Now’s your chance to measure outcomes, make changes before PPS
Flexibility is the key to rehab survival
The federal Health Care Financing Administration (HCFA) may have put the inpatient rehab industry into a long limbo with regard to the Medicare prospective payment system (PPS), but that doesn’t mean facilities have had to wait to make any operational changes.
Some rehab hospitals took the past year’s reimbursement uncertainty as an opportunity to make changes that could lead to better outcomes and quality, while either helping or at least not harming the financial bottom line.
For example, INTEGRIS Jim Thorpe Rehabilitation Hospital at Southwest Medical Center in Oklahoma City continued to expand and adapt by reassessing its outcomes measurement tools and improving those processes wherever possible.
"[Southwest Medical Center is a] tertiary hospital, and we have all the well-known measuring tools and state-of-the-art benchmarking tools, but these didn’t focus on the individual patient," says Sharon Smeltzer, MS, director of operations for the 131-bed rehab hospital. "We decided we needed to measure exactly what was happening with that patient," she adds.
With that goal in mind and with PPS on the horizon, the hospital restructured its departments, changed the management structure, and changed all of its measurement systems.
"For the next three to five years, a lot of rehab facilities are going to be profoundly challenged because of increasing competition," says Pam Clark, PhD, director of research and development for the hospital. "We need to re-examine resource utilization and organizational effectiveness," she says.
One way to improve efficiency is to expand rehab coverage to weekends, which would be expected to lower costs and lengths of stay because therapy would be provided continuously without the typical weekend break.
"We decided to offer consistent therapy no matter what day a patient is admitted," Smeltzer says.
Jim Thorpe Rehab Hospital’s changes already have resulted in efficiency and other improvements since expanding to weekend therapy. For total hip cases, the functional improvement measured against patients’ lengths of stay improved from 3.38 to 3.46, Smeltzer says. For total knee cases, the improvement was from 3.55 to 3.96. Both the before and after numbers showed the hospital to be more efficient than the regional average of 2.78 for total hip procedures and 3.22 for total knee procedures, she adds.
The expansion to weekend coverage is only one small part of what the hospital did to improve operations and outcomes. Here is a look at some of the hospital’s other changes:
• Restructure management, departments, and even the dress code. The hospital divided the 131 beds into five departments, placing an interdisciplinary supervisor over each department. Therapists were moved to the same floor as nurses and patients, and physicians now can be reached at nursing stations. "We physically moved all of the staff to the patient floors, which was a major change," Smeltzer says.
Also, the entire staff of more than 500 now is required to wear a uniform to show patients that everyone is part of a team. The uniforms consist of khaki pants and white and blue polo-style shirts stitched with the hospital’s logo. Managers and nurses also wear the uniform colors.
Even physicians wear the uniform colors, along with their white coats, at least once or twice a week, says Al Moorad, MD, medical director of the hospital. "It’s a morale issue for employees, in my judgment," Moorad says. "And having the uniform makes it easier for patients to identify us; it shows that we’re all part of one team, on the same level, wearing the same clothes."
Employees now welcome the change, Smeltzer says. "No one likes to be told what to wear, but we’ve had so much positive feedback since the beginning. Also, we have a committee that occasionally will adopt a new shirt color, so employees feel like they have had definite input on the change."
• Educate physicians, pharmacists, and others about PPS and costs. The hospital has created a new team that will help pharmacy staff, physicians, and physician assistants learn about costs. "With PPS, I want everyone to be aware of and educated about everything we do," says Moorad. "We need to do what’s best for the patient, of course, and quality of care is our highest issue, but what is the cost per diagnosis, per admission?"
The education will take the form of meetings with physicians, lectures by various members of the team, and meetings with pharmacists, who help keep physicians up-to-date. The team will keep track of various diagnoses, looking at incidence rates, co-morbidity issues, and complication issues, then compare these to national averages.
Physicians will do their part by filling out weekly time studies and reviewing trends and costs. Part of the education will involve teaching physicians and nurses to look at costs over a long term, as in the costs of complications if certain precautions are not taken.
For example, the hospital will use a protocol for all spinal cord injury patients. The protocol will address the possibility of a complication called deep venous thrombosis by having physicians order a baseline bilateral venous doppler study of the legs of all spinal cord injury patients. That will be done regardless of the patient’s age, Moorad says.
"We’re instituting a very active anti-thrombotic protocol to prevent blood clots in their legs, and what we also will do is follow these patients and repeat these doppler studies depending on the patient’s length of stay," he adds.
The hospital also asks physicians to continue the same program when patients return home. "If you have a lower incidence of deep venous thrombosis, then you cut down on lots of morbidity and mortality from complications," Moorad explains. "And we think if you do these things and spend the money on the front end, then you will save a lot of money in the end and provide better patient care."
Physicians have been very receptive to those sorts of protocols and changes, which are suggested rather than mandated, Moorad says.
• Expand research and development. Rehab facilities may need to expand research and development (R&D) to stay ahead of cost and service trends. "In order for Jim Thorpe to become nationally recognized, we need to concentrate on research and development," Clark says. "I’ve spent a lot of time traveling around the United States and meeting with professionals from the top 10 rehab facilities, and what I realized is that most — if not all — have research and development departments."
One of the hospital’s first R&D projects involves using telecommunications technology to provide speech and language therapy to children in a rural community about 150 miles from the rehab facility.
The hospital received a $900,000 grant in 1997 from the Health Resources and Services Administration for rural telemedicine to provide specialty services to medically underserved communities.
• Measure outcomes and costs associated with each change. With new measurement systems, the hospital can show physicians how their own patients’ morbidity and mortality rates compare with the hospital’s average and how they compare with national benchmarking numbers, Smeltzer says.
"We have all of our state-of-the-art financial measurements interfaced, and they’re hooked up on a big system that is rehab-specific," she explains. "So we can show physicians the areas where they can make changes, and then they’re very willing to make those changes."
By the same token, physicians, therapists, and other staff can use those statistics to demonstrate productivity and outcomes and to ask managers for changes to procedures and processes.
Outcomes measurement also is a morale booster when the data show staff how the hospital already is performing better than regional or national averages in some areas, Smeltzer says.
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