Rehabilitation Outcome Reviews-It's time to start reorganizing
Rehabilitation Outcome Reviews-It's time to start reorganizing therapy department for PPS
By Doris B. Reinhart, Principal
Chesapeake Consulting Inc.
Alexandria, VA
When it comes to the prospective payment system (PPS), the old scouting motto applies: Be prepared. With a little research into your own therapy organization, some staff education, and a few changes, you could put your facility in a strategic position when PPS is implemented.
Until the Health Care Financing and Adminis tra tion (HCFA) publishes the proposed regulations for rehabilitation PPS, much of your preparation will be based on the general facts that we do know. For instance, the Balanced Budget Act of 1997 mandated that the PPS be developed and implemented for acute rehabilitation facilities by October 2000. HCFA has determined that the PPS for acute rehabilitation will be an episodic payment structure based on the Functional Related Groups (FRG). There will be a two-year transition period. (For PPS time frame, see chart, p. 143.)
PPS Guide to Government Deadlines | ||||
The Balanced Budget Act of 1997 established deadlines and provisions for implementing the prospective payment system (PPS) for rehab facilities.The Health Care Financing Administration has outlined these features of rehab PPS: | ||||
Type of health care service | BBA # provision | Provision | Statutory effective date | Status of change |
Inpatient rehab | BBA 1460 | Inpatient rehab PPS | Oct. 1, 2000 | Regulation will be developed in 1999 |
Outpatient therapy | BBA 1870 | Application of standards to outpatient OT and PT services in physician offices | Jan. 1, 1998 | Manual changes issued May 1998 |
Outpatient therapy | BBA 1880 | Payment based on fee schedule | Jan. 1, 1999 | In HCFA-1006-F published 11/2/98 |
Outpatient therapy | BBA 1890 | Application of $1,500 annual limit to rehab services | Jan. 1, 1999 | In HCFA-1006-F published 11/2/98 |
Outpatient therapy | BBA 1895 | Report on revised coverage policy | Jan. 1, 2001 | Will start report after fee schedule done |
The decision to use an episodic payment structure makes the change a little less traumatic because the current reimbursement system, the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) is basically a per discharge payment. The major change is that instead of one payment for all patients regardless of services needed as with TEFRA, the new system will have several payment tiers based on the patients' functional levels and care needs within the classification system. It will be imperative to know costs for each FRG. These data are not easily available to facilities, and it will take some time for most facilities to organize and review the data. (For guide to payment provisions under the Balanced Budget Act, see p. 144.)
However, October 2000 is less than one year away, and proactive therapy services are beginning preparations now. These services are beginning to review tasks, procedures, and processes that affect all patients regardless of diagnosis or FRG to determine where efficiencies can be gained, which costs can be reduced, and how to still deliver high quality care.
To get started and stay focused, form a PPS preparation team. Some people will hear the term "PPS preparation team" and think, "Oh no — not another committee! Nothing will ever get done." Yet, this is important because by formalizing the preparation process, you will help ensure a systematic and organized approach to identifying problems and implementing solutions.
The team should include a broad representation of therapists, management, and finance. If the department is small enough, all therapists can participate.
First step: Educate staff about PPS
The first step for the team is to ensure that everyone is fully informed about the Balanced Budget Act of 1997 and the impending implementation of PPS. The staff have heard and read about the impending reimbursement changes, but the information is sketchy and often incomplete. Informing them about the impact of the changes and the need to plan for the changes and involving them in the process will help achieve their buy-in for any changes that need to be made. The staff need to know and see that the focus remains on the patient. The goal is to find ways to deliver the best care to the patient given the resources, including time, staff, and money that are available.
Initially, the PPS team should focus on identifying tasks, procedures, and processes that affect all patients regardless of diagnosis or FRG. Each facility will have unique procedures or practices that have evolved over the years but have not been challenged. When asked why they exist, the response is "because we have always done it this way." Preparing for PPS gives therapy services the perfect opportunity to review those procedures. To stay organized and avoid coming up with a hodgepodge of items, knee-jerk reactions and random problem solving, structure the review as if you were following a patient through each stage of the episode of care: pre-admission, admission, evaluation, treatment, and discharge. For each stage of the episode of care, ask these questions:
o Are there tasks, procedures, and processes involved in this stage that take time but do not add value to the patient, pull the therapists away from patient care, or interfere with the care delivery process?
o Are there less costly ways to deliver care or perform tasks in this stage and still achieve the same patient goals?
For example, is the evaluation process often delayed because the physician has not written orders? Are there ways to have all patients evaluated on the same day as admission so treatment can start the next day? Is treatment sometimes delayed or extended because patient equipment has not been delivered? Is there a way to speed up and/or streamline the ordering process? Also in the treatment stage, are we using groups, dovetailing techniques, and including therapy extenders to maximize the amount of therapy a patient receives?
As the team identifies areas for change, the team should take these steps before implementing the changes:
o If the therapy departments are part of a larger organization, any change will have "ripple effects" within the facility. Determine all parties who would be affected by the change and ask for their input.
o Develop a plan that details what the change is, how it is to be implemented, by whom, when it will start, and what the criteria are for success.
o If education is necessary, such as a new or revised procedure or introducing a new or revised form, complete the educational process before instituting the change.
o Identify one or more people to answer questions and/or troubleshoot during implementation. These typically are team members.
o Monitor progress of the change and solicit feedback from the parties affected.
o Modify the change, if necessary, based on success criteria and feedback.
Regardless of what changes are decided, pilot the change first, make adjustments as necessary, then incorporate into the permanent routine.
Case studies show efficiency planning
Here are some examples of facilities that made efficiency changes in preparation for PPS:
o Mountainland Rehabilitation, Salt Lake City: The facility calls its review process an "efficiency safari," says Melissa Gus-Hoffelmeyer, corporate director of clinical services. The goal is to identify procedures and/or processes that when modified will reduce nondirect care time and increase the amount of time available for direct patient care.
Mountainland identified that the amount of time spent in family conferences and team meetings was more than needed to accomplish the goals. A goal was set that family conferences last 15 minutes, with an outside maximum of 20 minutes. As a result, the conferences became more focused, goal-oriented, and concise, and the goals of the conference could be accomplished within the allotted time. Also, patient, family, and team member satisfaction increased.
Likewise, patient team meetings were pulling therapists away from treatment for long periods of time. It was decided that only one therapist, usually the lead therapist for the patient, would attend the patient's team meeting and represent all therapies involved. Once again, the meetings became more focused, goal-oriented, and concise. This shortened the team meetings and increased the amount of direct care time for each therapist. (For story on how Mountainland prepares staff for PPS, see p. 145.)
o The National Rehabilitation Hospital, Wash ington, DC: For more than a year, the hospital targeted therapy services in order to find ways to streamline their operations and reduce overall costs, says Cathy Ellis, director of inpatient physical therapy, occupational therapy, thera peutic recreation, and vocational therapy. The team recognized that the evaluation process could be streamlined. Each service was "doing its own thing." Several people were collecting the same information, and therapists were spending more time than necessary on the evaluation process. Also, patients were becoming annoyed with answering the same questions several times.
By working together, the clinical team designed a multidisciplinary evaluation packet. Common information is collected only once and is available for everyone to review. Each therapist focuses evaluation on the problem areas specific to his or her service. This has reduced the amount of time needed to complete an evaluation for each therapist and has helped focus the evaluations on the functional needs of the patient.
Another implemented change, Ellis says, was to evaluate all patients on the day of admission. This presented a challenge because the majority arrived after 2 p.m. Each therapist is assigned a day on which they are responsible for evaluating all new admissions. The therapists adjust their hours and treatments accordingly. The result has been that the majority of the patients begin therapy within 24 hours of admission, one to two days sooner than previously. A side benefit has been an increase in referring physician satisfaction because patients receive treatment sooner.
Even though we may not have all the cost information we need about specific groups of patients at this time, we still found opportunities to increase efficiency and reduce costs in areas that affect all patients regardless of diagnosis or FRG.
While preparing for the implementation PPS can be stress inducing and frightening, it gives facilities the opportunity to look at these issues:
• How is care being delivered currently?
• What processes are involved?
• How much does it cost per patient group?
• What changes can be made to positively affect the care delivery?
As the facilities are able to identify costs and revenues by patient group, the planning focus will shift to the specific care delivery for each group. Remember the goal of this process is not only to be organized to operate under PPS but to find ways to deliver the best care to the patient given the resources available. By starting the preparation process now, therapy departments will be well positioned and organized to do both. With only 11 months left, it is not too soon to start.
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