Want to see your TBI program thrive? Follow this SC rehab hospital’s lead
SC program’s census rises from 14 to 16 filled beds since 1996
If you’re considering starting a traumatic brain injury (TBI) program, or if your current program has been declining financially in recent years, you need to know how a South Carolina rehabilitation hospital successfully launched and maintained its profitable TBI program.
Greenville, SC-based Roger C. Peace Rehabilitation Hospital’s traumatic brain injury program has grown from a staff of six in 1988 to 30 employees today, serving a population that includes some of the poorest people in one of the nation’s poorest states, and it’s still managed to make a tidy profit.
In the past three years, the program has grown from an average of 14 inpatient beds to almost 16 out of a maximum of 18 beds. The TBI program has been profitable and consistently meets its budget, even while serving a patient population that consists of 10% to 20% Medicaid reimbursement, says Sheldon Herring, PhD, program director of the traumatic brain injury program for Roger C. Peace (RCP), which is part of the Greenville Hospital System in northwestern South Carolina.
"South Carolina’s Medicaid program has minimal reimbursement for rehabilitation, and we’re one of the leading providers of brain injury rehab services to the underfunded, so our profit margin has not come at the expense of denying admission to nonreimbursing cases," Herring explains.
"Also, we’ve been able to provide good outcomes and still be a very viable, financially stable program that is going on at least five years of strong financial performance," he adds.
How has the program pulled this rabbit out of its hat? Herring describes the program’s basic building blocks this way:
1. Sell brain injury services everywhere.
When Roger C. Peace, which has 53 beds, decided to add a TBI program in the late 1980s, it was an unusual concept for the textile region in the northwestern part of the mostly rural state. Until the 1990s, textiles were the region’s biggest employers, and health care benefits were less generous than they were in more unionized Northern industries. Also, because South Carolina is one of the states that does not require auto insurers to insure the health costs of drivers who are at fault in an accident, drivers suffering brain injuries receive rehab services only to the extent their health insurer will provide coverage or they can pay out of pocket.
Nonetheless, South Carolina has a high accident rate, which sometimes is attributed to the lack of systemized driver’s training and the early legal driving age of 15. Also, Greenville County began to grow very rapidly in the 1980s, a trend that has escalated since BMW opened a major auto plant in the area in the early 1990s. So the region served by the hospital system has had a great need for TBI services.
Herring started the program with a single treatment team of an occupational therapist (OT), a physical therapist (PT), a speech therapist (ST), a neuropsychologist, and a case manager. The program shared nursing staff with the rehab center.
From day one, Herring advocated TBI services locally and statewide, speaking with school officials, state rehabilitation and disability directors, and other groups that hold the purse strings.
"We’ve been advocating for our patients, and at the same time we’ve been providing services to these folks," Herring says. "I’ve done so many dog and pony shows it’s not funny."
When a state agency called Herring in those early years and asked him to conduct a one-day workshop, he’d show up at no charge. "I’ve provided inservices for thousands of state employees over the past 12 years," he adds. Herring also served on various state committees and task forces formed by the state’s Department of Education, the governor’s office, and the Department of Disabilities and Special Needs.
Also, by using a resource center developed through a state Developmental Disabilities Council grant, the TBI program shares brain injury training information with local schools and state agencies. "We developed a whole set of curriculum for professional training in areas of brain injury, and we’ve used it in workshops for staff as well as for training school teachers, school psychologists, vocational rehabilitation counselors, and for other public organizations," Herring says.
Marketing program pays off
The benefits of this extensive, hands-on marketing include the following:
• The TBI program has a state vocational rehabilitation counselor, who is assigned to the program on a part-time basis at no cost to the program.
• The program also benefits from the services of a state employment training specialist, who works full time for RCP. "Instead of having the hospital system provide these services, we’ve partnered with state rehabilitation providers, and they’re on an affiliated staff and are part of the team," Herring says.
• When RCP learned that the state Depart ment of Vocational Rehabilitation couldn’t provide funding for full-time outpatient neuropsych ology services, the TBI program made the state an offer it couldn’t refuse. RCP provides the neuropsychology tests that the state psychologists have no training to provide, and the state psychologists conduct the remaining psychology tests. In exchange, the state pays RCP $340 for its half day of testing services, instead of paying the normal neuropsychology testing fees of $800 to $900. For its part, RCP has one more steady customer for its TBI program.
"If we can do the neuropsych test, even if we’re at a break-even point, it provides more business because it identifies the need for outpatient services," Herring explains. "And the state is not under such funding limitations when paying for PT and OT."
• The TBI program, in collaboration with the state Department of Disabilities and Special Needs, is applying for a federal grant to expand its outpatient work re-entry program.
2. Build a teamwork model to increase staff flexibility.
From the beginning, the TBI program was set up so all therapists report to their program leader instead of their individual therapy departments. The rehab center traditionally has had a departmental structure, although it’s moving a little in the program direction, Herring says.
"When we started, there were OT, ST, PT departments at Roger C. Peace, but therapists who worked in brain injury would report to the TBI leader," he explains. "This structure reflects a philosophical orientation of, Let’s build the program around the patient.’"
This approach has built a team cohesiveness that made it far easier to cross-train the staff and remain flexible when the department’s census shifts. It also bypassed departmental politics. "If you’re a speech therapist or occupational therapist and on the brain injury team, you don’t have a home department to run to if things get uncomfortable," Herring says. "So if the speech therapist is concerned about what the occupational therapist is doing, then the speech therapist and the occupational therapist have to work it out because they don’t have any other options."
Therapists also are given an opportunity to evaluate their peers in other disciplines as part of a formal review process. (The peer review form is inserted in this issue.)
Herring maintains this type of structure also builds rapport with patients and reinforces to staff that the patients’ needs are the first priority. By making the entire team responsible for a patient’s treatment, the TBI program ensures there won’t be problems like one discipline stopping treatment without informing the others.
Also, the team approach has made it easier to cross-train staff to follow up on care provided by a different discipline. For instance, the entire TBI staff must understand the cognitive, emotional, and physical areas relating to brain injury. "I expect my physical therapist to understand the cognitive issues the speech therapist is working on," Herring says. "The recreational therapist should understand and participate in the behavioral interventions going on."
Each employee is expected to develop some expertise in an area outside his or her own domain. So the TBI program provides extensive training, including an orientation process that takes one year and in-depth training in cognition, memory and how it affects treatment planning, and awareness deficits.
For example, the physical therapist might have to ask this type of question: "How can I make this physical exercise challenge the person’s memory or awareness or any other cognitive deficit that other team members are working on?"
The same is true for behavioral issues. An OT might ask the following questions:
• How will this affect the patient behaviorally, and how will my interaction style be received by the patient?
• What types of interventions are the rest of the team members using?
• Am I up-to-date on what the team is doing with this patient?
3. Add a program serving people who were active before their strokes.
The rehabilitation hospital naturally provided services for stroke patients. But there was an additional need to serve the segment of the stroke population that had been healthy and active before their strokes. They would need more specialized services to help them regain their former independence.
To serve this group, the facility created the Young Stroke Program in 1995. The program has helped stabilize the entire TBI program, Herring says.
"A lot of programs across the country have had trouble maintaining their autonomy because of fluctuating census and decreased market share," he adds. "But by bringing on a team of Young Stroke therapists, it has allowed us to weather the changes."
Sometimes the Young Stroke team will pick up brain injury patients, and other times the brain injury therapists will treat Young Stroke patients, depending on which area has the higher census.
Young Stroke patients are not necessarily young patients. The oldest patient was in his 80s, but he had been working part time before his stroke at a media communications job. The main criteria are that the patient had an active lifestyle before injury and has potential to return to that level of activity.
The Young Stroke Program also enabled the rehabilitation hospital to fill an extra six beds. The hospital had the TBI inpatient section on the third floor, where 20 beds were available. However, the brain injury program was licensed at 14 beds.
"So we had to figure out which population to put in those six beds, and our evaluation data revealed that almost one-third of our cardiovascular accident patients were under the age of 65," Herring says. "Then when we looked at their clinical needs to see what they required in intensity of therapy and team concentration, we thought there would be enough overlap to start a successful Young Stroke team."
4. Fight for per diem payment structure.
Between 30% and 33% of the rehabilitation hospital’s patients are insured through managed care organizations, Herring says, although the type of managed care found in South Carolina controls the state’s health care costs and reimbursements a bit less than those in California or Minnesota, for example. "So with the exception of maybe psychology benefits, we’re seeing them want a high degree of accountability, but we’re still able to get reasonable reimbursement."
Per diem payments prevent shopping’
The rehabilitation hospital always has been structured to charge on a per diem basis, which prevents insurers from cafeteria shopping; that is, eliminating particular therapies from their coverage. Insurers are offered one program that RCP decides is best for a particular patient. The per diem payment structure has been particularly important to the TBI program, Herring says.
For example, reimbursement for recreation therapy (RT) has been dropping nationwide, forcing some facilities to reduce RT staff. But at Roger C. Peace, the TBI program still employs RTs, who directly treat patients’ physical and cognitive deficits that come with brain injury. Their involvement is due to the per diem structure.
The only exception to per diem is the TBI outpatient program, which is set up to charge whatever structure will accommodate the needs of external case managers. Some will pay a single daily charge, others a per-service reimbursement, and others a hybrid of that, Herring says.
"The per diem structure was already in place, but a number of times the hospital system con sidered dropping it," he says. "But we strongly lobbied in favor of maintaining the per diem structure for as long as we can."
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