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Overall Plan of Care
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Using Team Conference to Drive Your Rehab PlanLisa Werner, MBA,
MS, CCC-SLP Overall Plan of Care Overall Plan of Care What is the
Overall Plan of Care?
Document required since January 1, 2010. Purpose is to create a
single document that all team members use to direct the care of the
patient throughout the stay. Should be used throughout the stay to
ensure that the patient is staying on the ideal course of treatment
to enable him/her to meet goals in a reasonable amount of time. The
Rule Requirement for an Individualized Overall Plan of Care
Essential to providing high-quality care in IRFs, since
comprehensive planning of the patients course of treatment early on
leads to a more coordinated delivery of services to the
patient.Such coordinated care is a critical aspect of the care
provided in IRFs. Requires that an individualized overall plan of
care be developed for each IRF admission by a rehabilitation
physician with input from the interdisciplinary team by the end of
the fourth day following the patients admission to the IRF. Must
support the determination that the IRF admission is reasonable and
necessary. Must be maintained in the medical record. The Rule
Requirement for an Individualized Overall Plan of Care
Synthesized by a rehabilitation physician from: Pre-admission
screening Post-admission physician evaluation Information garnered
from the assessments of all therapy disciplines Information from
the assessments of other pertinent clinicians The Rule Requirement
for an Individualized Overall Plan of Care
Purpose is to support a documented overall plan of care.The overall
plan of care must detail: Estimated length of stay Patients medical
prognosis Anticipated functional outcomes Anticipated discharge
destination from the IRF stay Anticipated interventions that
support the medical necessity of the admission Based on patients
impairments, functional status, complicating conditions, and any
other contributing factors. Should include these details about the
PT, OT, SLP, P/O therapies expected: Intensity (# of hours/day)
Frequency (# of days/week) Duration (total # of days during IRF
stay) The Rule Requirement for an Individualized Overall Plan of
Care
Individual clinicians will contribute, but it is the sole
responsibility of a rehabilitation physician to integrate the
information that is required in the overall plan of care and to
document it in the patients medical record. If the overall plan of
care differs from the actual length of stay and/or expected
intensity, frequency and duration, then the reasons for the
discrepancies must be documented in detail in the patients medical
record. Good practice to conduct the first interdisciplinary team
meeting within 4 days of admission to develop the overall
individualized plan of care. It is the IRFs choice to develop the
internal process. The Interpretation CMS Provider Education call
stated:
The physician is responsible for documenting the information that
pulls the overall plan of care together. Signing the plan of care
is not equivalent to synthesizing a plan of care completed by the
clinicians. The Interpretation CMS Q&As:
Rehab physician has to synthesize the plans of care, but he does
not have to write it out himself. The purpose of the overall plan
of care is to provide general direction for the team and to
establish broad goals for the patients treatment.The team members
are responsible for setting their specific plan. The intensity of
therapy should be stated, but since treatment is adjusted for the
patients individual need consider adding a statement that reflects
the times stated are an average that will be varied based on the
patients daily needs. Physician extenders can complete and sign the
form. Team Conference Weekly Team Conference
Purpose: Weekly meeting attended by a member of each treating
discipline. The purpose of the conference is to problem solve the
most effective way to meet the patients needs. Assess the
individuals progress or the problems impeding progress Consider
possible resolutions to problems Reassess the validity of the
rehabilitation goals initially established The Rule Requirement for
Evaluating the Appropriateness of an IRF Admission / Inpatient
Rehabilitation Facility Medical Necessity Criteria The patient must
require an intensive and coordinated interdisciplinary approach to
providing rehabilitation. IRF documentation indicates a reasonable
expectation that the complexity of the patients nursing, medical
management and rehab needs requires an inpatient stay and
interdisciplinary team approach. The complexity of the condition
must be such that the rehab goals indicated in the pre-admit
screening, post admission evaluation and overall plan of care can
only be achieved through weekly team conferences by an
interdisciplinary team of medical professionals. Each individual
team member will work within their own scope of practice, but is
also expected to coordinate his or her efforts with team members of
other specialties, as well as with the patient and the patients
significant others and caregivers. The Rule Requirement for
Evaluating the Appropriateness of an IRF Admission / Inpatient
Rehabilitation Facility Medical Necessity Criteria Purpose of the
interdisciplinary team is to foster frequent, structured, and
documented communication among disciplines to establish, prioritize
and achieve treatment goals. At a minimum the team must document
participation by professionals from each of the following
disciplines (each of whom must have current knowledge of the
patient as documented in the medical record at the IRF): Rehab
physician with special training and experience in rehab services;
RN with specialized training or experience in rehabilitation; A
social worker or case manager (or both); and A licensed or
certified therapist from each therapy discipline involved in
treating the patient. The Rule Requirement for Evaluating the
Appropriateness of an IRF Admission / Inpatient Rehabilitation
Facility Medical Necessity Criteria Team should be led by a rehab
physician who is responsible for making the final decision
regarding the patients treatment in the IRF.The rehab physician
must document concurrence with all decisions made by the
interdisciplinary team at each meeting. Periodic team conference
held at least once per week must focus on: Assessing the
individuals progress towards the rehabilitation goals; Considering
possible resolutions to any problems that could impede progress
towards the goals; Reassessing the validity of the rehabilitation
goals previously established; and Monitoring and revising the
treatment plan as needed. The Rule Requirement for Evaluating the
Appropriateness of an IRF Admission / Inpatient Rehabilitation
Facility Medical Necessity Criteria May be formal or informal;
however, a review of notes is not a conference. All treating
professionals from the required disciplines are expected to attend
every meeting or, in the infrequent case of an absence, be
represented by another person of the same discipline who has
current knowledge of the patient.Documentation must include the
names and professional designations for the participants in the
team conference. The occurrence of the team conferences and the
decisions made during such conferences, such as those concerning
discharge planning and the need for any adjustment to goals or the
prescribed treatment program, must be recorded in the patients IRF
medical record. Review of this requirement will focus on the
accuracy and quality of the information and decision-making, not
the internal process used by the IRF. The Interpretation CMS
Provider Education call stated:
The definition of a licensed or certified therapist from each
therapy discipline involved in treating the patient means PT, OT or
ST, but not therapy assistants. As with the requirement of a
registered nurse, the intent is that the individuals present at the
team meeting have the proper credentials to collaborate on and
adjust the patients plan of care. The Interpretation CMS
Q&As:
Patient care conferences should be held weekly, which was defined
as once every 7 days. If you move care conferences, you should hold
an interim conference to discuss the patient should the new day be
outside the 7 day window. The rehab physician can participate in
conference by phone if it is absolutely necessary.The physicians
participation by phone should be clearly documented. The
participant does not have to be the primary clinician, but
participant needs to have enough knowledge of the patient to be
able to actively participate in the evaluation of the patients
progress toward his or her goals and the modification of the
treatment plan so that it best contributes to future progress.
Patient Care Conference Notes
Barriers to getting the information that CMS asked for: Status
reporting Not understanding what a barrier to discharge is
(problems that impede progress) Plan of care is not a working
document Lack of knowledge of the patient Time limits Patient Care
Conference Notes
What do you report? Statement on progress relative to goals
Problems impeding progress and aspects that are facilitating
progress Focus for next week Things that need to be changed on the
plan of care Items that the team needs to know such as compensatory
strategies that have been working Patient Care Conference
Notes
Overcoming barriers: Status reporting Provide that information on
paper (or a screen) beforehand Allow a only general statement by
each discipline Have a physician leader coach the rehab physicians
on what to say Not understanding what a barrier to discharge is
(problems that impede progress) Provide team with a list of common
barriers Include the list in your note and check off what applies
Provide education on what a barrier is and have an enforcer in
conference Patient Care Conference Notes
Overcoming barriers: Plan of care is not a working document Bring
the plan of care to conference Review the plan of care Have a place
to document updates Review each functional and medical
problem.Determine if plan of care addresses it adequately (like an
H&P problem list) Lack of knowledge of the patient Pull notes
from prior treatments rather than passing off summaries Time limits
Have a time keeper who is the problem solver for what requires
follow-up at another time Make sure the time keeper is assertive
Enforce reviewing the plan of care and all supporting elements.Do
not move on to another patient if you are not done Give every
attendee a chance to report as a procedure of care conference
Patient Care Conference Notes Patient Care Conference Notes
Problems that Could Impede Progress: ADLs Balance Behavior Bladder
management Bowel management Caregiver education Cognition
Communication Community resources Disposition issues Equipment
Medical management Medication management Mobility
Motivation/initiation Nutrition/hydration Pain management Patient
education Safety Skin/wound care Support system Swallowing
Tone/spasticity Weakness/endurance Weight bearing restrictions
Other Patient Care Conference Notes
Plan of Care Revisions Based on Problems: Bowel program Caregiver
identification Consult equipment vendors Consult
orthotist/prosthetist Consult psychology Consult PT for wound care
Consult respiratory therapy Consult seating clinic Consult wound
care nurse Dietary changes Disposition planning Education:BI
support group (family) Education: Caregiver Patient Care Conference
Notes
Plan of Care Revisions Based on Problems: Education: Patient
Education: SCI Ed Education: Stroke Ed Equipment assessment FEES
Funding source assessment ICP Initiate behavior plan IV fluids MBS
Medication change NMES for swallowing Serial casting Splinting
Timed voids Other Review your Patient Care Conference Note Audit
Evaluate the scope of the patient care conference notes for the
following components: Assessing the individuals progress towards
the rehabilitation goals; Considering possible resolutions to any
problems that could impede progress towards the goals; Reassessing
the validity of the rehabilitation goals previously established;
and Monitoring and revising the treatment plan as needed. Were all
team members present at the patient care conference? Did the team
conference occur every 7 days? Weekly Team Conference
Using the team to drive the plan of care: 1st step:Have the plan of
care in team conference. Case Manager report- First conference
goals as written on the team plan of care or overall plan of care
Subsequent conferences-goals as stated or revised during the last
meeting Medical Director report- Medical needs that were addressed
Ongoing needs Weekly Team Conference
What to do next: Discuss current situation: strengths, barriers,
and plan for next week including reports from: Physician Therapists
Nurses Social worker/case manager Identify strategies for removing
the barriers to discharge Update plan of care by adjusting goals
for addressing identified barriers to discharge Specifically state
why the patient needs to stay in the hospital for another week
Weekly Team Conference
What to do next: Recap the list of ICD-9 codes.Add codes to the
list from information conveyed during the meeting Ensure that the
physician documentation matches the report given during the
conference to ensure proper coding Set a discharge plan Weekly Team
Conference
What NOT to do: Fill out the functional portions of the form during
the conference. Come to the meeting with the form mostly completed
Fill in only new information gathered during the meeting Review
each functional item Instead focus on progress and barriers You
should be reporting the level of assistance with each task on the
FIM scoring form Weekly Team Conference
What NOT to do: Plan the discharge based on the Medicare expected
length of stay This indicator is meant to be an average not a
guideline Weekly Team Conference
Rules: What every good team should do. Be knowledgeable of the
patient so you can adjust the plan of care appropriately. Aim for
8-10 minutes per patient. Be solutions based. Seek contributions
from all team members. Assure that documentation supports continued
physician, nursing, and therapy involvement. Weekly Team
Conference
Success Elements: How the good team measures their success. You
came prepared and everyone could knowledgably discuss the patients
care. Each patients case took 10 minutes or less to complete. The
weekly conference form is completed sufficiently to justify the
continued stay of the patient. Significant goals from the previous
weeks conference are discussed and updated. You developed
collaborative solutions to eliminate or minimize remaining barriers
to discharge. Length of Stay Management
How do you establish a length of stay? Specific patient needs
Pathways or protocols eRehabData facility averages National and
regional benchmarks Medicare CMG length of stay Length of Stay
Management
Review your goals: Keep your patients discharge goal in mind How
much time will it take to achieve the goals? Medical Nursing
Rehabilitation therapy When will family teaching be initiated and
how long will that take? Length of Stay Management
How does this measure up? Does your clinical plan fall within
benchmarks? If yes, good job. If no, evaluate treatment plan,
discharge plan, coding and scoring. Analyze the Facility
Report
Do You Have a Problem? Analyze the Facility Report Transfer
Patients: Percentage of patients that are discharged to another
Medicare bed Acute care SNF LTACH Another IRF Discharge
Destination: Breakdown of discharge locations for the patients
served Analyze the Facility Report
Do You Have a Problem Analyze the Facility Report Averages: Two
benchmarks:Weighted and unweighted Onset days:Different
instructions by RIC Length of stay considerations FIM scoring data-
Admission Totals Discharge Totals FIM Change Motor subscale at
admission Analyze the Facility Report
Do You Have a Problem Analyze the Facility Report Individual FIM
Items: Admission, discharge, change, and follow-up Explains
difference between facility totals and benchmark totals First
glance at isolating FIM scoring errors Team Conference
Documentation of Team Conference:
Level of function at admission Discharge goals Medical needs
Nursing needs Functional status by major functional areas
representing function across 24 hours Include multiple weeks on a
team conference form to allow you reflect progress Include barriers
to discharge Update plan of care / team goals Identify strategies
for attaining the goals State discharge plan and estimated length
of stay Questions? Lisa Werner, MBA, MS, CCC-SLP
Director of Consulting Service