Differences between inpatient rehabilitation & skilled nursing care
Appropriate Patient Placement
Definitions of Skilled and IRF Care Definition of Definition of the Skilled Rehabilitation Care Nursing Care: The Inpatient Rehabilitation Facility (IRF) provides The SNF provides services to an inpatient intermittent and/or daily who needs a relatively skilled care services. intense rehabilitation These services are program that requires a multidisciplinary provided by professional coordinated team approach nurses and/ or to upgrade his functional rehabilitation ability. professionals.
Definitions Continued IRF Requires a Relatively Intensive Rehabilitation Approach The general threshold for supporting IRF care is that the patient must require and receive at least 3 hours a day of PT, OT or ST. Daily is defined as 5 days per week.
Definitions Continued Skilled Care requires that patients be in an appropriate RUGs payment group to be considered a “skilled” patient.
Both Programs Require: Additional Requirements: These services must be reasonable and necessary for the treatment of the patient’s condition; and, It must be reasonable to furnish the care in an inpatient hospital setting, rather than in a less intensive setting such as SNF, an SNF level of care in a swing bed, or on an outpatient basis.
Overview of these MedicarePrograms Historical Perspective: Medicare/Medicaid legislation passed in 1965 Amended in 1982 by TEFRA act, which limited payment to IRFs, while SNF remained cost- based. Both programs excluded from hospital DRG payment system. In 1997 the HCFA/CMS published criteria for Prospective Payment Systems (PPS) for IRFs & SNFs. In 1998 the Final Rule for SNF PPS was published In 2001 the Final Rule for IRFs was published.
Same Program Philosophies Both Use a Philosophy of Rehabilitation Focus on rehabilitative and recuperative care Monitor health status Facilitate self-care Maximize functioning and independence
IRF Patient Characteristics IRF Patient Characteristics – 13 Diagnosis Diagnosis of patients ○ Fracture in the IRF ○ Brain injury ○ Stroke ○ Polyarthritis, ○ Spinal cord injury including rheumatoid arthritis ○ Congenital deformity ○ Neurological ○ Amputation disorders, including ○ Major multiple trauma MS, motor neuron ○ Burns disease, polyneuropathy
SNF Patient Characteristics Patients are admitted that fall into these specific RUGs groupings: Rehabilitation – PT,OT, ST & Restorative Nursing Extensive Services – Nursing Services Special Care – Nursing Services Clinically Complex – Nursing Services
RUGs III Prospective PaymentSystem (PPS) In 1998, Medicare introduced Resource Utilization Groups (RUGs) and the RUGS III Perspective Payment System (PPS) that defined specific patient categories and services that are considered “skilled”. Therefore, patients falling into one of these “skilled” groups met the requirements for Medicare payment of skilled care.
Services IRFs Must Provide Types of services that must be provided: Rehabilitation Nursing: B/B Training, etc. Rehabilitative Services: Physical therapy, occupational therapy, speech therapy Audiology Prosthetics Orthotics Social and/or psychological services
Services SNFs Must Provide Nursing Restorative Services: ROM, B/B Training, etc. Rehabilitative Services: Physical therapy, occupational therapy, speech therapy Audiology Prosthetics Orthotics Emergency Dental Social and/or psychological services
Regulatory Components Regulatory Components for Both Programs Administration Physical environment Patient rights Rehabilitative nursing services Multidisciplinary approach to care
The Medicare Program Medicare: Federal health insurance program available for people over 65 years of age, and certain individuals under age 65 Part A – hospital services, including IRF, skilled, hospice ○ Included as part of social security benefits, subject to deductibles Part B – outpt/physician services, equip ○ Monthly fee; annual deductible
The Medicare Program IRF - 90 Days per spell of illness SNF – 100 Days per spell of illness Hospital deductible due for each spell of illness IRF - first 60 days fully covered if meets acute care criteria; co-pay for 61st-90th day; no pre-qualifying hospital stay required SNF – first 20 days fully covered if meets RUGs criteria; co-pay for the 21-100th day; 3-day pre-qualifying hospital stay required.
The Medicare Program Spell of Illness: The period which begins when a patient is furnished inpatient hospital care. The spell of illness ends when the patient has neither been an inpatient of the hospital or skilled nursing bed for 60 consecutive days. The benefits (days) are renewable with each new spell of illness.
SNF Prequalifying Stay 3 day qualifying stay in the rehabilitation unit would qualify a patient for skilled care.
Criteria for IRF Care Technical requirements Rehabilitation Diagnosis Coverage of services
Criteria for IRF Care Technical Requirements The patient must ○ Require the therapeutic services of physical therapy, occupational therapy or speech therapy for three hours a day, five days a week; ○ Have potential for improvement; ○ Be somewhat medically stable; ○ Be motivated. ○ Rehabilitation services must be reasonable and necessary for their condition. ○ As a practical matter, services must be provided on an inpatient basis.
Criteria for IRF Care Rehabilitation Diagnostic Groups – 13 diagnosis specified Must require intensive rehabilitative services for the treatment of one or more of the following conditions: Stroke Spinal cord injury Congenital deformity Amputation Major multiple trauma Fracture
Criteria for IRF Care Polyarthritis, including rheumatoid arthritis Neurological disorders, including multiple sclerosis, motor neuron diseases, polyneuropathy, muscular dystrophy and Parkinson’s disease Burns
Criteria for IRF Care-Rehab Diagnosis 95 Case Mix Groups (CMGs) Pain syndromes: back, soft tissues, etc Cardiac disorders: CHF, MI within 8 weeks, CIHD Pulmonary disorders: bronchitis, COPD, asthma, pulmonary insufficiency Development disability: mental retardation Debility: muscular wasting, CFS Medically complex conditions: infections, neoplasms, nutrition, circulatory DO, resp. DO, terminal care, skin disorders, renal failure
Criteria for IRF Care-75% Rule Phase In to Compliance – now at 60 or 65% 75% rule: Seventy-five (75%) of patients admitted into the IRF must fall into one of the 13 specified diagnosis. Twenty-five (25%) of patients admitted can fall into the other categories defined in the CMG impairment groups.
Criteria for IRF Care Coverage of Rehabilitation Services: Services must be provided with the expectation that the condition will improve in a reasonable and generally predictable period of time. Inpatient rehabilitation services are a more coordinated, intensive program of multiple services than is typically available outside of the hospital.
Criteria for IRF Care Coverage of Rehabilitation Services: A patient who has one or more conditions requiring intensive and multidisciplinary rehab care, or who has a medical complication in addition to his primary condition, so that the continuing availability of a MD is required to ensure safe and effective treatment, probably requires a hospital level of rehabilitation care.
Criteria for IRF Care Coverage of Rehabilitation Services: Coverage is available for an inpatient stay for a patient to assess the potential for benefiting from an intensive coordinated rehabilitation program. Generally, for a 3-10 day period. However, it must have been reasonable and necessary to perform this 3- 10 day inpatient rehabilitation assessment as supported from clinical data in the acute care chart.
Criteria for IRF Care Coverage of Rehabilitation Services: If the rehabilitation assessment stay results in the conclusion that the individual is a poor candidate for rehab, coverage for further inpatient hospital care is limited to a reasonable number of days needed to find placement elsewhere for the patient.
Criteria for SNF Care Technical Requirements The patient must require skilled care - provided by professional nurses and/or professional therapists. Skilled services as a practical/economical matter can only be provided on an inpatient basis. The patient must receive treatment in the SNF for the same illness/injury for which the patient was treated in the hospital.
Criteria for SNF Care Technical Requirements All ordered SNF services must be reasonable/necessary for the condition the pt. was treated for in the hospital, including freq. and duration of such services. The pt. must be certified and recertified as requiring skilled care by the MD on admission, the 14th day and every 30 days thereafter.
Criteria for SNF Care Technical Requirements The patient must be placed in a Medicare-certified bed in the SNF. Physician orders for specific SNF services must be present in the medical record.
Criteria for SNF Care Coverage of Services – i.e. RUGs Groups - Rehabilitation Group - Includes PT, OT & ST 5 Rehabilitation Groups Ultra High – In the last 7 days: Received 720 or more minutes of therapy At least 2 disciplines, 1 for at least 5 days, and the 2nd for at least 3 days
RUGs GroupsVery High – In the last 7 days: Received 500 or more minutes of therapy At least 1 discipline for at least 5 days High – In the last 7 days Received 325 or more minutes At least 1 discipline for at least 5 days
RUGs Groups Medium – In the last 7 days: Received 150 or more minutes of therapy At least 5 days of therapies across the 3 disciplines Low – In the last 7 days: Received 45 or more minutes of therapy At least 3 days of any combination of the 3 disciplines, and Two or more nursing rehabilitation services received for at least 15 minutes each with each administered for 6 or more days
RUGs GroupsExtensive Services Group Any one of the following services received within the last 14 days with an ADL sum >=7: – IV Feeding/parenteral feeding (within last 7 days) – Suctioning – Tracheostomy Care – Ventilator/Respirator – IV Medication
RUGs Groups Special Care Group Any one of the following: Multiple Sclerosis with ADL sum >= 10 Quadriplegic with ADL sum >= 10 Cerebral Palsy with ADL sum >= 10 Respiratory Therapy = 7 Ulcers (2+ sites over all stages ), with treatment Any stage 3 or 4 pressure ulcer with treatment
RUGs Groups Special Care Group Any one of the following: Surgical wounds or Open Lesions with treatment Radiation therapy Tube Fed+ and Aphasia Fever with one or more of the following: ○ Dehydration ○ Pneumonia ○ Vomiting ○ Weight Loss ○ Tube Feeding+
RUGs GroupsClinically Complex Group Any one of the following: – Burns – Coma and not awake and completely ADL dependent – Septicemia – Pneumonia – Foot Lesions or Infections w/dressings – Internal Bleeding – Dehydration – Hemiplegia with ADL sum >=10
RUGs Groups Clinically Complex Group – Tube Feeding – Oxygen Therapy – Transfusions – Chemotherapy – Dialysis – Number of Days in the last 14 days, that the MD Visited/made order changes: – Diabetes Mellitus and insulin injection 7 days and MD order change >=2 days – Or Qualified for Special Care with ADL <=6
RUGs GroupsAs of 1-1-2006 Medicare introduced a new RUGs Group: Rehabilitation, Plus Extensive Services Highest Paid RUGs Group Patient’s who are receiving both therapy minutes and a nursing service specified in the Extensive Services Group Refinements still being made to this payment system.
IRF PPS CMG’s being refined Case-Level Adjustments: Transfer Adjustment Short Stay Payment Expired Interrupted Stay Co-morbidity Adjustment – continues to change/adjust payment for patient co- morbidities
IRF PPS Recent FI focus of audits Many FI’s have introduced Local Coverage Determination (LCD) documents to further redefine appropriate IRF patients. AHA and CMS discussions
Conclusion Many similarities between the two programs Both mainly used by Medicare beneficiaries Patient placement influenced by the two PPS. Diagnosis in an IRF is a significant issue Skilled documentation is a must in a SNF