Sg2 Web Seminar 06012007 Emerging Trends In Irf[1]


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Inpatient Rehab Trending; Expert Speaker for Webinar 6/07 with Sg2 /Chicago

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Sg2 Web Seminar 06012007 Emerging Trends In Irf[1]

  1. 1. Emerging Trends in Orthopedics and Neurosciences Inpatient Rehabilitation Holly Wisniewski, MBA Consultant Kelly Huseby Consultant Guest Expert Presenters: Susan Gregg, VP Darlene D’Altorio, PT, MBA, Director Of Rehab & Support Services Akron General Edwin Shaw Rehab June 1, 2007 5250 Old Orchard Road Skokie, Illinois 60077
  2. 2. Agenda Introduction Changing World of Inpatient Rehabilitation Strategies for Successful Management of Inpatient Rehab Facilities Questions
  3. 3. Inpatient Rehabilitation: A Time of Flux Demand for postacute care has increased over the past 20 years and will continue to increase. Baby boomers are entering the prime age for strokes and heart attacks. Over the next 10 years, the most common procedures requiring rehabilitation will be: Stroke: +21% TJR: +51% Fracture: +9% Advanced technologies save larger proportions of babies with birth defects or special needs. Increasing evidence highlights the value of early rehab integration. Rehabilitation needs of patients are changing with the evolvement of acute care treatment, regulation and reimbursement. Effective management and differentiation are key for financial and care delivery success. TJR = total joint replacement. Sources: Impact of Change® v6.0; NHDS; Sg2 Analysis, 2007;; 3 Confidential and Proprietary © June 2007 Sg2
  4. 4. Spending for Postacute Care Has Risen in Each Setting Medicare Spending in the Postacute Care Setting, 1992–2005 Dollars (Billions) Postacute 45 Home Health 42.1 SNF 40 38.9 IRF 35.7 LTACH 35 34.1 32.9 32.6 31.3 30 29 27.7 25.3 25 25 24 20 18.5 18.2 17.9 17.4 17.2 15.7 15.2 15 13.1 14.7 14 13.2 12.9 12.9 12.8 12.3 11.3 10.9 10.8 10.6 10 9.9 9.9 9.7 8.9 8.8 6.6 8.4 8.4 7.2 7.1 6.4 6.2 5 5 4.9 3.6 4.6 4.2 4.1 4 3.9 3.8 3.8 3.6 3.5 3.4 3.4 3.1 2.8 2.5 1.9 1.7 1.7 1.4 1.2 1.1 0.8 0.6 0.3 0.4 0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Note: These numbers are program spending only, and do not include beneficiary copayments. SNF = skilled nursing facility; INF = inpatient rehab facility; LTACH = long-term acute care hospital. Source: MedPAC, 2006. 4 Confidential and Proprietary © June 2007 Sg2
  5. 5. About Akron General Edwin Shaw Rehab (ESR) 4 Scopes of Service Inpatient medical rehabilitation: 48 beds Inpatient skilled nursing services: 49 beds Outpatient medical & vocational services 4th location opening in July Chemical dependency services Most CARF-Accredited Rehab Programs in Ohio 19 programs accredited 2007 to 2010 Inpatient medical rehab (child, adult) Brain injury, inpatient, outpatient, vocational services (child, adult) Inpatient case management (child, adult) Inpatient and outpatient stroke specialty Outpatient single service, multiservice (child, adult) Vocational employment services A 100-acre freestanding rehabilitation facility ~50 miles south of Cleveland, OH Governance standards applied CARF = Commission on Accreditation of Rehabilitation Facilities 5 Confidential and Proprietary © June 2007 Sg2
  6. 6. Edwin Shaw Rehab: Answering Community Needs, 1915 to Present Akron General Edwin Shaw Rehab History Opened to serve 4-county area in the treatment of tuberculosis 1915 Transitioned to skilled nursing facility 1961 Added chemical dependency treatment 1974 Opened IRF beds while retaining skilled beds 1977 Added vocational rehab outpatient services Early 1980s Introduced multiservice outpatient medical rehab Late 1980s Added outpatient locations 1990s Acquired by Akron General from Summit County to complete a full continuum of care 2005 Accredited by CARF in 19 programs 2006 Participated in numerous research studies (eg, electrical stimulation on the stroke affected hand). Showed financial improvement in first full year post transition that was 43% better than 2005 and 66% better than 2004 (last year of full county ownership) Demonstrated an average FIM (24.3 vs 22.3) gain that was 8% higher than national average despite having patients with 11% higher acuity from 2002 to 2006 FIM = functional independence measure 6 Confidential and Proprietary © June 2007 Sg2
  7. 7. Agenda Introduction Changing World of Inpatient Rehabilitation Strategies for Successful Management of Inpatient Rehab Facilities Questions
  8. 8. Fragmentation of the Postacute Care World Makes Management Difficult Comparison Between Therapy Requirements, Payment, and Outcomes Assessment Between IRF, SNF, LTACH, HHA and OP Rehab Type IRF SNF LTACH HHA OP Rehab Hours/Day 3 hrs/day 0.5–2 hrs/day — 0.5–1 0.5–2 hrs/day hrs/day Days/Week 5–7 days/week 5–7 days/week 3 days/week 3 days/week Payment Unit 100 CMGs + tiers 44 RUG-III LTACH DRGs 80 HHRGs Physician groups Fee Schedule Type of Per discharge Per diem Per discharge, Per 60-day Per therapy Payment per 60-day episode unit episode Assessment IRF PAI (Uses MDS None OASIS — Tool/Basis rehab impairment (Diagnosis and of Payment code [RIC] and clinical service ICD-9 codes oriented) Functional FIM MDS–Section — — — Tool G/ADL scores HHA = home health agency; CMG = case mix group; IRF DAI = Inpatient Rehab Facility Patient Assessment Intrument; MDS = minimum data set; HHRG = Home Health Resource Group; OASIS = Outcomes and Assessment Information Set. Sources: VCU Health System: Rehabilitation and Research Center, 2002. 8 Confidential and Proprietary © June 2007 Sg2
  9. 9. Inpatient Rehabilitation Offers Unique Benefits to Patients and Families Benefits Challenges Intense medical oversight that Continuous regulatory changes and allows for the management of increasingly difficult claims process multiple medical comorbidities and Stringent provision of care requirements the reduction of potential No common patient instrument used to complications assess patient care and guide placement Rigorous therapies that enable decisions patients to achieve maximum Limited evidence-based standards and independence upon departure research Unique interdisciplinary clinical Resource-intense care provisions— approach and environment that medical supplies and equipment, staffing, fosters patient and family education etc Social, emotional and physical Little data transparency across the support that assists a variety of postacute settings—quality, outcomes, medically complex patients financial, patient diagnosis 9 Confidential and Proprietary © June 2007 Sg2
  10. 10. Inpatient Rehabilitation Regulation Has Impacted the Provision of Care 75% Rule This is a component of the strict criteria that a facility must fulfill in order to qualify as an IRF. Under the rule, facilities must prove that at least 75% of their patients have 1 of 13 designated medical conditions for which CMS deems inpatient rehab medically necessary. Phased Approach of the 75% Rule Since 2003, there has been continuous debate over the fairness of the 75% Rule. To ease implementation, CMS has created a 4-year transition period for compliance: 50% for cost reporting cycles beginning on or after July 1, 2004 and before July 1, 2005 60% for cost reporting cycles beginning on or after July 1, 2005 and before July 1, 2006 60% for cost reporting cycles beginning on or after July 1, 2006 and before July 1, 2007 65% for cost reporting cycles beginning on or after July 1, 2007 and before July 1, 2008 75% for cost reporting cycles beginning on or after July 1, 2008 Legislation pending in Congress would freeze the threshold at the current 60%. Source: MedPAC, 2007 10 Confidential and Proprietary © June 2007 Sg2
  11. 11. Shifts in Case Mix Illustrate the Direct Impact of Regulatory Change Akron General Edwin Shaw Rehab, Distribution of Most Common Types Volume by Patient Diagnosis 1997–2006 of Cases in Inpatient Rehabilitation Facilities, MedPAC 500 Types of Cases 2004 2005 2006 470 440 450 437 437 Stroke 16.6% 19.0% 20.3% 419 400 397 Major joint Ortho 372 24.6% 21.3% 18.4% 357 replacement 350 Hip fracture 13.1% 15.0% 16.0% 300 Burns 11.8% 10.4% 10.2% 250 Stroke Neurological 5.1% 6.0% 6.7% 208 203 191 186 182 200 184 180 174 Brain injury 4.0% 5.1% 5.8% 201 Brain Injury 163 150 141 Other orthopedic 5.2% 5.1% 5.0% 140 140 123 119 126 100 Spinal cord injury 4.4% 4.4% 4.6% 97 64 93 79 77 Gen Med 65 60 58 Cardiac 5.2% 5.2% 4.0% SCI 54 53 50 50 49 43 36 36 34 32 31 28 26 23 17 17 Other 14 10% 9.5% 9.0% Neuro 0 1997 2000 2001 2002 2003 2004 2005 2006 IRF PPS 11 Confidential and Proprietary © June 2007 Sg2
  12. 12. Beware of Basing Future Success With the 75% Rule on Past Performances ESR 75% Rule—Conditional and Presumptive Compliance, Newest Regulatory Rule Application Percent 90 85 77 80 75 73 70 67 66 70 65 60 75% Conditional 58 60 50 75% Presumptive 40 30 20 10 0 2002 2003 2004 2005 2006 12 Confidential and Proprietary © June 2007 Sg2
  13. 13. Government Effort to Control Cost Has Shifted Acuity and Discharge Disposition There has been a decrease in days in acute care facilities.* This is due to a multitude of factors, such as reimbursement changes and technology advancements. ESR has seen a 15% increase in the average CMI from 2002 (CMI=1.17) to YTD (CMI=1.37). Regulation has dramatically impacted discharge disposition. IRF percent discharge to the community has decreased from 84% in 1998 to 70% today. Despite the acuity shift, Medicare continues to redefine CMG length of stay. IRFs at a Glance, MedPAC 2002–2005 Annual ∆ ∆ 2002 2003 2004 2005 2002–2004 2004–2005 Number of Cases 439,631 478,723 496,695 449,321 6.4% -9.5% Medicare Spending (Billions) $4.9 $6.2 $6.6 $6.4 15.5% -3.0% Payment per Case $11,152 $12,952 $13,275 $14,248 9.1% 7.3% ALOS (days) 13.3 12.8 12.7 13.1 -2.4% 3.6% *ESR has traditionally accepted patients from acute care sooner than regional and national averages, but this disparity has begun to level out. CMI = case mix index. 13 Confidential and Proprietary © June 2007 Sg2
  14. 14. Despite the Regulatory Challenges, Large Margin Variability Suggests Opportunity The aggregate Medicare margin for 2005 was Medicare Margins by Type of IRF 13%. Type of IRF 2003 2004 2005 25th percentile: -4% margin 75th percentile: 22% margin All IRFs 17.8% 16.2% 13.0% For-profit has 2x margin of nonprofit 2007 margin estimates: 2.7% due to 75% rule Urban 18.6% 16.8% 13.5% Payer mix will continue to shift. Rural 10.0% 10.5% 8.4% Medicare may no longer be the majority payer due to Medicare Part D. Freestanding 23.0% 24.3% 20.9% Edwin Shaw payer mix example: 2003: 59% Medicare Hospital-based 14.9% 12.0% 8.5% 2006: 47% Medicare April 2007 YTD: 32% Medicare Nonprofit 14.3% 12.4% 9.6% Reimbursement will continue to fluctuate. For-profit 24.5% 24.5% 20.0% National Medicare reimbursement/day 2001 pre PPS : $1,414 Government 10.8% 9.0% 5.0% 2002 post PPS : $976 2006 post PPS : $1,114 PPS = prospective payment system. Sources: MedPAC: Report to Congress: Medicare Payment Policy, March 2006. 14 Confidential and Proprietary © June 2007 Sg2
  15. 15. Regulatory Changes Has Caused the Roles of Postacute Care Settings to Blur There is increasing debate over the best care setting as the government pushes for universal outcome and reimbursement methodology. Individual “silos” of postacute care don’t function as an integrated system. There is no common patient instrument used to assess patient care and guide placement decisions. Payment reflects the resource needs of the patient and not the setting. Outcomes don’t gauge the value of the care furbished. Almost nothing is known about: Patterns of postacute care use across settings The costs associated with particular patterns How providers have altered patterns of postacute care use in response to changing financial incentives Several barriers inhibit integration. Case mix measurement is inaccurate. Data on quality and outcomes are not comparable. Evidence-based standards are lacking. 15 Confidential and Proprietary © June 2007 Sg2
  16. 16. Data Suggest Shift From IRFs to Other Settings Number of Rehabilitation Facilities, 1985, 1996, 2004–2006 % Change 1985 1996 2004 2005 2006 2004–2006 Rehab Hospitals and Units 454 1,050 1,359 1,233 1,227 -9.7% Hospitals 68 195 218 218 218 0% Units 386 841 1,141 1,015 1,009 -11.6% CORFs 86 378 638 637 634 -0.6% Long-Term Care Hospitals 86 185 317 363 385 21.5% SNFs 6,725 15,338 14,935 14,129 15,028 +0.6% Major Takeaways: <13% of IRFs will qualify as such if they continue to serve populations excluded from the 75% rule. Facilities are either closing, merging or changing to LTACH or SNFs. LTACH growth is expected to slow. MedPAC, stating that there is excess capacity and few clinical studies, suggested a $460 million cut from Medicare reimbursement over the next 3 years. CORF = comprehensive outpatient rehabilitation facility. Source: American Medical Rehabilitation Providers Association. 16 Confidential and Proprietary © June 2007 Sg2
  17. 17. What Does the Future Hold For Postacute Care? ? 1998 SNF: PPS 2000 HH: PPS Increased postacute care utilization 1997 HH: Interim 2004 IRF: 75% Rule Continued government reaction to increase Payment System utilization and cost 2002 IRF: PPS Drive for additional rehabilitation research 2002 LTCH: PPS Push for consistent reimbursement and patient functional measures 2000 OP: Pmt Cap Past Future 1995 2000 2005 2010 2015 2020 2025 2030 1997: BBA 2003: MMA 1999: IHI Report 1996: HIPAA BBA = Balanced Budget Act; MMA = Medical Modernization Act; IHI = Institute for Healthcare Improvement; HIPAA = Health Insurance Portability and Accountability Act. 17 Confidential and Proprietary © June 2007 Sg2
  18. 18. Agenda Introduction Changing World of Inpatient Rehabilitation Strategies for Successful Management of Inpatient Rehab Facilities Questions
  19. 19. Utilize 4 Strategies for Success in the Management of IRFs 1. Understand your current market and operations to determine feasibility of IP rehab. 2. Monitor and collect data to improve outcomes and reimbursement. 3. Communicate, educate and coordinate. 4. Differentiate your services. 19 Confidential and Proprietary © June 2007 Sg2
  20. 20. 1. Assess Your Market Location of IRFs in the US, 2004 Implications: The number of IRFs vary geographically making competition differ greatly by region. The IRF setting may not be appropriate for your market. Key questions to help assess your market: Who provides IRF services in your market? Are there subacute rehabilitation or long-term acute care services available? Who provides home health and outpatient services? How has Medicare Part D affected your payer mix? Is there population growth in the 45+ age cohort? How are your services differentiated? 20 Confidential and Proprietary © June 2007 Sg2
  21. 21. 1. Understand Current Capabilities Where does rehabilitation fit in your system? Is rehabilitation a core service? Assess your internal capabilities. Consider all options for Women’s Health providing rehab. Cancer Orthopedics Internal development Partnership Acquisition Joint venture Cardiovascular Pediatrics Neurosciences 21 Confidential and Proprietary © June 2007 Sg2
  22. 22. 1. Understand Current Capabilities Current Capabilities Checklist Clinical Expertise Do you have a physician champion (physiatrist) for rehabilitation? (MD, PT, OT, SP) Does your staff have particular specialized expertise (RN, PT, OT)? Current Patient Mix Do you have the volumes to support the 75% rule? Resource What resources is your organization willing to dedicate to Dedication rehabilitation (financial, facilities, equipment, training, etc)? Care Coordination Do strong referral pathways exist? (Internal and What relationships do you have with other postacute care providers? External Referrals) Equipment Do you have appropriate equipment to meet patient demand? Dedicated Space Do you have enough dedicated space to meet patient volume? 22 Confidential and Proprietary © June 2007 Sg2
  23. 23. 1. Consider Various Structural Models for Providing IP Rehabilitation IP Rehab Models: Partnership Example: Rehabilitation Institute of Chicago and St Joseph Regional Medical Center, South Bend, IN Example: Telemedicine and St Luke’s Rehab Institute, Spokane, WA Joint Venture Example: Seton Family of Hospitals, Austin, TX, and RehabCare Group, Inc Internal Development For hospitals that don’t offer rehab or are considering limiting rehab, a specialized hospital unit trained to care for specific patient population can be successful. Example: comprehensive stroke units Specialized interdisciplinary stroke teams Patient remains in same bed throughout acute and rehab stages of care Lower ALOS Higher patient satisfaction Better outcomes Acquisition Example: Akron General Edwin Shaw Rehab 23 Confidential and Proprietary © June 2007 Sg2
  24. 24. 1. Partnership Case Example Partnership between St Joseph Regional Medical Center (South Bend, IN) and the Rehabilitation Institute of Chicago Evaluated growth rate in its regional market of north central Indiana and southwest Michigan Determined there was a 12% 5-year growth rate in the aged 65+ population, the largest users of rehabilitation Partnered with RIC to expand physical medicine and rehabilitation (PM&R) services Allows SJRMC to be only health care system in region to offer RIC’s full spectrum of PM&R for acute and postacute care Med/surg rehab Inpatient rehab Long-term acute care OP rehab 24 Confidential and Proprietary © June 2007 Sg2
  25. 25. 1. Partnership Case Example Technology can assist with staffing limitations. St Luke’s Rehab Institute (Spokane, WA) Telemedicine: 20 telemedicine sites across rural eastern Washington link Inland Northwest Health hospitals to St Luke’s. St Luke’s therapists can teleconference with PTs in tertiary care hospitals. Assist PT in setting up treatment regiments Perform physical examinations of patients Form support groups Results: Improves communication Uses staff resources more efficiently Helps with specialist shortages Printed with permission of InTouch Health. 25 Confidential and Proprietary © June 2007 Sg2
  26. 26. 1. Joint Venture Case Example Joint Venture Between Seton Family of Hospitals (Austin, TX) and RehabCare Group, Inc Freestanding Facility Rehab Unit Within Seton Medical Center 36 bed IRF 26 bed SNF 40 bed LTACH Initial Steps: Joint venture: Initially losing money in SNF despite high 80%/20% ownership (RehabCare/Seton) occupancy rates meant minimal capital investment for Moving rehab to a freestanding facility to Seton allow SNF beds at Seton to be converted into 50%/50% representation on board additional acute med/surg beds Can still capture rehab patients In interim, re-licensed SNF beds as IRF beds unqualified for IRF until the new facility is built Enhanced care provision and patient experience 26 Confidential and Proprietary © June 2007 Sg2
  27. 27. 2. Monitor and Collect Data Collect data. Uniform Data Set for Medical Rehabilitation Understand the regulatory impact for your system. Understand Ruling: 85-2’s definition of “reasonable and necessary” in order to defend a rehabilitation level of care using the 8 screening criteria established by CMS. Make this part of the mind set for the preadmission screening process. Compare conditions in 75% rule and associated ICD-9 codes with your patient population diagnoses and ability to meet “medical necessity” requirements. A predominantly neurologically impaired patient population will be able to more easily comply with the 75% rule. If you have an IRF, analyze acute care discharges to see if additional patients could be captured. 27 Confidential and Proprietary © June 2007 Sg2
  28. 28. 2. Monitor and Collect Data Understand Ruling 85-2’s definition of “reasonable and necessary” in order to defend a rehabilitation level of care using the 8 screening criteria established by CMS. Make this part of the mind set for preadmission screening process. 1. Close medical supervision by a physician with specialized training or experience in rehabilitation 2. 24-hour rehabilitation nursing: Review fall risk, pain level, safety interventions, skin interventions, bowel/bladder interventions and the need for rehabilitation nursing carry over in ADL training 24hrs/day. 3. Relatively intense level of rehabilitation services: Amount of therapy provided; either here or section 5; include specialty consults; orthotics, etc. 4. Multidisciplinary team approach to delivery of program, looking specifically at all persons that must be involved; must have at least 2 therapies 5. Coordinated program of care is required. 6. Significant practical improvement is expected. This takes an experienced clinician to review all the data and preadmission hints of recovery. 7. Realistic goals: Try to be certain the support systems are available to help meet those goals. 8. Length of rehabilitation program: Keep in mind that you are using the probable CMG LOS as the target. 28 Confidential and Proprietary © June 2007 Sg2
  29. 29. 2. Monitor and Collect Data Evaluate staffing coverage. Set guidelines to assist in staff coverage: Number of patients with infections that result in isolation Number of high level spinal cord injury Number of brain injury patients If applicable, cross train in order to float staff between care settings. Outpatient staff can move to inpatient. Nursing and therapy staff can float between skilled and rehab units. 29 Confidential and Proprietary © June 2007 Sg2
  30. 30. 2. Monitor and Collect Data Johns Hopkins Hospital Average Length of Stay (ALOS) Reduction Project Background/ Longer stay doesn’t result in higher payments. Goal LOS was measured against country’s most efficient hospitals and adjusted for case mix and severity. LOS was compared among similar cases with different physicians. Actions Based on data, an action plan was created. Delays in diagnostic tests and consultative work were reduced. Social workers and case workers began postdischarge planning early on. Clinicians focused on proven best practices. Proper coding of the severity of cases was assured so that predicted LOS was appropriate. For given diagnosis, appropriate LOS was determined and adhered to. Results Overall ALOS was reduced to 9 days. There is a point when LOS levels off—it is important to maintain equilibrium between LOS and quality of care. 30 Confidential and Proprietary © June 2007 Sg2
  31. 31. 3. Communicate, Educate and Coordinate Communicate and Educate Physicians Improve outcomes and initiate ownership Case Managers by informing all stakeholders of: Regulatory changes and implications Therapists Operational data Nurses Care model changes/care protocols Care coordination Administration Coding changes Technology adoption Patients The rehabilitation staff must be flexible. Acute care treatments are changing rapidly, which requires customized postacute patient care plans. Education is key. Not only must staff continue to seek education around new care protocols and best practice, but staff must also understand regulatory and reimbursement changes that impact care provision. 31 Confidential and Proprietary © June 2007 Sg2
  32. 32. 3. Decision Trees Assist in Appropriate Patient Placement Yes Yes Will Insurance permit level of Does patient demonstrate the need for 24 hr availability Can patient be safely managed care suggested after patient of a rehab physician, close medical supervision, ie, needs in a nonacute environment? information is reviewed? to be examined by a physician every 2-3 days? No No No Yes Delay admission until Follow criteria for admission outlined Admit to skilled if meets skilled information is received. by insurer (advocate when possible). nursing or therapy criteria. Is there potential for significant Does the patient require and have the ability to tolerate an extensive level of Does patient Yes Yes improvement in a reasonable therapy (≥2 disciplines) generally ≥3 hrs/day within the first 10 days? Or is require 24 hrs length of time that is of practical there the presence of a secondary diagnosis or medical complication that availability of a value to the patient and may prevents participation in 3 hrs/day therapy initially but can soon be ramped up? rehab nurse? result in return to community? No Yes Follow SNF criteria. Yes Yes After medical necessity is met, Yes Is family/caregiver Is the patient a is there a qualifying RIC or Does the patient have a cognitive/memory deficit available for recent brain injury a diagnosis that follow the that impairs/prohibits the ability to learn? teaching with a Rancho 75% rule? requirements? score ≥3? No No No Check with PPS coordinator and Review if appropriate for short term SNF care. If Rancho <3, follow SNF look at SNF criteria. If not appropriate, do not admit to ESR. criteria. Yes If it is expected that the patient Does the patient require a Does the patient require that a Admit to No No will require assist at discharge, Yes dialysis, radiation or prosthesis be fabricated within is there presence of a capable ESR chemotherapy? initial rehab stay? care giver? Yes Yes No Team discussion, if answer still ‘no’, Follow SNF criteria. Follow SNF criteria. Source: Akron General Edwin must be approved by med. Dir/or VP. Shaw Rehab. 32 Confidential and Proprietary © June 2007 Sg2
  33. 33. 3. Decision Trees Can Be Tailored to Specific Conditions Framework for Rehabilitation Decisions Poststroke Yes Yes Is patient medically Does patient have a Is patient able to Yes moderately stable? functional disability? learn? Rehabilitation Does patient have setting with low No No endurance to sit No intensity services supported for 1 hour (nursing facility or Delay rehabilitation Provide care in setting Does not need and to participate No home program) decision until medical with adequate rehabilitation actively in stability is achieved. supportive services. rehabilitation? Level of Supervision Moderate/ Maximum Independent Minimum Assistance Assistance Can patient manage IADLs, including Is adequate home Can patient tolerate intense meals, telephone, and transportation? support available? rehabilitation (≥3 hours/day)? Yes No Yes No Yes No Home or OP program, a Does patient Brief IP Setting with brief IP program in a need 24-hour program in Home or OP lower intensity Is adequate nursing facility or hospital medical care or nursing facility rehab services services home support may be indicated if patient monitoring? or immediate as needed (nursing facility, available? has multiple complex care facility home program) deficits. No Yes Yes No IP rehab hospital nursing facility Setting with intense services and Home or OP rehab with intensive rehab program Rehabilitation services in adequate medical coverage may services as needed capabilities and adequate acute nursing facility or other be IP rehab hospital, nursing care coverage supervised living setting facility or home program IADL = instrumental activities of daily living. Source: Gresham GE et al. Stroke 1997. 33 Confidential and Proprietary © June 2007 Sg2
  34. 34. 3. Communicate, Coordinate and Educate Case Example: University of Iowa Hospitals and Clinics, Iowa City, IA Relied on Physician Referrals Referrals Based on Consultation of for Rehab Volumes All Patients by PM&R Physician Results Results Wide variation in referrals Determines care plan and coordinates patterns by physicians appropriate rehab and follow-up Discharge planning left to primary Does not rely on individual physician physician, care manager, social prescribing patterns worker and PT/OT, not rehab Results in early initiation of therapy, which physician can improve functional outcome No team-specific rehab team Reduces LOS and improves operating Underutilization of PT and poor margins capture of OP PT/OT Increases patient satisfaction, leading to Prolonged LOS increased utilization of other services (elective) Increases utilization of OP rehab services 34 Confidential and Proprietary © June 2007 Sg2
  35. 35. 4. Differentiate Your Services Technology adoption in rehabilitation is expected to be slow, making differentiation in service and programming key. Service and comprehensive programming Patient and family access (location and convenience) Quality of care Spa/fitness center Family education Support groups Facilities Specialized programs (eg, stroke program) Flexible care model (staffing and bed type) Continuous survey of the market Technology 35 Confidential and Proprietary © June 2007 Sg2
  36. 36. 4. Differentiate Your Services: Incorporate a Flexible Care Model Changes in acute care utilization will impact location and volume of rehab services. Technology/Trend Impact on Rehabilitation MIS approaches Shifts from IP to OP, OP and Reduce patient length of stay home based services increase Increase patient volumes and session numbers reduced Shift care outpatient Medical therapies Reduce inpatient admissions Reduce IP, increase OP Increase physician office visits Reduce LOS Implantable therapies Increase IP, increase OP Increase inpatient and outpatient volumes 36 Confidential and Proprietary © June 2007 Sg2
  37. 37. 4. Differentiate Your Services: Incorporate a Flexible Care Model “We leverage and coordinate the admission to SNF and IRF by using the decision tree and ruling 85-2. We also negotiate with payers that tend to place ALL their patients on SKILLED by defending expected outcomes and data we have for a specific patient population treated on REHAB. Expertise and programming are very specific on the brain injury unit for example. To fully execute the brain injury protocol and functional cognitive training advancements, the patient must be placed on that unit.” —Edwin Shaw Rehab 37 Confidential and Proprietary © June 2007 Sg2
  38. 38. 4. Differentiate Your Services: Emerging Technology Advances in Rehab Technology Considerations Constraint-Induced Low-tech approach and requires no capital investment Movement Therapy Utilized in IP, OP and home-based rehab Robotics High-tech and high capital investment Various models in development for many different impairments Could be utilized in IP and OP rehab; home-based rehab in the long term Virtual Movement High-tech and high capital investment Spaces Various models mostly for support of occupational therapy Could be utilized in IP and OP rehab; home-based rehab in the long term Stem Cell Research Stem cell transplantation combined with exercise training to enhance repair and regeneration of nervous tissue after spinal cord injury Genetic Genes turned on/off, simple variation on genotype to produce wide differences in Engineering phenotype; possible direct implications for the variability among rehab patients and functional outcomes in patients with the same diagnosis Response to exercise training determined partially by the activation of certain genes, therefore matching patients to rehab interventions may be more successful Tissue Engineering Evaluation of clinical/functional demands on new cartilage, muscle and bone needed before designing new organs and tissues Nanotechnology Better materials to fabricate better assistive devices (artificial limbs, orthotics, other assistive devices) 38 Confidential and Proprietary © June 2007 Sg2
  39. 39. 4. Regenerative Medicine Is the Next Generation of PM&R Tools of regenerative medicine expand neurorehabilitation. Neurorehabilitation Tomorrow Emerging technologies Physical medicine and rehabilitation and approaches increase Mechanical and electrical implants demand for physical Injectable biologics medicine and rehabilitation Bionics specialists, making them highly sought after in the Today 2010s and 2020s. Physical medicine and rehabilitation 39 Confidential and Proprietary © June 2007 Sg2
  40. 40. 4. Differentiate Your Services: Incorporate a Flexible Care Model Regenerative medicine will create an opportunity for long-term relationships. Significant time is required to regenerate neuronal connections. April Today: March February Rehabilitation lasts weeks to months. 10 January 10 Short-term opportunity exists to 10 2006 10 2006 capture secondary utilization. 2006 2006 Tomorrow: January Rehabilitation lasts years. January January 10 Long-term opportunity exists to 10 January capture secondary utilization. 10 2006 2007 10 2008 2009 40 Confidential and Proprietary © June 2007 Sg2
  41. 41. Agenda Introduction Changing World of Inpatient Rehabilitation Strategies for Successful Management of Inpatient Rehab Facilities Questions
  42. 42. Questions?
  43. 43. Sg2 is a forward-thinking health care research, consulting and education company. Sg2 analyzes emerging clinical developments, technological advancements and market trends to help clients make informed business decisions, advance clinical excellence, streamline operations, grow market share and exceed financial goals. 43 5250 Old Orchard Road Skokie, IL 60077 866 681 3343 Confidential and Proprietary © June 2007 Sg2