To survive managed care, maximize what you have
Provider uses creativity to eke out benefits
When she hears rehab providers in other parts of the country whine about the influx of managed care, LeeAnn Sims, MS, CRRN, has one comment: "been there, done that."
The health care market in Portland, OR, where Sims serves as clinical nurse specialist for Legacy Rehabilitation Services is 90% managed care. Among the Medicare population, 63% already are covered by Medicare managed care plans.
The rapid shift to a managed care market has forced the staff at Legacy to find creative ways to maximize patients' insurance benefits, Sims says.
Legacy has a thorough pre-admission screening process to make sure patients enter the system at the most appropriate part of the continuum. "We instituted our screening process to make sure that when we admit a patient into a program, it's unlikely that they will fail or not have the endurance for the therapy they need," she explains.
The screening process enables the staff to triage patients to different levels of the continuum according to need and ability. "In the old days, to discharge a patient from rehab to a skilled nursing facility was considered a failure. We had to rethink that philosophy," she says.
Now patients who have complex problems but limited days of inpatient rehabilitation coverage may be admitted to rehab, start therapy, establish a bowel and bladder training program, then be transferred to a skilled nursing facility, where they receive less intensive therapy at a lower daily rate than in acute rehab.
When they have gained endurance, they may be returned the acute rehabilitation facility to complete the process.
In the Legacy Rehabilitation system, patients in an acute rehab unit receive three to five units of therapy and 24 hours of rehab nursing a day. In the skilled nursing facility, they receive one to two units of therapy a day and less rehab nursing.
A typical example would be a quadriplegic patient with a halo brace who has an early stay in acute rehab while the staff take care of his early equipment needs and get his bowel and bladder training program established. The patient then may transfer to a skilled nursing facility or foster care until the halo is removed. Then he will return to the acute rehab unit for final equipment adjustment, intensive therapy, and family and caregiver training.
"We do this because patients today just don't have that many inpatient rehab days. Now there's more pressure for families to adjust quickly, and transferring them to a lower level of care gives the family time to adjust and us an opportunity to maximize the patient's gains in acute rehab," Sims adds.
Sometimes, when a patient's acute care visits are limited, the staff at Legacy may be able to negotiate with the insurer to switch some of his or her other benefits for inpatient rehab. For instance, if patients have a lot of outpatient benefits and are unlikely to need them, the hospital may investigate the possibility of trading some of that outpatient coverage for inpatient reimbursement.
Another option is to discharge patients who can't function alone into Oregon's network of adult foster care. For some patients, it's an interim step to independent living, Sims says.
The Legacy Rehabilitation system has two nurse admissions coordinators. One spends most of her time on the trauma unit and sees patients very early in their disability. The other coordinator focuses on diagnoses such as strokes, multiple sclerosis, and referrals from outside the Legacy system.
Treatment starts fast
With the preadmission process, the staff are ready to start treating patients when they come in the door.
"We moved away from three days of eval uation. We start treatment as soon as they get here. We may still be gathering informa - tion, but our admissions coordinators give us enough so we are treating at the same time," Sims explains.
The preadmission screeners give the rehabilitation staff a 21¼2-page summary that includes the diagnosis, functional level, and key issues such as whether the patient needs range-of-motion or strengthening therapy and whether he or she needs to start learning how to transfer from a wheelchair.
All patients attend the goal-setting meeting, which is held within the first 48 to 72 hours after admission to clarify goals and time lines.
The weekly conferences, attended by treatment team members, patients, and family members, are called "discharge planning conferences" to emphasize that the staff are working on discharging patients from the moment they are admitted.
[For more information on Legacy Rehabilitation and its programs, contact LeeAnn Sims at (503) 413-6783.]
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