discharging the patient and keep the length of stay as short as possible, she adds.

"Conveying information over the telephone is no longer enough, and information must be complete. The preadmission screening by the inpatient rehabilitation facility staff must be done by a review of clinical records sent to the rehab facility no more than 48 hours before a patient's anticipated discharge. Any missing clinical note can hold up the acceptance of the patient and may even close the 48-hour window, forcing the process and the clock to restart," she says.

Being able to use health care information technology can help discharge planners and case managers work with the new rule, she says.

"With the 48-hour clock running, the secure, automated transmission of clinical records will make communication easier," she says.

Facilities without discharge planning services 24-7, including holidays, are likely to have to keep patients longer because they won't be able to work within the 48-hour window on weekends and holidays, she adds.

"With greater scrutiny of the admissions process, fewer, but more appropriate, patients will be transferred to inpatient rehabilitation facilities, causing a backup elsewhere," Birmingham predicts.

Patients who previously would have been sent to an inpatient rehabilitation facility are going to be transferred to other settings for rehabilitation, including skilled nursing facilities, outpatient rehab clinics, and home with rehabilitation services, she adds.

Patients may be staying longer

"With the shortage of physical therapists, these post-acute providers will be stretched to accommodate more patients, making it necessary for hospitals to keep patients longer in order to set up an appropriate plan for post-acute care. And, without good planning, hospitals may be keeping patients when they no longer meet inpatient criteria," says Birmingham.

She recommends that hospitals redesign their clinical work flow and adapt technology to identify early on patients who could benefit from a transfer to an inpatient rehab facility and develop alternative plans for those who may not meet inpatient rehabilitation facility admission criteria.

"If hospitals set up a process that starts early in the stay to rule out patients who won't be eligible for an inpatient rehabilitation stay, they can involve the patients and families and facilitate transitions to other levels of care," she says.

(For more information, contact: Jackie Birmingham, RN, MS, CMAC, Vice President of Professional Services, Curaspan Health Group, e-mail: jbirmingham@curaspan.com.)