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Improvement in recording patient assessment scores affects PPS
Training, audits improve payment documentation
[Editor’s note: In this issue of Rehab Continuum Report, there are several articles based on sessions at the 2004 annual Educational and Leadership Conference of the American Medical Rehabilitation Providers Association (AMRPA), held Nov. 3-5 in New Orleans. Prior to the conference, RCR interviewed several of the scheduled session presenters to learn about the big picture of the issues concerning the rehab industry this year. The cover story discusses achieving excellence in documentation for the prospective payment system (PPS), and inside stories discuss forming a violence prevention program and determining an organization’s compliance with inpatient rehabilitation standards.]
Performance improvement and staff education about PPS are as important in 2005 as they were five years ago when the rehab industry was anticipating the change, experts say. For Southern Kentucky Rehabilitation Hospital in Bowling Green, PPS preparation entered a new phase of performance improvement once the original 18 months of training were ended.
The rehab hospital’s staff prepared for PPS for 18 months, planning for this significant change in the rehab industry, says Lou Anderson, MS, CCC, SLP, director of rehabilitation services at the hospital. "And after the implementation, we continued the process improvement to increase the accuracy of our information that goes into the patient assessment instrument [PAI]," Anderson says. "So for the past two years, our hospitalwide performance improvement project has been focusing on accuracy with the PAI."
Since the Centers for Medicare & Medicaid Services (CMS) requires rehab facilities to capture scores over a 72-hour period, the rehab facility’s staff have worked hard to obtain the most accurate measurements from nurses and other staff, says Jan Bohannon, RN, PPS coordinator. "We feel we’ve done an exceptional job of getting nursing staff trained to a level where they’re accurate and making sure training helps us get the right number of scores for placing patients in the right categories," she says.
Here is how the rehab facility has maintained its performance improvement focus:
• Update training.
"We’ve revised our training several times," Anderson says. Training includes videos, lectures, and hands-on sessions in which rehab staff train nurses to some therapy tasks, she explains. "We let them see what it feels like when a patient is doing 50% of a task. We go through quite a few scenarios so they can get some ownership and feel like they can make a judgment call on correct [scoring] numbers."
Staff attend a catch-up training session once a quarter, and new employees attend follow-up training sessions every other week, Anderson says.
Bohannon monitors how staff rate patients according to PAI and will present specific examples of problem areas during these staff meetings. "We watch our therapists and see how they compare with the night shift and evening shift; and if there’s a difference in scoring, we see whether there is communication between the shifts," she says. "We expect to see in the daily notes that they talked with the evening staff and trained them on a particular transfer or feeding technique."
• Change care planning format.
"We’ve changed our care planning format for our patients," Anderson adds. "This is to make sure patients on the night shift are doing comparably to what they’re doing in the day shift." The functional improvement numbers do not tell the whole story, so staff compare scores from the evenings and nights to daytime scores to make certain patients are achieving their personal highest functional levels, she says.
Before the care planning format was changed, the interdisciplinary team would meet weekly and discuss current status reports on patients. However, they didn’t discuss the barriers that existed from an interdisciplinary team standpoint, Anderson explains. For instance, from a nursing perspective, a patient might need a bowel and bladder program, but from a therapy perspective, the patient may need to focus on transfer technique, she says.
Other issues include family education and the barriers that keep a patient from being ready to return home, Anderson says. "The barriers to the successful completion of rehab have become the focus and lead patients to achieve higher functional outcomes," she points out. The staff are excited about the care planning process changes because they feel it will help their patients achieve better functional outcomes, Anderson adds.
The case manager serves as a facilitator who discusses care plans with the staff. For example, she says, the case manager might name an area of function, saying, "Locomotion — what are our barriers?" or "With activities of daily living [ADLs] — what are our barriers?"
Case managers also point out the differences recorded by night shift, evening shift, or day shift; and those differences are discussed to see what might be the cause. "Maybe there’s a certain medication that creates problems for a patient," Anderson says.
• Focus on pain management.
Because rehab staff see patients completing ADLs successfully in the rehab setting, they sometimes overestimate the patient’s ability to succeed after discharge to the community, she notes. "At the discharge date, the patient may still be a significant burden of care."
And often pain is a barrier to successful completion of rehabilitation, Anderson adds. "Patients may have pain in ambulation or pain in ADLs, and suddenly we all realize that even though they’re taking pain medication and even with that, the pain is inhibiting more movement."
Pain also might lead to depression, and a lack of motivation to succeed could come into play, she explains. So it’s important for rehab staff to focus on pain management before therapy and monitor it as the patient prepares for discharge, Anderson adds.
• Audit charts.
Bohannon checks patients’ rating numbers daily and writes a monthly report in which numbers are compared. "I write monthly confidence rating scores, and we do a presentation on the different aspects that we’d be comfortable with on a score," she says.
The goal is to know which levels would indicate accurate scores and then to compare those levels to the actual scores, Bohannon explains. For example, when rehab managers compare functional improvement scores from day shifts to night shifts, they needed to understand why scores were different and what justified those differences, Anderson says. "If we saw a score that was different, then we had to go back to the documentation and written information to support the scores we saw," she notes. "We looked at the different areas and decided what was acceptable at each level."
For instance, a seven point difference in scores would be difficult to justify, while a two-point difference could be explained by how a patient receives more assistance with locomotion in the evening than in the daytime, Anderson explains. "Or if a patient is on medication in the evening to help him rest, then we’d say that two-point difference is acceptable," she says.
If Bohannon sees a significant difference in scores, she will call the nurse or therapist to obtain verification for the scores. "Maybe there’s something that I don’t understand about the scores," she says. "Or maybe their documentation doesn’t match the number they put down." Also, checking back with rehab staff helps to improve the process by giving everyone an additional learning experience regarding documentation and scoring, she says.
It helps if someone can act as an outside auditor and remain objective when reviewing the scores, Bohannon notes. "I try not to superimpose my judgment of what I feel like the scores should be," she says. "It’s not that we want a higher or lower score, but we want a correct score, and we want documentation to support that," Bohannon adds.