Pre-Admission Screening
and Case Finding
Lisa Bazemore, MBA, MS, CCC-SLP
Director of Consulting Services
Objectives
• Today we will talk about the following topics:
 Completing a pre-admission screening that
reflects medical necessity
 Review of census development strategies
 Analyzing your facility's patient selection
criteria
Conducting a Pre-Admission
Screening That Sets the Stage
Lisa Bazemore, MBA, MS, CCC-SLP
Pre-Admission Screening
• Why do we conduct a pre-admission screening?
 To gather information on whether the patient is a good
rehabilitation candidate
 To determine whether the unit is equipped to manage the
medical and functional needs of the patient
 To gather preliminary information on the anticipated reason
for admission
 To determine whether the patient will benefit significantly
from an inpatient rehabilitation stay
 MOST IMPORTANTLY-to set the stage for the medical
necessity of the admission
Pre-Admission Screening
• One Local Coverage Determination Policy quotes the Medicare Benefit
Policy Manual saying:
 While preadmission screening is a standard practice in most
rehabilitation hospitals and may provide useful information
for claims review purposes, the absence of preadmission
screening in a particular case is not adequate reason for
denying a claim. However, in a case where an inpatient
assessment showed that a patient clearly was not a good
candidate for an inpatient hospital program, then the
presence or absence of preadmission screening information is
important in determining whether the inpatient assessment
itself was reasonable and necessary. If preadmission
screening information indicated that the patient had the
potential for benefiting from an inpatient hospital program, a
period of inpatient assessment could be covered, up to the
point where it was determined that inpatient hospital
rehabilitation was not appropriate, since preadmission
screening cannot be expected to eliminate all unsuitable
candidates. CMS Publication 100-02, Medicare Benefit Policy
Manual, Chapter 1, Section 110.2
Pre-Admission Screening
• How do you ensure that the pre-admission screening is
reporting the right stuff?
 The obvious items include:
• Diagnoses
• Comorbidities with origin of the condition
• Age
• Current interventions
• Functional Assessment
• Vitals with height, weight, and BMI
Pre-Admission Screening
• How do you ensure that the pre-admission screening is
reporting the right stuff?
• Safety
• History
• Meds with reason for the prescription
• Pre-morbid status/function
• Recommendation of need for 3 therapies
• Rehab potential with preliminary discharge
destination
• Areas where improvement is expected
Pre-Admission Screening
• The less obvious things to report?
• Medical conditions with emphasis on what will
require ongoing treatment in rehab
• Quality and type of support offered by the care
giver
• What the patient’s pre-morbid participation level
and level of interest were
• What special needs the patient will have upon
admission (wheelchair measurements, oxygen,
isolation)
Pre-Admission Screening
• Look for information in all sections of the chart:
 Labs
 X-Rays
 Respiratory needs
 Cardiac needs
 Safety concerns
Pre-Admission Screening
• Make the case for medical necessity:
 Explain how the conditions of participation are met
 What are the anticipated medical needs?
 What will the nurses be involved in while caring for this
patient?
 Does this patient require on-going hospital level care
and intense therapy? For what?
Pre-Admission Screening
• Traps:
 Beware of forms that are not completely filled in
 Ensure that the medical director reviews each admission and
signs the pre-admission screening form to show consent to
admit
 Make sure the pre-admission screening form is available to
staff upon admission to be used for gathering additional
patient information
 This is a preliminary document that will have the anticipated
impairment group code and etiologic diagnosis, but physician
has the final say in what the reason for admission is following
his/her assessment
 Do not close a medical record before ensuring that the preadmission screening form is filed in the chart
Philosophy
• Goals for Census Development
 Serve the patients from the host hospital, in the
communities, and surrounding areas where we live.
 Extend the reach of case management
 Follow through for patients with post acute needs from
time of admission
 Reduce the burden on the referral source
Census Development
• Principles of census development
 Know
 Know
 Know
 Know
your hospital case mix
your market
your 60% rule compliance percentage
who is referring, when, and how much
Internal Case Finding
• Daily Activities
 Address all referrals
 Complete floor rounds
 Face to face meetings with physicians
 Surgical list, Pre-admission testing
 Review new admissions to the hospital in
previous 24 hours
 Analyze Out-migration
•ED, Transfers
 Plan for weekend coverage
Managing Internal Referrals
• Set goals
 Admissions and referrals
 Census, LOS
• Know
 60% rule compliance standing
 Hospital med-surg census
 Referrals
• Acceptance
• Pending
• Denied and the reasons why
Managing Internal Referrals
• Do not rely on referrals only
• Be proactive in approaching referral sources
• Be an extension of case management
• Educate with each acceptance / denial
• Share outcomes with physicians and referral
sources
• Reduce the following denials:
 Managed care
 Inappropriate denials from the Medical
Director
Tools for External Census Development
• What tools do you need to accomplish this?
 A map of your geographic primary and secondary
coverage area
 A list of all acute med-surg hospitals, skilled nursing
facilities and acute rehab facilities in your area – KNOW
their bed capacity, actual occupancy rate and trauma
levels
 Knowledge of affiliations, partnerships, alliances and
services offered
 MedPar data or hospital association data
 Hospital’s ER log to determine facility outmigration
Analyze your market data
• Map It
 Create a visual of your market – use a map to note all
hospitals, SNFs and acute rehab facilities in your
geographic coverage areas
 Complete a SWOT – Strengths, Weaknesses,
Opportunities and Threats of each of you competitors
Develop a Customer Hit List
 Create a Customer Hit list for each organization
that you plan to market – Hospitals, SNFs,
Physician clinics, Payors, Home Health
Agencies…
 Target all individuals who can influence and/or
decide the next level of care for the patient
Ranking
• Rank your referral sources based on the volume
that they send
 “A”- highest volume referral sources
• Visit these on a regular basis
 “B” - potential growth customers
• Increase the time dedicated to these referral sources
 “C” - low volume referral sources or potential where
contact is necessary but excessive time spent here would
be wasted
• Fill in your free time with these referral sources
Preparing for a Marketing Call
• Establish your goals for the call
• Find out what you can up front
• What do you want to know/ask?
• Anticipate Their questions
• Anticipate Objections
• Practice!
Physician Calls
Information to give and receive
 Where are they on staff?
 What is the conversion ratio for their patients
 What have the outcomes been for their
patients
 Share Progress Notes as applicable
 Find out how your program can meet the
physician’s needs
 Conduct a needs assessment for specialty
programming
Discharge Planner Calls
Information to give and receive
 What is the conversion ratio for their patients
 What have the outcomes been for their
patients
 Your Location - what areas your patients
come from
 Community discharge rate
 Utilization of Post Acute Continuum
Managed Care Plan Calls
• Information to give and receive
 Your conversion percentage
 Your location
 Average length of stay & outcomes
 Specialty Programs
 Continuum of Services
 Admit 24/7 – Weekend/Holiday Therapy
 Percentage transferred to SNF, Acute, Home
Making Admission Decisions
• How should the process work?
 The admissions coordinator or liaison screens the
patient
 The AC makes a determination about whether or not
the patient meets the conditions of participation
 If yes, the AC reviews the case with the program
director
 If no, the patient is denied and the reason for denial is
tracked for later review under the performance
improvement plan
Making Admission Decisions
• How should the process work?
 The program director determines if the patient meets
the criteria for 60% rule compliance and whether they
are eligible for admission given their current
compliance threshold
 If yes, the case is taken to the medical director to
make a final admission decision
 If no, the case is tracked as a denial for later review
Making Admission Decisions
• Making a good decision demands good information, so
what does the medical director need to know in order to
make good decisions:
 Why does the patient need a stay on rehab?
 What do you think will be involved in the caring for that
patient?
 Are their 60% rule compliant conditions? Tiering
comorbidities?
Making Admission Decisions
• Making a good decision demands good information, so
what does the medical director need to know in order to
make good decisions:
 Will the patient be able to participate in 3-hours of
therapy?
 What evidence supports the medical necessity of this
admission?
 Is the patient ready for transfer?
Making Admission Decisions
• What are your barriers to admission?
 Does your medical director advocate for patients to
have an opportunity at rehab?
 Do you advocate for patients to have an opportunity at
rehab?
 Rehab patients no longer fit the typical mold. Who do
you take? Who do you deny?
 Being able to calculate the risk is necessary. What is a
smart risk?
Making Admission Decisions
• What are your barriers to admission?
 What can your staff handle? How do you know?
 What are you doing to remove the barriers?
 What is the alternative placement?
 Is that a good option for you patient?
Making Admission Decisions
• So how do you sell it to the Medical Director and the team?
 Present the case as if rehab is the only place for the patient.
 Discuss the medical needs and how you plan to meet them.
 Talk about your experience with patients with that diagnosis.
 Talk about your facility averages and why you think this
patient is worth the risk. (Transfer payments, ALOS,
admission FIM scores, and 60% rule compliance)
 Discuss what the outcome would likely be if the patient was
seen in another level of care.
Questions?
Lisa Bazemore
Lbazemore@erehabdata.com