The Road to PPS Success
Rehab hospital takes team approach to PPS
Emphasis on staff education, feedback
[Editor’s note: January marked a year since the first inpatient rehab facilities began to be reimbursed under the prospective payment system (PPS). Rehab Continuum Report will take an ongoing look at the challenges and successes of implementing PPS. If you know of a facility that has done a particularly good job in this area, please let us know for possible inclusion in the series. Contact Editor Ellen Dockham by e-mail ([email protected])].
When PPS took effect last year, many rehab facilities jumped on the skilled nursing facility bandwagon by naming a PPS coordinator to take charge of the necessary documentation. But Madonna Rehabilitation Hospital in Lincoln, NE, bucked that trend and developed a model for PPS success that relies on a team effort.
"We did not go in the direction of having one PPS coordinator," says Paul Dongilli, PhD, vice president of rehabilitation at Madonna. "We did not want to centralize that to one person; we wanted a variety of staff to share the responsibility. We’ve implemented a structure here that we call the Madonna model’ where we’ve formed a triad with the physician, the case manager, and the nurse therapist."
Each member of the team works to collect the information needed for the inpatient rehabilitation facilities patient assessment instrument (IRF-PAI). The case manager on each team, who is usually a social worker, puts all that information together, synthesizes it, and reports the final scores through the IRF-PAI and the software.
"What’s unique to us is the whole notion of the case manager having such a strong working relationship with the primary nurse and the same physician," Dongilli says. "We spent a lot of time and energy educating our staff so they were very knowledgeable and could provide the input we needed to complete that document. We thought this would provide us the most flexibility and would result in more than just getting the IRF-PAI done — it would result in good care."
Madonna looked at PPS as more than an onerous new system to learn; the hospital treated it as an opportunity to improve patient care, increase efficiency, and promote better communication among staff members. Looking at the results from the first quarter (July to September 2002) after going on-line with PPS, Madonna appears to be meeting those goals. The hospital’s goal for discharging patients to a non-institutional setting is about 80%, and the first quarter rate came in at 79%. Last year in the same quarter, the rate was 75%. Madonna is also keeping a close eye on patient satisfaction rates at 72 hours after discharge and three months after discharge. The scores have remained high since the new system was put into place. "Our new system seems to be effective," Dongilli says. "We’re getting people home and we’re keeping them happy."
As for the big question — how PPS has affected the hospital’s finances — Dongilli was not able to share specific numbers but says Madonna has been able to meet its budget expectations for the financial performance of the program. "There are challenges to the new system, but it has been manageable," he says.
It’s harder to quantify Madonna’s main goal for the new PPS model — improved staff communication leading to better patient care — but Dongilli says by all accounts the system seems to be working. "We had portions of this team model in place, but we strengthened it in response to PPS requirements and the quick time lines for turnaround of data," he says. "We knew it had to be like a finely oiled machine, that we had to make this happen and we had to decrease the inefficiencies of communication."
One change the hospital made was to house the nurse and the case manager for each team in the same office. They round with the physician each morning, and the team meets daily to share scores and information on their patients. "We wanted to increase the amount of time the team members are interacting so they can bring up issues," Dongilli says.
Another important element of the hospital’s PPS effort is staff education. The hospital spent six months getting staff members up to speed on PPS so they would understand not only the IRF-PAI system but also the impact on the industry as a whole. "The education wasn’t a one-shot deal; it was repetitive," Dongilli says. "We met in large groups and also in smaller groups with supervisors. We did sample testing and made sure the staff had information related to their respective roles and to the whole coordination of care. Now they have information that is more globally focused."
Much of the education time was spent on guidelines for scoring and how the scores tie back to the case mix group. Dongilli, who also is a surveyor for the Tucson, AZ-based Commission on Accreditation of Rehabilitation Facilities, says the problem with having one PPS coordinator is that the staff members who are providing the functional independence measure (FIM) scores are two steps removed. "Without this team effort, people tend to have only a vague notion of how the FIM score goes into the IRF-PAI. If someone else is responsible for PPS, the other staff members don’t really understand how the IRF-PAI drives the determination of payment."
Staff members take ownership of FIM score
Madonna’s education effort addresses that issue by making sure staff members take ownership of the FIM score. "It’s not just that they are giving a score, but that they are making decisions that drive our reimbursement," Dongilli says. "Now they know that what they are doing is going to impact how we are paid and that it needs to be accurate and timely. They know they can have a huge impact on the resources available to meet the needs of our patients."
The hospital also includes coding staff in its PPS education. "We have concurrent coding by our medical records staff to make sure we’re capturing information accurately," Dongilli says. "We analyzed our patient population to see what are the top comorbidities we’ve seen in the last two years and shared that information with the whole group. Now they have a common framework to be on alert that our patients typically have this profile."
To make sure the PPS model accomplishes its purpose, the hospital has tied documentation to staff performance appraisals. The monitoring effort also is funneled to the corporate compliance committee so the hospital can keep an eye on accuracy. "As part of each performance appraisal, we’re looking at each clinical area and looking at FIM scores to make sure there is documentation in the medical record to support the scoring," Dongilli says. "If there are problems, we go right back to the therapist or the nurse and let them know. Then we provide more education to ensure accuracy."
PPS has required a big shift in mindset for rehab professionals, says Kathy Kuehn, LCSW, a case manager who has worked at Madonna for 22 years. "In the past, we tended to want to show patients at their best, but now we really need to document what their worst performance is," she says. "We have to make sure the FIM score isn’t arbitrary and that we are supporting in the medical record the reason the patient got that score. PPS has forced us to be more efficient."
PPS also has forced clinicians to become more aware of the financial ramifications of their decisions, Kuehn says. "Clinical people were somewhat sheltered from the financial aspects of patient care. But now they have a much greater appreciation for fiscal realities," she says. "We’ve always worked to make sure patients are getting appropriate levels of service, but now we have to be even more conscious of things like noting comorbidities, rescheduling therapies, and not making decisions based on patients’ social concerns. If they’re done on Friday, they can’t wait until Saturday to leave the hospital just because it’s better for their family."
Kuehn says Madonna’s PPS model has led to stronger relationships among physicians, nurses, and case managers. "The proximity of being in the same office really helps with team collaboration. It’s very effective," she says.
When PPS took effect last year, many rehab facilities jumped on the skilled nursing facility bandwagon by naming a PPS coordinator to take charge of the necessary documentation. But Madonna Rehabilitation Hospital in Lincoln, NE, bucked that trend and developed a model for PPS success that relies on a team effort.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content