MDS Alert

Put everyone's piece of the care, fiscal equation on the table.

If your facility wants to get residents' rehab therapy off on the right foot--and keep its fiscal balance--it might consider following in the steps of Sunshine Terrace Foundation Rehabilitation Center.

The facility has honed its team approach to accomplish both goals.

How they pull it off: The facility's Medicare team meets weekly at noon to identify each resident's rehab goals and potential. In addition, a Medicare billing specialist on the team shares the number of days the resident has left in his Medicare benefit period and any information about secondary and primary payer issues.

"We look at reimbursement ... but the [treatment] decisions are driven by the resident's clinical needs," says Inne Taylor, RN, the certified MDS coordinator for Sunshine Terrace in Logan, UT.

Know the goals: The resident's and family's goals and discharge plans make the biggest difference in how the team sets the therapy goals, says Taylor. "If [the plan is for the resident to go to] assisted living or long-term care, the rehab goals will be different than if the person plans to go home and must take care of herself," she notes.

"One of our key rehabilitation people is famous for saying that anyone can go home--it just depends on how much help there is at home." 

Get The Inside Scoop From These Players

During the weekly meeting, everyone on the team provides assessment data to develop a complete picture of the resident's rehab potential, as follows:

Rehabilitation therapy. The rehab team evaluates the resident and makes an initial decision about how many minutes of rehab to provide for the MDS assessment period, says Taylor. But if the initial plan doesn't work, the rehab therapists consult with the rest of the interdisciplinary team to see how much therapy they think the resident can do, she relays.

Social work. "The social worker comes with the understanding of the resident's and his/her family's dreams and goals for the rehabilitation therapy--that is, the optimal outcome or situation in their view," says Taylor. The social worker also works with the resident and family to determine what the person could do before his illness or trauma.

The social work domain also includes an assessment of mood and behavior, says Wendi Shurtleff,  the medical social worker for the facility. "For example, if someone  is depressed, we see if the person needs an evaluation for antidepressant therapy or regular social worker visits to vent their feelings," she says.

Behavioral symptoms can also interfere with therapy--for example, if the resident is combative or resists care. A person with dementia may have difficulty following cues or directions due to short-term memory loss. "We identify those issues and report them to the team," says Shurtleff.

Dietary. The dietitian discusses the resident's nutritional status, intakes and weight and helps evaluate the resident's speech therapy needs.

Nutritional deficits can prevent the resident from progressing in therapy, notes Cheryl Connors, the consulting dietitian for the facility. To evaluate a resident's nutritional status. 

Connors will review the person's condition, meds, labs, history, intakes and functional eating ability. "Labs can reveal a good deal about a resident's condition and abilities," she notes. "For example, someone with a low hematocrit won't have the energy to participate fully in therapy."

Check the MDS: Have you coded anemia on the MDS (I1oo)? Look for anemia as a reason people are refusing therapy due to lethargy, fatigue--or because they feel depressed, advises Garry Woessner, MA, MBA, CAS, principal of Woessner Healthcare Consulting Group in Edina, MN.

Nursing. The resident's unit nurse shares information about any barriers the resident might face in terms of achieving rehabilitation goals, says Taylor. Examples might include pain, depression and lack of motivation, etc.

"The nurse also discusses what the team can do about those obstacles to enhance the resident's rehab experience," says Taylor.

Set the Best ARD

With the nine rehab plus extensive services RUGs now on board, Sunshine Terrace uses a new preadmission form to collect data from the hospital for extensive services (IV fluids, IV meds, suctioning, trach care and ventilators). Taylor also keeps a calendar for each Medicare resident to record key assessment information and their assessment reference periods.

Taylor also highlights the days of extensive services provided in the hospital and in the nursing facility. That way, the team can select the ARDs that offer the "best windows" possible for both the 5-day and 14-day MDSs.

ARD tip: If the resident can clinically tolerate and benefit from high-intensity therapy, consider using day eight as the ARD for the 5-day MDS to capture enough therapy for ultra-high, suggests Chicago consultant Joan McCarthy.