By Jeffrey H. Brochin, J.D.
A recent case review of inpatient rehabilitation hospitals conducted by the HHS Office of Inspector General (OIG) found that a number of patients who were not suited for intensive post-acute rehab therapy nevertheless remained in inpatient rehab hospitals for extended periods of time. Some of the patients were in very poor condition suffering from pre-existing physical limitations, altered mental status, or unresolved health problems, or were lacking in the endurance necessary to benefit from the intensive rehab regimen prescribed. The report called upon CMS to provide additional technical assistance to ensure that Medicare patients are placed in the most appropriate setting for post-acute care (OIG Report, No. OEI-06-16-00360, December 23, 2016).
Background. Providers of post-acute care offer recuperation and rehab services to Medicare beneficiaries who are typically admitted for rehab after stays in acute-care hospitals. The providers include skilled nursing facilities (SNFs), home health agencies, long-term care hospitals, hospital-based rehab units (rehab units that are part of acute-care or critical access hospitals), and freestanding inpatient rehab hospitals (rehab facilities that are not managed as units within other hospitals). In 2012, statistically many more SNFs than inpatient rehab hospitals billed Medicare for post-acute care. SNF patients are typically older, more frail, and more likely to report poor health status and to be disabled than patients in other post-acute settings. In contrast, inpatient rehab hospitals are designed to treat patients who can tolerate intensive rehab therapy and gain from it. Although the different types of post-acute-care providers often treat patients with similar conditions, Medicare pays different benefit amounts depending on the setting. For example, Medicare pays 40 to 50 percent more for patients recovering from strokes and hip replacements in hospital-based rehab units and inpatient rehab hospitals than it does for those in SNFs. The OIG case review of intensive post-acute rehab therapy focused on patients admitted to inpatient rehab hospitals.
Inpatient rehab hospitals defined. Inpatient rehab hospitals are freestanding facilities that specialize in providing intensive rehab therapy to patients recovering from illness, injury, or surgery. In contrast, hospital-based rehab units provide the same type of care as inpatient rehab hospitals and are reimbursed through the same prospective payment system, but are located within a larger hospital and are managed as part of that hospital. In 2012, hospital-based rehab units constituted approximately 80 percent of the market for intensive inpatient rehab therapy while inpatient rehab hospitals accounted for the remaining 20 percent.
Intensive rehab therapy criteria. Medicare has established criteria for the coverage of post-acute care in order to ensure that patients receive the most appropriate level of care for their needs. The primary distinction between inpatient rehab hospitals and other settings for post-acute care is the intensity of the rehab therapy provided. The Medicare coverage criteria require that patients, at the time of admission, can be reasonably expected to actively participate in, and benefit significantly from, an intensive rehabilitation therapy program. As the name suggests, intensive rehab therapy is intensive in that it generally requires a substantial time involvement (at least three hours of therapy per day, five days per week); a coordinated, interdisciplinary approach among multiple therapies (physical therapy and occupational therapy); and rehab physician supervision. Because such intensive therapy is beyond the endurance level of some patients receiving post-acute care, those who are unsuited for such therapy are better candidates for placement in an alternate setting such an SNF.
Patients unable to benefit from tensive rehab therapy. The OIG’s case review followed a study of adverse events in inpatient rehab hospitals which examined the medical records for 426 inpatient rehab hospital stays. That study found a small number of cases in which patients appeared unable to participate in and benefit from intensive therapy. In response, the OIG decided to extend its medical record review to provide additional information about inpatient rehab hospital stays in which patients were unable to actively participate in and benefit significantly from intensive therapy. Physician reviewers had access to complete medical records for the sampled beneficiaries’ stays in inpatient rehab hospitals, including preadmission screening information, post-admission evaluations, and notes from scheduled therapy. They paid particular attention to therapy notes recorded during the first three days of each inpatient rehab hospital stay, and they identified 39 inpatient rehab hospital stays in which patients were unable to actively participate in and benefit significantly from intensive therapy. The physicians identified the factors most affecting a patient’s ability to participate in or benefit from the therapy.
Four categories of limiting conditions. The limiting factors identified by the physician reviewers fell into four categories:
- Pre-existing physical limitations—For 30 of the 39 stays, physical limitations restricted the patients’ ability to participate in therapy. The physical limitations included pre-existing functional disabilities, limited mobility, and inability to carry out activities of daily living such as getting in and out of bed; dressing; bathing; eating; and using the bathroom. Patients with physical limitations had comorbidities such as cerebral palsy, degenerative joint disease, and morbid obesity.
- Lack of endurance—For 27 of the 39 stays, inadequate physical endurance limited the patients’ ability to participate in intensive therapy. For example, one patient was severely compromised by muscle weakness and malnutrition at admission.
- Unresolved health problems—For 21 of the 39 stays, unresolved health problems limited the patients’ ability to participate in therapy. Medical records for those patients described problems such as inadequate recovery from a prior illness or surgery; uncontrolled pain; debilitation from cancer; and pressure ulcers. One patient had not adequately recovered from numerous cardiac issues to fully participate in therapy at the time of admission to an inpatient rehab hospital. In another instance, a patient had uncontrolled pain from a chronic pain disorder which was compounded by experimental chemotherapy to treat metastatic colon cancer.
- Altered mental status—For 18 of the 39 stays, altered mental status limited the patients’ ability to participate in therapy. Medical records for the patients in this category described cognitive problems such as delirium and dementia. For example, one patient was difficult to rouse and unable to remain alert during therapy due to significant delirium. Another patient had severe dementia and was unable to follow commands during therapy.
Retaining patients unsuited for intensive rehab therapy. The case review determined that for 32 of the 39 stays in which patients were deemed to be unsuited for intensive therapy those patients nevertheless remained in the inpatient rehab hospitals for extended periods of time. Extended stays were defined as stays lasting longer than three days, and those patients were allowed to remain in the intensive rehab hospitals despite being unable to participate in and benefit from the intensive rehab therapy.
Conclusions. The OIG concluded its report by encouraging CMS to consider providing additional technical assistance to ensure that Medicare patients are placed in the most appropriate setting for post-acute care and that inpatient rehab hospitals do not admit patients who are unable to participate in and benefit from intensive therapy. An OIG audit that is currently in progress will provide a national assessment of the proportion of inpatient rehab stays that do not comply with all Medicare coverage and documentation criteria, including stays in hospital-based rehab units and inpatient rehab hospitals. The report was issued directly in final form because it contained no recommendations. The comment period remains open for 60 days.
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