Using Team Conference to Drive
Your Rehab Plan
Lisa 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 patient’s 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 patient’s 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
• Patient’s medical prognosis
• Anticipated functional outcomes
• Anticipated discharge destination from the IRF stay
• Anticipated interventions that support the medical necessity of
the admission
Based on patient’s impairments, functional status, complicating
conditions, and any other contributing factors. Should include
these details about the PT, OT, SLP, P/O therapies expected:
o Intensity (# of hours/day)
o Frequency (# of days/week)
o 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 patient’s 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 patient’s 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 IRF’s 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 patient’s 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 patient’s individual need consider adding a
statement that reflects the times stated are an average that will be
varied based on the patient’s 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
patient’s needs.
• Assess the individual’s 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 patient’s 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 patient’s 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 patient’s 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 individual’s 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 patient’s
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 patient’s
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 physician’s 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 patient’s 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 individual’s 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 patient’s care.
• Each patient’s 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 week’s
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 patient’s 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.
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 patient’s served
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
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
Lwerner@erehabdata.com