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THE REHABILITATION PROFESSIONAL’S ROLE IN REDUCING RECIDIVISM

Presented by: Natalie Phillips, M.A., CCC-SLP

Company: Paragon Rehabilitation

Designation/Title: Clinical Support Specialist

Sponsored by: Synchrony Health Services

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IntroductionNatalie Phillips is a Clinical Support Specialist for Paragon Rehabilitation with more than 12 years of experience in the long-term care industry, including skilled nursing facilities, memory care units, and assisted living facilities, where she gained experience evaluating and treating geriatric patients with a variety of disorders including, but not limited to, voice disorders, expressive and receptive language disorders, dysarthria, dysphagia, and cognitive-linguistic deficits. She had the opportunity to provide supervision to two clinical fellowship year clinicians. She holds a Bachelor of Science degree in Speech and Hearing Sciences from Purdue University and a Master of Arts degree in Speech and Language Pathology from Western Michigan University. She is a holder of the Certificate of Clinical Competence in Speech-Language Pathology from the American Speech-Language Hearing Association.

Natalie Phillips would like to thank IHCA / INCAL for the opportunity to present today!

OVERVIEW

I. Define recidivism

II. Impact recidivism has in the

post-acute and long-term

care industry

III. Value of rehab services to

reduce recidivism

IV. Interdisciplinary collaboration

to reduce recidivism

OUR DISCUSSION TODAY

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RECIDIVISM DEFINED

Recidivism DefinedWhat is recidivism? Isn’t that when a prisoner is released and then re-arrested?!

Meriam Webster Dictionary defines recidivism as, “A tendency to relapse into a previous condition or mode of behavior.”

Recidivism comes from the Latin word recidivus which means, “recurring.”

Post-acute and long-term care professionals frequently use this term to refer to patients who are readmitted to the hospital during an admission to a skilled nursing facility in which the patient was admitted from a hospital and up to 30 days post discharge from the facility.

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IMPACT RECDIVISM HAS IN THE POST-ACUTE AND LONG-TERM CARE

INDUSTRY

Impact of Recidivism

On the patient:

• Physical function / Outcomes

• Medical implications

• Mental / emotional impact

On the patient’s family:

• Mental / emotional impact

On the facility:

• Heavy administrative burden

• Financial impact –Medicare penalty up to 2%

• Five‐star Quality Rating System

• Community reputation

• Discharge planners 

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Statistics(Mor, Intrator, Feng, et.al 2010):23.5% of all hospital discharges to a SNF resulted in readmission to the hospital within 30 days of

discharge from the hospital.

SNF rehospitalizations to the hospital accounted for $4.34 billion per year in Medicare fees.

78% of SNF readmissions to the hospital within 30 days of the initial hospital discharge were determined to be potentially avoidable.

Potentially avoidable SNF rehospitalizations within 30 days of the discharge resulted in an excess cost of $3.39 billion to Medicare.

(Modern Healthcare 2018):About 20% of SNF’s received the maximum 2% penalty for fiscal year 2019 under the SNF Value

Based Purchasing Program.

Only 3% of SNF’s received the 1.6% maximum bonus to Medicare A reimbursement

VALUE OF REHAB SERVICES IN REDUCING RECIDIVISM

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Value of Rehab ServicesTherapy Outcomes in Post-Acute Care Settings (TOPS)

Value of Rehab: TOPS Study

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Value of Rehab: TOPS Study

Source:  APTA/AOTA

So… What can Rehab do??Consistent rehab screening process

What: Screen conducted by a therapist or therapy assistant determines if a therapy evaluation is indicated.

Who: ALL residents: new admission, re-admission, long-term residents should be screened for therapy routinely and following an incident such as a fall.

When: Upon demonstration of a change in function – either improved or decreased function, weight loss, coughing at meals or while taking medication, positioning in bed or chair, walking, joint stiffness, or cognitive changes. Consider prior level of function, current, and prognosis.

How: Staff or family can request a rehab screen. Completed with the IDT input:

Nursing – physical functioning, ADL’s, level of assistance, increased confusion?

Dietary – intake, self-feeding, swallowing difficulty?

Social Services – reduced communication, increased confusion, changes to environmental needs

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Additional Rehab Considerations

Comprehensive Evaluation

Order to evaluate and clarification 

order

Patient‐ and discipline‐specific 

detail

Functional Deficits and Underlying Impairments

Establish patient‐specific, 

measurable, and realistic goals

CPT codesFrequency and 

duration

Assistive devices and adaptive equipment

Caregiver involvement and 

education

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Documenting Skilled Services

Justification of Skilled ServicesSkilled need clearly proven at evaluationSkilled services go beyond the scope of a restorative aideSkilled services are documented in detail at each progress noteDocumentation supports evolution of careConsider what the patient performed or participated in, how it relates to

function, and why the skills of a therapist were requiredEmphasize skilled interventions provided by the therapist that cannot be

provided by a non-skilled caregiverDescribe progression of the treatment plan to meet short- and long-term

goals

Documentation Tips

INCLUDE

+Skilled terminology

+Collaborative discussions 

+Specify education/teaching/training and report success

+Feedback from other staff/family

+Modifications to treatment that impact other disciplines

+Objective data to show progress

+Address changes to the plan of care

AVOID

‐Vague terms

‐Second‐hand reports

‐Conflicting entries

‐Non‐skilled terms

‐Statements that reflect no benefit for the patient 

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Standardized Assessments

Establish a baseline

• Interpret the score and correlate to function

Track progress or regress

• Indicate updated score

• Compare to baseline

• Correlate to function with the positive impact of therapy

Provides detail of subtle changes in physical functioning and cognitive skills

Many available on a public domain and can be printed online

Modes of TherapyPDPM allowed for various modes of therapy to be considered.

Individual

1 Patient:1Therapist

Co‐Treat

1Patient:                   2 Therapists

Concurrent

2 Patients:                 1 Therapist

Group

2‐6 Patients:             1 Therapist

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Telehealth

Therapy associations – advocating to make permanent

Certain CPT codes approved

Adjunct to in-person therapy services

Benefits:

- increased access to healthcare

- decreased risk of exposure

- decreased negative effects of social

isolation

Caregiver Education

Clearly communicate recommendations to ensure optimal carryover 

Consider:

• Diet modifications or restrictions

• Home exercise program

• Medication management

• Adaptive equipment / Assistive devices

• Environmental or home modifications

• Communication strategies or AAC systems

• Compensatory strategies

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INTERDISCIPLINARY COLLABORATION TO REDUCE RECIDIVISM

Interdisciplinary Team CollaborationDetermine

• Determine, re‐assign, delegate responsibilities amongst IDT members; the entire team should know the expectation of the campus.

Establish

• Establish daily, weekly, monthly processes to:

• Identify status changes

• Discharge planning

• For Part A: PDPM considerations such at IPAs and Section GG input.

• For Part B/LTC/AL: Ensure status changes are communicated. 

Ask

• Ask for feedback to determine what is working and what is not.

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Interdisciplinary Team Collaboration

Begins prior to admission – Pre-admission Assessment

Provider to provider communication: Hospital – SNF – Home

Timing of medication in relation to therapy treatmentPain managementParkinson’s medicationsFatigue/ altered mental status

Appointments, dialysis schedule, patient preferences

Patient’s response to treatment, progress, regress, significant changes.

Pre-admission Assessment

Proactive rather than reactive!

Prior to admission:

• Medication review

• Physician’s orders

• Diagnoses

• Recent History & Physical and therapy notes

• Adaptive equipment and assistive devices

• Follow‐up appointments

• Post‐discharge location

• Payor requirements

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Electronic Medical Record

Patient demographics, payor, census 

detail

Hospital records and transfer 

ordersPhysician’s orders

Events and observations

MDS schedule, assessments, and 

care plans

Nursing documentation

Physician History and Physical and 

visits

Pharmacology

Review

Review each patient’s medication list as part of the evaluation.

Encourage

Encourage patient and family involvement for feedback.

Communicate

Communicate any concerns with the IDT immediately.

Empower

Empower yourself to become more familiar.

REFER

REFER THE PATIENT TO A PHARMACIST OR PHYSICIAN FOR A MEDICATION REVIEW AND RECONCILIATION FOR ANY CONCERNS.

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Refer to a Specialist

Audiologist Cardiologist Endocrinologist Gerontologist Nephrologist Neurologist

Nutritionist Oncologist OphthalmologistOrthopedic Specialist

Otolaryngologist Pharmacist

Podiatrist Pulmonologist Rheumatologist Urologist

Determining Duration of CareDocumentation should support the full duration of care of skilled therapy

services from evaluation through the last treatment based on medical and treatment diagnoses, medical complexity, and sophistication of services.

Outcomes should clearly support the length of each therapy discipline episode of care.

Positive response to therapy intervention

Describe how the skills of the therapist were required to adjust or modify the treatment plan to maximize the patient’s rehabilitation potential.

Supporting duration of care through documentation in the Plan of Care, Progress Notes, Daily Notes, and Discharge summary

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Discharge Planning

Consistent Care Plans

• Build rapport and trust

• Discuss concerns and offer solutions

• Review current level of function, goals, and patient‐specific details

• Reduce fear and anxiety

Discharge Meeting

• Inter‐disciplinary participation

• Home evaluation offered as indicated

• Review medication and specialized services needed upon discharge

• Determine appropriate community resources

• Recommend outpatient or home health services when warranted

Home Evaluation

Focus on Function!

Include the family or caregiver

• Entrance

• Navigate in the kitchen

• Toilet and shower transfers

• Address adaptive equipment and assistive devices

• Environmental Modifications

Typical routine

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Post-Discharge Follow UpInitiation of recommended services

Scheduled follow-up appointment with physician

Medication adherence

Utilizing assistive devices and adaptive equipment

Consistent home exercise program completion

Address concerns or questions

In Summary

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ReferencesBrock J, Mitchell J, Irby K, Stevens B, Archibald T, Goroski A, Lynn J; Care Transitions Project Team. Association between quality improvement for care transitions in communities and rehospitalizations among Medicare beneficiaries. JAMA. 2013 Jan 23;309(4):381-91. doi: 10.1001/jama.2012.216607. PMID: 23340640.

Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418–1428.

McIlvennan CK, Eapen ZJ, Allen LA. Hospital readmissions reduction program. Circulation. 2015;131(20):1796-1803. doi:10.1161/CIRCULATIONAHA.114.010270.

Mor V, Intrator O, Feng Z, Grabowski DC. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010;29(!):57-64 doi: 10.1377/hlthaff.2009.0629.

Most Skilled-Nursing Facilities Penalized by CMS for Readmission Rates. Modern Healthcare. https://modernhealthcare.com/article/20181128/NEWS/181129930/most-skilled-nursing-facilities-penalized-by-cms-for-readmission-rates. Published November 28, 2018. Accessed April 15, 2021.

Readmission Reduction Program. Centers for Medicare and Medicaid Services. CMS.gov. https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html. Modified August 24, 2020. Accessed April 15, 2021.

“Recidivism.” Merriam-Webster.com Dictionary, Merriam-Webster, https://www.merriam-webster.com/dictionary/recidivism. Accessed April 16, 2021.

Therapy Outcomes in Post-Acute Care Settings, 2021 | www.aota.org/TOPS | www.apta.org.

THANK YOU!

Contact me with questions:Full Name: Natalie PhillipsEmail address: Natalie.Phillips@paragonrehab.comPhone number: 574-226-4109

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