The Road to PPS Success
Standardized orders, new therapy hours mean profit
PPS pushes rehab unit toward greater efficiency
Rehab staff members at St. Francis Hospital in Greenville, SC, haven’t looked at the inpatient prospective payment system (PPS) as an onerous task. Instead, they’ve treated PPS as an opportunity to become more efficient, productive, and profitable.
Since the 19-bed Inpatient Rehabilitation Center began receiving reimbursement under PPS in September, length of stay is down and profits are up, says Bill Munley, MHSA, CRA, administrator of the rehab/neuro/ortho service line at St. Francis. "The patients are very, very happy. We’ve reduced our length of stay by a day, and their outcomes are the same or better," he says.
Part of the reason patients are happy is that St. Francis now offers physical and occupational therapy seven days a week, which gets patients home faster and prevents backsliding from the progress they’ve made in therapy during the week. "A heavy dose of therapy leads to gains in a shorter period of time so patients can move on," Munley says.
And it helps the hospital’s bottom line as well. Munley credits the new therapy schedule for decreasing average length of stay from 10 days in 2001 to nine days in the third and fourth quarters of 2002. Previously, the unit offered only a half-day of therapy on Saturdays and limited therapy on Sundays. The change in the therapy schedule has such an impact on the St. Francis unit because the case mix averages about 70% orthopedic patients, Munley says.
Joe Golob, PT, director of the St. Francis Inpatient Rehabilitation Center, is quick to point out that the hospital isn’t pushing patients out with the extended therapy schedule and that patients aren’t necessarily getting more, or fewer, overall hours of therapy. It’s just that the new schedule allows therapists to be more productive and to distribute their hours in a way that better meets each patient’s needs. "We think it helps to keep up the momentum through the weekend. Some patients felt like they were taking a step back on the weekend," Golob says. "We did not increase staff to add to the weekend therapy time. We just readjusted our schedules so someone is off during the week. And everybody works smarter and more efficiently with less nonproductive therapist time."
St. Francis also boosted productivity with the help of the hospital’s nutrition services department via a relatively simple change in daily schedules. "Lunch used to be delivered to our unit at 11:30, and patients would complain if they didn’t get back to their food before it got cold," Golob says. "That lunch time seemed to hurry things in therapy, so we worked with nutrition services to change it. Now lunch is delivered at noon, and therapy starts again at 1 p.m. That allows the patients a short rest period after lunch."
Implementing PPS spurred the unit to increase communication among physicians, nurses, and therapists about each patient. "We now have more informal conferencing about patients and more frequent communication with physicians," Golob says. "We have formal conferences weekly, but we tell staff that if circumstances change, they shouldn’t wait until next week to bring up that issue."
Because of the nature of the IRF-PAI documentation required for PPS, Golob works to be sure he’s getting input from each member of the clinical team. Staff members have attended numerous educational sessions and meetings to understand the importance of documentation under the new system. "Nurses weren’t so used to documenting on functional activities in the past," he says. "We’ve worked to make everybody aware of all the information we need to complete the assessment, because proper reimbursement is dependent on it. For the IRF-PAI, there is a three-day assessment period, during which time we are to determine the patient’s most dependent level of care for each function. We need the entire team’s input in order to make that determination."
Each team member is responsible for documentation in the charts, but two staff members have been specifically trained in completing the IRF-PAI. "We don’t have eight different people filling out this form. One person does it, but it’s based on the documentation from all the disciplines," Golob says. "CMS [the Centers for Medicare & Medicaid Services] said from the beginning that this assessment has to be justified by the documentation. So that’s our standard. Everything can be backed up in the chart. We have even preprinted references to the various functions on the nurse’s progress sheet, so they will remember to record a score when they observe the patient perform that function."
Education improves teamwork
The educational process has helped staff realize that time really is money, Golob says. "Our goal is to get our patients to the next level of care in a safe way," he says. "We have patient care as our highest priority, but we’re also emphasizing improved efficiencies within that framework. We stress things like moving patients in a timely manner from acute care to our unit. We also try to leave expectations open-ended for how long the patient will be here. Sometimes the patient isn’t suited for our intensity of care and maybe needs to go to a skilled nursing facility instead. This takes some education for the referring physicians as well."
Another change the unit has made to keep an eye on costs and to enhance patient care is to employ standardized orders. Physicians formed a more structured division of physical medicine and rehab to work on this issue. "We strengthened our ties with all the physiatrists on our medical staff and named a chairman of the division to get things going," he says. "It was a group decision by the physicians to look at the effects of their orders on cost. By all means we want what’s best for the patients, but we also want to get our best bang for the buck."
The physician group came up with standardized, preprinted orders that include what the majority of physicians do for every patient. The orders help control pharmacy and lab costs and keep physicians aware of cost issues on a daily basis, Munley says. "To make sure they’re not ordering every PRN medicine in the world, they felt they should standardize the things they do with every patient. That way they’re not just saying to continue with the meds from the patient’s acute care stay. If they want to give the patient something different, the physician has to write it in, and that forces an assessment of what each individual patient truly needs."
(Editor’s note: January marked a year since the first inpatient rehab facilities began to be reimbursed under the prospective payment system. 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 at [email protected].)
Need More Information?- Bill Munley, Administrator of the Rehab/Neuro/ Ortho Service Line, St. Francis Hospital, One St. Francis Drive, Greenville, SC 29601. Telephone: (864) 255-1871.
- Joe Golob, Director of the Inpatient Rehabilitation Center, St. Francis Hospital, One St. Francis Drive, Greenville, SC 29601. Telephone: (864) 255-1953.
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