While a similar bill has already been introduced in the House, on Wednesday Senators Robert Menendez, D-N.J. and Deb Fischer, R-Neb. put forth The Two-Midnight Rule Coordination and Improvement Act of 2014 to address the hospital observation stay vs. inpatient issue and revise CMS’s impending “two-midnight rule,” reports McKnight’s Long-Term Care News.
Less than a month ago, RehabCare Advantage reported that when hospitals keep patients in observation status rather than admit them as inpatients, it can result in lack of Medicare coverage for follow-up skilled nursing care and leave patients with out-of-pocket expenses.
CMS responded to the issue in 2013 with a reduced requirement – the two-midnight rule – which establishes that Medicare beneficiaries receive inpatient status for a hospital stay lasting two or more midnights. The two-midnight rule was set to take effect on Oct. 1, 2013 but has been delayed several times – now to Sept. 30 of this year.
Some lawmakers and physicians allege that the two-midnight rule does not do enough to alleviate the problem and wish to delay the rule further. In a joint statement published on Health Data Management, Senators Menendez and Fischer stated that “While this approach addresses some longstanding issues for beneficiaries requiring longer hospital stays, it fails to acknowledge instances where it is medically necessary for a beneficiary to receive inpatient services for a period spanning less than two midnights. The rigid approach currently taken by this rule could lead to instances where a physician is unable to make the proper medical determination for a beneficiary’s treatment.”
The Senate bill would require the HHS secretary to consult with stakeholders to determine criteria for inpatient stays that do not last midnights. The bill also codifies the delay of the two-midnight rule enforcement.
The American Hospital Association and Association of American Medical Colleges have voiced their support for the bill, reports Modern Healthcare.
RehabCare will continue to provide updates as the situation develops.
Patient Safety Awareness Week is a time to reflect on our rehab teams’ concerted efforts to maximize patient safety at each stage of care. We all go to great lengths to keep our patients safe within the walls of our rehab departments. We also take every measure to ensure our patients’ safety when it is time to abandon the gait belt or standing and transfer aids and return home.
Occupational therapists play an essential role in ensuring that this transition from rehab to home or the prior living situation is secure and seamless. OTs implement adaptations that accommodate common conditions and use their problem solving skills to devise solutions to confounding scenarios without precedents – which is why we fondly refer to OTs as the original “life hackers.”
In the following Q&A, RehabCare Occupational Therapist and Clinical Performance Specialist Allen Johnson shares how OTs create an environment of safety through their recommendations and interventions:
Q. What are the most important steps OTs take to prepare the home at the time of a patient’s discharge?
A. OTs collaborate with the interdisciplinary team, patient’s family and other caregivers to perform a Plan of Care home assessment. We walk the patient through the paces of what they will need to be capable of when they return home, and one of our primary objectives is to look for environmental barriers to safety both inside and outside the home. We ask ourselves which adaptation or compensation we need to utilize to enable the patient to function safely at home.
Q. What are some of the most high-risk areas and activities? What specifically can you implement to maximize safety?
A. Minimizing risk for falls is a top concern due to the likelihood of injury and the chance of rehospitalization. Outside the home, we examine the number and condition of steps, for example. We look for handrails, and then we determine if the handrails are sturdy enough. Inside, we may optimally arrange furniture, see if there is a need for grab bars, widen doorways and remove area rugs. These are just a few of the things we take into account when we analyze the setting with falls in mind. OTs also look for cooking, driving and bathing issues.
Q. How can you help patients prepare food, bathe and drive safely?
A. We have to see if it is safe for our patient to use the stove or microwave. Often you will see OTs working with patients on kitchen tasks while at the rehab center. We observe whether the individual is able to set the correct cooking temperature and tell when cooking is done. Do they remember to turn the burner off? Are they careful not to leave paper towels or dishrags near the stove? For bathing, we can install seats, no-slip mats, long-hosed shower heads and temperature limiters on the hot water if needed.
Driving is one of the most dangerous activities of daily living, and many OTs specialize in this area. First and foremost we determine if it is safe for the patient to drive. If critical skills are intact, there is much we can do to adapt the vehicle. Vans are commonly outfitted to accommodate wheelchairs. Special hand controls or joystick replacements may be added. Plus, technology now exists in some cars for automatic breaking, side impact warnings, automatic parallel parking and backup camera alerting.
Q. Sometimes solutions and adaptations are not immediately apparent, though. Give us an example of a time when you had to devise a solution to a perplexing problem.
A. For years, my specialty was working with dementia patients. This population has its own set of challenges, but if you understand the reasons for dementia and follow an abilities-based assessment, an OT can offer much to a person with these impairments. I had a patient who suffered from frequent falls, and the interdisciplinary team was struggling to understand why. She’d completed physical therapy with success and had good strength and balance. She had middle to late stage dementia but was able to accomplish many tasks independently or with supervision and cues. So I began to look for trends in her falls. I found that she often fell in the hallway exiting her room in the mid-afternoon. I observed that at that time of day, the lighting was such that a shadow fell across the floor outside her door. Dementia patients retain their physical abilities, but they have perceptual deficits. Therefore this patient perceived the shadow as an obstacle to be stepped over. We increased the lighting, and she no longer fell.
Q. What qualities should program directors look for when they are hiring an OT?
A. OTs must be compassionate and persistent. We never give up on trying to find a solution, because we have the vision to see solutions for patients when they might otherwise give up on themselves.
Q. Might job interviewers present a scenario to an interviewee and ask the candidate to come up with a solution?
A. Absolutely. Doing this will give the interviewer a peek into the prospective OT’s ability to perform at the level that will be expected of them. I have always done this with my job candidates as it is an invaluable predictor of that candidate’s methods and how well they will fit on your team.
A new analysis proves that the benefits of knee and hip rehab continue for months after a stay in an inpatient rehabilitation facility, reports Reuters.
Dr. Kenneth Ottenbacher and his team at the Center for Rehabilitation Sciences at The University of Texas Medical Branch in Galveston studied 12,199 American patients who received care in an inpatient rehabilitation facility following a knee or hip replacement. Most patients were white females, and the average age was 71. Researchers studied the patients’ function prior to surgery, at discharge and three to six months after discharge. The study gauged patients’ memory, ability to eat, bathe and ambulate and scored function on a scale of 1 to 7, with 7 indicating highest function. The results showed a dramatic improvement in patients’ ability to move:
“When it came to their ability to move around, patients entered surgery with an average score of 1.6 on that scale. That improved to 4.2 at discharge and 5.6 a few months later,” according to the article.
The 5.6 figure demonstrates that patients keep reaping the benefits of inpatient rehab months after therapy ends. Dr. Ottenbacher claims that “If you can get patients to a certain threshold level, they can do the rest of the rehabilitation on their own.”
As the most involved setting of care in therapy, inpatient rehab holds several advantages. Patients receive around-the-clock care and benefit from dedicated nurse and physician attention. Low clinician to patient ratios allow for daily individualized and intensive therapy, which contributes to short lengths of stay so that the patient can return to independence as soon as possible. Inpatient rehabilitation also helps patients avoid readmission to the hospital resulting from complications during treatment.
Dr. Robert Bunning, director of the arthritis program at MedStar National Rehabilitation Hospital in Washington, D.C., said the study supports that “acute rehab is a good investment.”
To access the full journal article, visit the Archives of Gerontology and Geratrics here.
The Centers for Medicare & Medicaid Services announced on Tuesday that the expansion of coverage to chronic heart failure patients is official.
As RehabCare Advantage wrote in December, Medicare proposed including coverage for chronic heart failure (CHF) patients in 2013. The previous standard meant that patients only received coverage for major coronary events that took place within a certain time frame. But an analysis of cardiac rehab literature that began in 2006 convinced CMS that rehab is appropriate for patients with steady and chronic heart failure.
An article from MedPage Today states that, “Under the final decision, Medicare would pay for rehab services — exercise, behavioral risk factor reduction, health education, and personal counseling — for patients with left ventricular ejection fraction of 35% or less and New York Heart Association class II to IV symptoms with at least 6 weeks of heart failure therapy.”
For the full memo from CMS, click here.
When hospitals admit patients under an observation stay rather than on an inpatient basis, patients may unknowingly have to pay out of pocket for necessary follow-up skilled nursing care. The admission distinction is important because Medicare covers subsequent nursing and rehabilitation only if a patient has stayed in a hospital for at least three consecutive nights as an inpatient.
The observation vs. inpatient designation has been an issue for several years, reports The Columbus Dispatch. Hospitals are encouraged to reduce expensive short-term stays. Plus, if a patient who receives observation care returns to the hospital within 30 days, the repeat visit does not count as an actual readmission that subjects the hospital to a potential penalty.
Medicare held an “open door” conference call last week with hospitals and doctors to address the admission issue, and lawmakers are trying to pass legislation that would limit the use of “observation days” because of the financial consequences it can have for thousands of patients. The most recent bill, introduced by Rep. Tom Latham, R-Iowa and primary sponsor Rep. Joe Courtney, D-Conn., proposes counting observation stays toward the three-night rule and has 162 co-sponsors in Congress, according to Live Well Nebraska.
RehabCare will continue to closely follow this story as it develops.
The American Physical Therapy Association Combined Sections Meeting (CSM) brings together more than 10,000 attendees each year, ranging from students to seasoned clinicians. At the CSM, all 18 physical therapy specializations are represented, from hand rehabilitation and geriatrics to acute care and sports physical therapy. The event provides PT professionals and aspiring PTs the opportunity to network, browse exhibits and attend educational sessions pertaining to their specialization.
This year’s CSM was held in Las Vegas from February 3-6, and RehabCare hosted a booth to allow PT students to ask questions about employment and clinicals as well as receive giveaways. Students were also able to network with current RehabCare physical therapists.
Two of our PTs conducted a seminar at CSM titled Seating Mobility and Geriatrics. On Tuesday, clinical performance specialists Judy Freyermuth, PT, and Leta Kant, PT, ATP for RehabCare, delivered an animated presentation on proper alignment and the impact on a patient’s function. To access Judy and Leta’s presentation, click here.
Thank you to everyone who registered to receive more information about our programs and share stories about your clinical experiences. See photos from the week, below:
“Who can say that therapy after surgery is an enjoyable experience? But I just love it.”
Though sessions are challenging, Father William Kurz was pleasantly surprised by how much he liked his physical therapy treatment following hip surgery. He was thrilled by how quickly he made progress as his therapists helped him begin to walk again.
“One week after the surgery, she [the therapist] had me using the cane already. I think that’s almost unheard of,” said Kurz. Two weeks after surgery, Father Kurz was able to walk nearly unaided.
To hear Father Kurz discuss his therapy, watch our video: