1 ACUTE INPATIENT REHABILITATION: MEETING THE NEEDS OF THE TRAUMA PATIENT St. Mary Rehabilitation Hospital
2 Goals for today s presentation: Admission 1. Clarify the inpatient rehabilitation admissions process. 2. Identify trauma programming needs in the inpatient rehabilitation level of care. 3. Discuss environmental needs of the trauma patient. 4. Communicating outcomes - closing the loop with the trauma staff. Discharge 5. Discharge from inpatient rehab what happens next? Best Practice
3 St. Mary Rehabilitation Hospital Acute Inpatient Rehabilitation Goals: Quickly and appropriately identify, assess and transition trauma rehab candidates from acute care to inpatient rehabilitation.
4 Benefits of Early Rehabilitation Why Early Transfer is Important 1. Prevent complications that could later impact mobility and function. (Spasticity, Contractures, Heterotrophic Ossification, Atrophy, Pressure Ulcers) 2. Mobilize the patient as early as possible. (Facilitate verticality, proper seating/ seating schedules, assist with pulmonary function and circulation, prevents muscle atrophy and facilitates strengthening, prevents medical complications associated with bed rest such as DVT and pressure ulcers) 3. Restore Function. (ROM activities and strengthening exercises, gait training, ADLs such as dressing, bathing and using the toilet, access to augmentative communication devices, implementation of cognitive and behavioral treatment plans). 4. Patient / Family Teaching (Proper positioning and re-positioning, ROM, communication techniques, inclusion in cognitive and behavioral treatment plans).
5 Transition to Acute Rehab Early identification of trauma patients appropriate for acute rehabilitation Rehab Admission Liaison(s) participate in acute trauma rounds Candidates identified early and followed by rehab admissions PM&R consulted ASAP to follow Pre- Admission Assessment completed Face to face assessments on ALL referrals Updated within 48 hours of transfer Once patient is medically stable, quick turnaround time from referral to admit < 24 hours
6 Inpatient Rehabilitation Admission Criteria Who is an appropriate acute rehab candidate? Medical Necessity Criteria Complex enough to meet Medical Necessity criteria Stable enough to tolerate 3 hours of therapy 60% Rule 100% Rule
7 Inpatient Rehabilitation Admission Criteria 60% Rule 1. Stroke 2. Spinal Cord Injury 3. Congenital Deformity 4. Amputation 5. Major Multiple Trauma 6. Fracture of Femur (hip fracture) 7. Brain Injury 8. Neurological Disorders 9. Burns 10. Active, polyarticular rheumatoid arthritis, psoriatic arthritis and seronegative arthopathies 1. Systemic vasculidities with joint inflammation 2. Severe or advanced osteoarthritis involving two or more major joints, with joint deformity and substantial loss of ROM and atrophy, significant functional impairment of ambulation and other ADLs. 3. Hip & Knee Joint Replacement patients if at least one of the following conditions also exist: bilateral knee or bilateral hip replacement, BMI of 50 or above, 85 years or older
8 Inpatient Rehabilitation Admission Criteria Medical Necessity All patients must meet Medical Necessity Criteria: ALL PATIENTS MUST MEET MEDICAL 1. Services must be reasonable NECESSITY and necessary CRITERIA in terms of efficacy, frequency, duration, and amount, for treatment of the patient s condition. 2.You must be able to show the patient CAN NOT be treated in a lesser level of care i.e. SNF or outpatient. This should be well documented in the acute care medical record.
9 Inpatient Rehabilitation Admission Criteria Medical Necessity Patient must be sufficiently stable at time of admission to allow patient to actively participate. The patient s condition must require 24-hour availability of a rehab physician for the management of medical conditions to support participation in an intensive program. At the time of admission, the patient must required the active and ongoing therapeutic intervention of at least two therapy disciplines. Patients must require an intense rehab program and are expected to actively participate and benefit from at least 3 hours of therapy per day at least 5 days per week. Patients are expected to make measureable improvement in functional capacity in a reasonable period of time (generally 2 weeks). There is the realistic goal that the patient will achieve modified independence in self-care and ADLs to allow the individual to return to a community based environment (home, assisted or independent living). The complexity of the patients nursing, medical management and rehabilitation needs require an inpatient stay and interdisciplinary team approach. The patient s prior level of function is taken into consideration to ensure goals are realistic.
10 Onset Days CY 2012 November YTD St. Mary Rehab Unit Mean Onset = 7.7 days Region Adjusted Mean Onset = 10.5 days Nation Adjusted Mean Onset = 10.9 days
11 St. Mary Rehabilitation Hospital Acute Inpatient Rehabilitation. Goals: Identify and meet trauma programming needs.
12 Inpatient Rehabilitation Trauma Programming Needs Managing Medical Complexity Brain Injury Spinal Cord Injury Multiple Fracture Hip Fracture Traumatic Amputation
13 Inpatient Rehabilitation: Trauma Programming Managing Medical Complexity Physician Model: PM&R Attending + Medical Co-Manager On Site Consultant Support ID, Cardiology, Pulmonary, ENT, Nephrology, Psychiatry On Site Ancillary Support Access to Radiology Lab Pharmacy Dialysis Nutrition Respiratory Clinical Staff Training & Competency to manage medical needs and identify complications
14 Inpatient Rehabilitation: Trauma Programming Emergency Management 1. Unit within an acute care hospital Integrated Rapid Response/ Code Teams Physician led 2. Freestanding Facility Facility Rapid Response Team RN leads in off-hours Acute Transfer 911
15 Managing Medical Complexity Transfers to Acute Care Impact on readmissions for referring acute care hospitals. Weekly / Real Time Review Transfer < 4 day LOS was admission appropriate? Look at onset days Were resources available to medically manage the patient in house? (consultants / equipment) Telemetry EKGs Lessons learned
16 Managing Medical Complexity Transfers to Acute Care SMMC Transfers to Acute = 12.9% Region Transfers to Acute = 12.5% Nation Transfers to Acute = 12.1% October 2012
17 Managing Medical Complexity Transfers to Acute Care October 2012 Admission Date Discharge Date CMG DX AGE LOS Adm FIM Dis FIM FIM Chg LOSE Onset 10/22/ /26/2012 A /12/ /23/2012 B /08/ /19/2012 A /09/ /17/2012 A /12/ /16/2012 B /29/ /09/2012 B /24/ /04/2012 B /28/ /01/2012 D0304 Ortho Miss. Stroke Stroke Miss. Stroke Miss. NTBI Average Admission FIM = 55 Average Discharge FIM = 92 Average FIM Change = 37 Average Length of Stay Efficiency = 3.33 Average Onset Days = 7.7 days
18 Inpatient Rehabilitation: Trauma Programming Brain Injury Admissions must meet criteria, determined on a case by case basis. Must be able to at a minimum respond to localized stimulation (Rancho 3) Cognitive & Behavioral Focus Neuropsychology co-captain Psychiatry meds All staff trained and competent in cognitive & behavioral strategies Regulate the environment low stimulation, structure, safety is key Physical Rehabilitation Spasticity Management Adaptive Seating & Positioning Dietary needs Psychological support/ counseling for family Community Reintegration (driving evaluations, accessible vans, ramps, ) Establish resources and relationships for the next level of care, including vocational rehab, community resources and advocacy.
19 Inpatient Rehabilitation: Trauma Programming Traumatic Spinal Cord Injury Admissions must meet criteria, determined on a case by case basis. Vent dependent patients accepted in some IRFs. Physical Rehabilitation: Respiratory Needs Adaptive Seating Spasticity Management Consultants to address: Sexuality / Fertility Urology Psychological Support for patient and family, peer mentoring, support groups Staff competencies ASIA Scale, Autonomic Dysreflexia, Bracing, Positioning (tenodesis), Bowel & Bladder Community Reintegration (driving evaluations, accessible vans, ramps, ) Establish resources and relationships for the next level of care, including vocational rehab, community resources and advocacy.
20 Inpatient Rehabilitation: Trauma Programming Multiple Fractures Admissions must meet criteria, determined on a case by case basis. Patient must be able to bear weight on at least 2 extremities. Physical Rehabilitation: Management of Medical / Orthopedic Complications Nerve Injury, Wounds Weight bearing status may affect admissions Orthotic Management Psychological Support Screen for Mild TBI Staff Competencies focused on prevention and identification of complications
21 Inpatient Rehabilitation: Trauma Programming Hip Fracture Admissions must meet criteria, determined on a case by case basis. Weight bearing status and discharge disposition may limit admission. Physical Rehabilitation: Management of Medical / Orthopedic Complications Fall Prevention Home Evaluation may be necessary Patient / family education re: fall prevention strategies Staff Competencies focused on prevention and identification of complications.
22 Inpatient Rehabilitation: Trauma Programming Traumatic Amputation Admissions must meet criteria, determined on a case by case basis. Patients may be eligible for 2 inpatient rehab stays, one for pre-prosthetic functional training and then prosthetic training once residual limb is healed and patient has prosthesis. Acute Inpatient Rehab can admit direct from home with NO 3-DAY QUALIFYING HOSPITAL STAY REQUIRED. (We are licensed as an acute care hospital). Physical Rehabilitation: Wound care Relationship with prosthetic vendors access to cutting edge technology Psychological support, peer mentoring, support groups Introduce to adapted leisure activities PA Adaptive Sports Asso. Establish resources and relationships for the next level of care, including vocational rehab, community resources and advocacy. Staff Competencies, including wound care, stump wrapping, donning & doffing prosthetics
23 St. Mary Rehabilitation Hospital Acute Inpatient Rehabilitation Goals:. Provide the right environment to suit the patient.
24 St. Mary Rehabilitation Hospital Projected Opening: December 2013
25 Inpatient Rehabilitation Environmental Needs Dedicated units for Brain Injury, Stroke, SCI, Musculoskeletal De-centralized Nurses Stations decrease noise bring staff closer to patients Overhead lifts available on all units Dedicated bariatric rooms on each unit Private rooms (infection control, bed management) Multiple ADL suites Outdoor therapy space Meditation room Home like environment, multiple indoor and outdoor gathering spaces Dining Options independent counter, outdoor space
26 Inpatient Rehabilitation: Environmental Needs Brain Injury Unit Secured Unit for Safety Self Contained Gym, Dining, Speech, Neuropsychology, Day Room within the secured unit Low stimulation, very structured setting Cognitive and behavioral focus Safety Features: Video Monitoring in all rooms 2 sound resistant rooms/ soft flooring Non breakable mirrors Windows with enclosed blinds Breakaway privacy / shower curtains Tamper proof smoke detectors, sprinklers, electric devises Dimmer lights Airplane lighting
27 Inpatient Rehabilitation: Environmental Needs Spinal Cord Injury Unit Respiratory located adjacent to unit Support equipment needs Consider vent dependent patients, gases in all head walls Loaner programs for seating, environmental control units, etc.. Special equipment needs (Exoskeleton, Lokomat, etc ) Access to community settings Outdoor surfaces, car transfers, etc
28 Inpatient Rehabilitation: Environmental Needs ADL Suites Simulated home setting Living Room, Bedroom, Kitchen, Bath, Laundry Live ADLs Working kitchen, laundry, showers/tubs Opportunity to practice real life situations Asses safety for return to home Simulated storefront Money exchange, balance opportunities, shopping carts, etc
29 Inpatient Rehabilitation: Environmental Needs Outdoor Therapy Space Therapy Courtyard Varied surfaces for gait training, transfer SUV, putting green, basketball court Wheelchair access gazebo Healing Gardens Contains wheelchair accessible areas Secured garden area for brain injury program For some patients, going outdoors is an experience they haven t had in many months of hospitalization. The benefits of spending time outdoors feeling sunshine, hearing birds, smelling flowers help to reconnect patients to the real world. Opportunities for Horticulture Therapy Outdoor Dining Provides an opportunity for socialization in a real life setting.
32 St. Mary Rehabilitation Hospital Acute Inpatient Rehabilitation. Goals: Demonstrate and communicate positive outcomes.
33 Inpatient Rehabilitation: Communicating Outcomes Outcome Scales Functional Independence Measure (FIMTM) A scale used to measure one s ability to function independently. 18 items are rated in the areas of self care, bowel and bladder management, mobility, communication, psychosocial adjustment, and cognitive function. FIM scores are collected the first 72 hours after admission to the rehabilitation unit and again within 72 hours before discharge. Some facilities do telephonic follow up FIMs between 80 to 180 days after discharge. The FIM score ranges from 1 to 7, with 1 (Total Assistance) being the lowest possible score and 7 (Complete Independence) being the best possible score.
34 Inpatient Rehabilitation: Communicating Outcomes What We Can Measure Onset to Admission Days Admission FIM Discharge FIM Change in FIM Length of Stay Length of Stay Efficiency Case Mix Index Discharge Destination Co-Morbid Capture
35 Inpatient Rehabilitation: Communicating Outcomes General Outcome Data Trauma mix averages 20-25% of total rehab mix
36 Inpatient Rehabilitation: Communicating Outcomes General Outcome Data Discharge goal is to return to the community. St. Mary Rehabilitation Unit Discharge Disposition CY 2012 October YTD Facility Region Nation Community 77.8% 73.4% 73.5% Long Term Care / SNF/ Other 9.9% 15.2% 15.8% Acute Care 12.3% 11.4% 10.8%
37 Admission FIM 2012 November YTD Facility Mean Admission FIM = 55.9 Region Adjusted Mean Admission FIM = 56.1 Nation Adjusted Mean Admission FIM = 55.8 Acute Care RNs can help by documenting any incontinence or accidents the patient has in acute care.
38 Discharge FIM 2012 November YTD Facility Mean Discharge FIM = 92.3 Region Adjusted Mean Discharge FIM = 87.1 Nation Adjusted Mean Discharge FIM =85.6
39 LOS Efficiency 2012 November YTD Facility Mean LOSE = 3.42 Region Adjusted Mean LOSE = 2.76 Nation Adjusted Mean LOSE =
40 Inpatient Rehabilitation: Communicating Outcomes Individual Patient Profiles PATIENT SUMMARY Patient ID: M Birth Date: 01/29/1926 Eating Age at Admission: 86 years Memory Grooming Gender: Female Problem Solving Social Interaction Expression Bathing UE Dressing LE Dressing CASE SUMMARY Admission: 06/17/2012 Impairment Group Code: Unilateral Hip Fracture Onset Date: 06/12/2012 Etiologic Diagnosis: Comprehension Toileting Actual Length of Stay: 15 days CMG Expected LOS: 17 days CMG: A0704 Stairs Bladder Primary Pay Source: 02 - Medicare Locomotion Tub/ Shower Transfer Toilet Transfer Bowel Bed / WC / Chair Transfer Special CMG: Admission Date: 06/28/2012 Discharge Date: 07/13/2012 Discharge Living Setting: Home
41 Inpatient Rehabilitation: Communicating Outcomes CMS Quality Indicators October 2012 New or Worsening Pressure Ulcers CAUTIs 2014 Readmissions Readmit to acute care facility within 30 days of IRF discharge
42 Inpatient Rehabilitation: Communicating Outcomes IRF PEPPER Reports First IRF PEPPER issued by CMS in September 2012 Target Areas: 1. Miscellaneous CMGs 2. CMGs at Risk for Unnecessary Admissions 3. Outlier Payments 4. STACH Admissions following IRF Discharge
43 St. Mary Rehabilitation Hospital Acute Inpatient Rehabilitation Goals:. Ensure the patient and family have resources to move seamlessly to the next level of care.
44 Inpatient Rehabilitation What s Next? Moving the Patient through the Continuum of Care What is the average Length of Stay for acute inpatient rehabilitation? SMMC = 12.9 Days, Region = 13.6 days, Nation = 14.2 days
45 Inpatient Rehabilitation What s Next? Moving the Patient through the Continuum of Care Discharge planning starts prior to admission. Assessment of available resources to meet potential needs Where the patient is planning on going after discharge from inpatient rehab What will the patient need to be able to do for themselves in order to be able to go there What kind of support they have from family and friends to be successful there What their insurance plan will cover after inpatient rehabilitation Family / caregiver education and training begins on admission, participation in the rehab process is encouraged. Barriers to discharge are discussed weekly in formal team conferences with the interdisciplinary team present. Follow up care initiated prior to inpatient discharge for ongoing clinical care, funding assistance, support groups, advocacy, vocational rehabilitation, driver training, etc..
46 Inpatient Rehabilitation What s Next? Moving the Patient through the Continuum of Care Facility Relationships Access to vocational rehab counselors, advocacy and support groups Peer Mentoring Relationships with post IRF providers who meet service line needs (OP, HH, Day Hospital, Cognitive programs, etc ) Links to ongoing psychological support for patient & family. BI / SCI require life long follow up
47 Inpatient Rehabilitation What s Next? Moving the Patient through the Continuum of Care Return to Work/ School Return to Spouse Return to Lifestyle Return to Home Return to Parenting
48 Inpatient Rehabilitation What s Next? Moving the Patient through the Continuum of Care Special concerns of the adolescent and younger adult must be addressed Home Environmental modifications, reintegration into family with cognitive or behavioral needs, hiring of personal assistant / caregivers, equipment Spouse Parent Work School Lifestyle Role changes, financial stress / funding for needs, sexuality, support groups, advocacy groups Caring for young children, fertility Vocational rehabilitation, driving, accommodations in the workplace Reintegration into school with cognitive or behavioral needs, transportation requirements Finances, adaptive driving, leisure activities (adaptive sports),
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