Special Report: Focusing on Performance

Rehab provider uses data to improve it PPS system

Educating staff on FIM was major focus

JFK Johnson Rehabilitation Institute of Edison, NJ, has spent the last several years improving its data collection and staff education to improve its prospective payment system (PPS) process. "In this facility, we receive data on a daily basis, and it’s all computerized, and it’s on an Internet-based program so it gets updated every day," says Christa Reineke, MA, PT, director of inpatient therapies. "So every day, I can go in and look at our data as of yesterday," she says.

This ability to see data quickly has been important to the rehab facility’s ability to improve its operational processes. Having real-time data helped Reineke identify areas in which the facility was not performing as well as regional and national benchmarks. "When I looked into it, it led me to identify some procedural processes at the facility that weren’t quite the way we needed them to be," Reineke says.

Other organizational process improvements implemented by the rehab facility include the following:

• Educate and train staff members to improve assessments.

"We started an education process for staff, based on FIM [functional improvement measures] scoring, and we saw a significant jump in that indicator," she explains. "We went from taking a discipline-specific scoring approach to scoring across the first three days of stay," Reineke adds. "We took the lowest scores from all disciplines and saw a big change in our case-mix index."

Staff were taught that the FIM scores should measure the burden of care to the caregiver, which may be more of the middle of the night score than how the patient did in the therapy gym, she says. "Prior to PPS, FIM scores didn’t impact payment so it was just an outcomes data management system, and it was something we did as a facility because we wanted to look at our outcome and see how efficient we were," Reineke explains.

"But now it’s the basis for our payments, so it became really important very quickly to make sure we were scoring patients correctly and recording the lowest score because that impacts which case-mix group the patient is put into." So the staff training focused on two main issues: the overall review of FIM scoring because that scale was changed a little, and the process of taking the lowest number per discipline per item, she notes. "We said that we’d have all disciplines record the FIM score over three days, and we’d take the lowest number to be the official FIM score," Reineke says.

The rehab facility’s case-mix index had been lower than the regional and national data, and since this is a reflection of payment, the trend was a problem, she says. Since the education program was implemented, the case-mix index improved and the change has been sustained, Reineke says.

• Show physicians how to improve their documentation.

Another potential problem area involves the inclusion of comorbid conditions, she notes. "When they put PPS in place, your payment was based on which case-mix group [CMG] you were in," Reineke says. Payment also was based on a patient’s comorbid conditions, which are documented by physicians. For example, a patient who has had a stroke could also be on dialysis, which would be a comorbid condition that complicates treatment and care in a rehab facility, she says. "Our numbers weren’t matching up with the region or nation, and yet I kept hearing from staff that we have a higher patient acuity, that our patients are very sick," Reineke says.

It made sense that the rehab facility would have a high patient acuity since it was attached to a medical acute care facility, but the numbers didn’t support this observation, so it appeared that there might be a problem with documentation of comorbid conditions, she says. "We went to physicians and said, Here are all the comorbid conditions that can qualify us to go into one of those other [payment] tiers, and it’s just a matter of physicians documenting it,’" Reineke recalls. "We weren’t asking them to document something that wasn’t there, but if a patient has a diabetic neuropathy and we’re treating it, then we should code it as a comorbid condition and receive additional revenue from Medicare," she adds.

The list of comorbid conditions was presented at a physician staff meeting, and doctors were told that if their patients had any of these conditions and the rehab facility was treating them, then the doctors needed to document them in the history and physical, she says. "We also worked with a coder who worked with physicians, and she’d say, Dr. So and So, I see that you’ve ordered a consult for diabetes, so does this patient have diabetic neuropathy?’" Reineke explains. "And if the doctor said, Yes,’ then the coder would ask him to document that."

Soon after this physician education program was implemented, there were positive results confirming the staff’s observation of greater acuity, she says.

• Follow up on any problematic trends immediately.

The inpatient management team puts together a tool with data that is reviewed every two weeks for trends that might need a change. For example, if rehab managers saw that discharges to home were suddenly decreasing, then they would quickly look into the trend to see why it was happening, Reineke adds. "We’d see where patients were going and whether there was a problem or anything we could do to turn that trend around," she says. "In the past, the data wasn’t available in as timely a fashion — we’d sometimes get it three or four months later, and you couldn’t make those changes because the time had gone by," Reineke notes.

"We’ve updated our tool and added in things that we consider important, such as a 75% compliance tool," she says. "So we use the tool to help our management team keep on top of all indicators that are important to us."