Team Documentation of Care
Conference and Weekly Progress
Lisa Werner Bazemore, MBA, MS, CCC-SLP
Director of Consulting Services
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 screen, post admission evaluation and
overall plan of care can only be achieved through weekly team
conferences of 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;
 A 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.
 It is expected all treating professionals from the required disciplines will
be at 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 decision made during
such conference, such as those concerning discharge planning and the
need for any adjustment in goals or in the prescribed treatment
program, must be recorded in the patient’s medical record in the IRF.
 Focus of review of this requirement will be on the accuracy and quality
of the information and decision-making, not the internal process used
by the IRF.
Weekly Team Conference
Purpose of the Weekly Team Conference
 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
Weekly Team Conference
Attendees
 Medical Director/Treating Rehab Doctor
 Case Manager and Social Worker
 Treating PT, OT, ST
 Registered Nurses
 Neuropsychologist
 Therapeutic Recreation Specialist
 PPS Coordinator or Program Director
 Coder
 Nutrition
 Pharmacy
Weekly Team Conference
What To Do
 Open the conference with a recap of the week including:
• Case Manager report –
 Prior level of function and planned discharge disposition
• Medical Director report –
 Medical needs that were addressed
 Tests ordered and outcomes
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
 List team’s goals for addressing barriers to discharge and
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 average
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.
Weekly Team Conference
A more in depth look at the process
 Report on the major areas of performance for each patient
being discussed.
 Review active medical conditions
 Report elements including functional performance and medical
status over the past 36-48 hours
Weekly Team Conference
Specifically consider:
 Consistency in the patient’s performance
 Progress made compared to team conference goals from the
previous conference
 Barriers
• Pain
• Endurance
• Adjustment issues
• Impulsivity and awareness
• Balance
• Cognition
• Nutrition and elimination
• Sleep/rest patterns
Weekly Team Conference
Address key areas when functional deficits impact the patient’s
ability to go home:
 Examples of key areas:
• Transfers-Bed, Toilet, Shower
 PT, OT, Nursing
• Lower body dressing
 OT, Nursing
• Toileting, Toilet Transfers, Bladder and Bowel Management
 OT, Nursing
• Problem solving
 OT, ST, Nursing
• Skin integrity
 PT, OT, Nursing
• Adjustment to disability
 Psychology, SW, OT, Nursing, TR
Weekly Team Conference
Address the discharge plan
 Discuss the discharge plan and functional ability required to
achieve this plan.
 Identify key barriers to the patient achieving the plan of care.
 Set team goals that will support the discharge plan.
 Modify the discharge plan (as needed).
 Estimate the length of stay.
Weekly Team Conference
What is a team goal?
 Something that all team members will work on together.
 It supports the key discharge goal and discharge plan.
 Individual disciplines have short term goals that support it.
 It is a necessary step to moving the patient along their path to
discharge.
Weekly Team Conference
Example:
 The physician would like to remove a patient’s foley catheter. To
do this successfully the team will need to work together on the
goal of bladder continence.
• PT – Transfers, strength, balance
• OT – Toileting, toilet transfers
• Nursing – Bladder program, post void residual scanning
• ST – Memory, problem solving strategies
Review Team Conference Form
Weekly Progress Reports
Showing progress
 At least weekly, return to the established team goals.
 Note where progress has been made by stating current status
compared to prior status.
 Review previous narrative notes to determine what burden of
care was present earlier that is now resolved.
 Indicate how therapy and nursing interventions resulted in a
positive outcome.
 Update short-term goals for the coming week.
 Adjust the long-term goals for the team by modifying the plan
of care.
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
Goal Attainment
Goal setting is important!
 Patient metrics
page reports
admit, discharge,
goal, and gain.
 Review again goal
at team and
following discharge
for success with
goal attainment.
Goal Attainment
Goal Attainment Strategies
 Emphasize goal revision on the plan of care.
 In-service on goal setting to include proper goal setting and
progression of treatment through incremental goal
achievement.
 Begin reviewing long term goals in the weekly team conference.
 Determine a method to communicate current status and goals
regularly through a functional status board, stand-up meetings,
and/or team conference.
Team Conference
Documentation of Team Conference
 Level of function at admission
 Discharge goals
 Medical needs
 Nursing needs
 Functional status by FIM areas or 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
 State weekly team goals
 Identify strategies for attaining the goals
 State discharge plan and estimated length of stay
Questions?
Lisa Werner Bazemore, MBA, MS, CCC-SLP
Lbazemore@erehabdata.com
(202) 588-1766