Eli's Rehab Report

Offering intensive rehab will help ortho patients and raise your bottom line

If you're an inpatient rehabilitation facility therapist, you know all too well the feeling of turning away orthopedic patients these days. Despite this frustrating situation due to the 75 Percent Rule, a handful of skilled nursing facilities have begun offering rehab models similar to an IRF's -- and one company's success story might be enough to spread a trend that benefits both the patient and the SNF.

The background: When CMS officials decided that most joint-replacement patients did not qualify for rehab or medical necessity to undergo an IRF level of care, those patients began falling through the cracks, either going straight home from the acute hospital or going into an SNF with less-than-adequate rehab programs.

Aegis Acute Rehab, a subsidiary of Aegis Therapies that provides hospital-based acute rehab management and also contracts to SNF-based orthopedic centers of excellence, caught on to this problem and developed a level of post-acute care in SNF settings geared toward the orthopedic patient who fell short of the IRF admission requirements.

The goal: Aegis Acute Rehab would train therapists and SNF staff to deliver an intensive, IRF-like regimen of therapy to return patients to a normal lifestyle as soon as possible.

The outcome: Patients were discharged fully functional in as little as eight days, physicians were impressed, and cases of deep vein thrombosis (DVT), infection rates, and returns to acute care significantly lessened.

Shift Your Paradigm of SNF Care

If you want to implement a similar program in your SNF, your entire perception of a patient's SNF experience must change --and so do all your therapists' and staffs'.

"The whole focus of the program is to get the patient home, not to settle into a long-term stay," says Denese Estep, OTR, interim program director for Aegis Acute Rehab and senior consultant for Fowler Healthcare Affiliates Inc. in Atlanta. "And that's a huge challenge to communicate to an SNF staff that is used to telling patients they 'don't have to go to rehab if they don't feel like it today,' etc."

Important: To make the program successful, you need to develop a strict regimen of therapy and daily activities that your therapists and staff adhere to around the clock. For instance, in the Aegis Acute Rehab program, patients get a minimum of 12 hours of therapy a week, and nursing staff is extensively trained to help by

• practicing bathing and dressing in a home setting

• practicing cooking, laundry and other daily tasks

• practicing stair climbing and walking on uneven surfaces

• giving the patient homework to do in his room.

"We trained nursing staff not only to do these tasks with the patients but also to let the patients do as many of the activities themselves as possible," Estep says. "We also trained the CNAs to watch the patients and monitor expectations of what the patient can and can't do, which they revised on a daily basis."

Use the High Rehab RUGs

If you want to tackle a program like this in your SNF, but you're unsure how such a model would work into your payment system, simply look to the Resource Utilization Groups (RUGs) that cover the maximum minutes of therapy you can deliver per week -- the Rehab Ultra-High and Very-High RUG categories. Rehab Ultra-High patients in the program get at least 720 minutes of therapy each week (12 hours), Estep says.

Bonus: A program like Aegis Acute Rehab's is "absolutely worthwhile" not only because Rehab Ultra High and Very High are the highest-paying RUGs but also because the nursing home can capture the Medicare Part A population, "which overall is a better reimbursement source," says Jane Maynard, MSW, vice president of operations for Aegis Acute Rehab.

Takeaway: "As with any new program, you're going to have some challenges that go along with it, but from a success standpoint, this program's truly been accepted," Maynard says. She says that orthopedic surgeons and discharge planners are happily accepting this program as "an alternative placement for orthopedic patients" who are getting squeezed out of the IRFs.

"The biggest challenge is the nursing home's ability to look at the patient a little differently," Maynard says, but "I would certainly recommend this model, especially in nursing homes that have extra bed capacity and want to increase their Med A census