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Health Care Issues Brief - Acute Inpatient Rehabilitation

Please note that in the current rapidly changing health care environment this information is subject to change, particularly in the area of reimbursement.

Developed by the Ad Hoc Committee on the Changing Role of the Speech-Language Pathologist Across the Health Care Continuum. Updated in November, 2005. Significant changes to the original text are indicated by *.

Working in an Acute Inpatient Rehabilitation Setting

Preface

ASHA's Executive Board appointed an ad hoc committee for 1998-99 on the Changing Role of the Speech-Language Pathologist across the Health Care Continuum. The charge of the committee was to provide current, relevant information about the rapidly changing arena of speech-language pathology service delivery across the broad spectrum of health care. The committee members prepared a series of issue briefs on four different settings: acute care in a medical setting; inpatient rehabilitation hospitals; long-term care and home care. The members of the committee included: Carole Roth, chair; Leora Cherney; Kathleen McAvoy; Gwen Reeves; Martha J. Smith; Carmen Vega-Barachowitz; and Louise Zingeser, ex-officio. Nancy Creaghead, 1997-99 Vice President for Professional Practices in Speech-Language Pathology, served as monitoring vice president.

Introduction

Health care across all settings has been experiencing a dramatic and unprecedented upheaval. The causes of this unrest are multiple, but largely relate to changes in reimbursement, demands of regulatory bodies, and patient factors. Fundamental changes in private and public systems of reimbursement, primarily a shift from fee-for-service to capitated and discounted arrangements, have been the most powerful change force affecting health care. The recent changes reflect measures to contain escalating health care costs, and they affect all aspects of health care delivery.

Private reimbursement systems began to move to one of several managed care models in the late 1980s, and now account for the majority of health plans nationwide. Public payers, predominantly Medicare, have also restructured their reimbursement systems. The Balanced Budget Act of 1997 mandated new methods of Medicare payment for most health care settings. In addition to direct cost-containment efforts, concerns about fraud and abuse have added to the drive to tighten payment mechanisms.

As these payment systems have been introduced, service delivery has by necessity changed. The most immediate and pronounced effect has been a closer examination of the nature, frequency, necessity, and costs of services. In addition to payers, health care providers must also respond to the requirements and expectations of various regulatory bodies. As service delivery changes, maintaining quality of care becomes an increasing challenge. Federal, state, and local licensing bodies; health care facility accreditors; credentialing entities; and institutional policies and procedures all may place demands on the provider. Factors that are frequently evaluated may include clinical competency, adequacy of documentation, quality of care, and measures of consumer satisfaction.

Patient factors are changing as well. Overall, the number of older Americans is rapidly growing, with accompanying shifts in the nature and severity of their illnesses. As America's population changes, many more patients from culturally and linguistically diverse backgrounds are being treated. Patients and families are becoming more involved in treatment decisions, and are seeking information and accountability.

This mix of changes in reimbursement, regulatory, and patient factors pose multiple challenges to providers. The nature of these factors as they affect speech-language pathology practice in an acute rehabilitation hospital setting will be examined below.

Changes Impacting Speech-Language Pathology Practice in an Acute Inpatient Rehabilitation Setting

Reimbursement issues

Changes in health care directed at reducing costs have resulted in new mechanisms for payment for rehabilitation facilities. Services provided in acute rehabilitation are reimbursed in a variety of different ways depending on the patient's health care plan. These include

1. Fee-for-service

The number of patients covered on a fee-for-service basis has decreased significantly.

2. Managed care

Managed care integrates both the financing and delivery of health care services. There are three major forms of reimbursement in the managed care context:

Discounted fee-for-service: An acute inpatient rehabilitation hospital agrees to provide services to patients covered under the insurance plan for a specific rate, typically much lower than normally charged fees.
Per diem: An agreed-on per visit rate where the number of visits the patient will receive is predetermined by the insurance company.
Capitation: An acute inpatient rehabilitation hospital agrees to provide all services to patients covered under the insurance carrier. The hospital is reimbursed based on a fee per subscriber per month.

3. Medicare

In 2001, the final Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) rule was published for Part A coverage.*
- Patients are assigned to Case-Mix Groups (CMG) based on results of the Patient Assessment Instrument (PAI).
- The payment rate per stay is based on the patient's CMG.
According to Medicare regulations, to qualify for an admission to acute inpatient rehabilitation, patients must require and be able to benefit from at least three hours of rehabilitation therapy.
Debate continues over the "75% Rule"*
- The 75% rule allows CMS to disqualify a rehabilitation facility from participation in the Medicare program if, annually, less than 75% of its admitted patients (phased in by 2007 from the current 50%) do not fall within one of 13 diagnoses/conditions.
- The rule disqualifies certain prospective new admissions based on their primary diagnosis, even though the patient may have a severe communication disorder that could benefit from intensive rehabilitation services.
Medicare and state Medicaid programs are moving toward managed care models.

4. Uninsured patients

Responsible for paying 100% of the charges themselves.
May receive uncompensated care, which results in lost revenue for the facility.

Trends resulting from these changes in reimbursement include:

Decreased patient length of stay
Reduced number of clinical services, including speech-language pathology
Staff reductions
Creation of clinical pathways to standardize care
Creation of new job classes, such as case managers or patient care coordinators, to ensure efficient quality care

Regulatory issues

1. Accrediting agencies

Several national agencies have established standards for organizations to use as guidelines in developing and offering quality rehabilitation services. Compliance is determined by on-site surveys.

Acute rehabilitation facilities may seek accreditation from:

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
CARF (The Rehabilitation Accreditation Commission)

2. Other regulatory agencies

In the majority of states speech-language pathologists are regulated by state licensure and other agencies.
Occupational Safety and Health Administration (OSHA) regulates infection control procedures and mandates standard precautions. State and local health departments may also have standards of practice that must be followed.
ASHA members are required to follow the ASHA Code of Ethics.

Patient Factors

Speech-language pathologists are experiencing changes in their patient population as a result of national demographic trends, technological advances, and health care reform, including the following:

1. Increased older population

Improvements in medical technology and greater consumer awareness of factors contributing to a healthy life-style have created an increase in life expectancy. With the increased proportion of older individuals in the population, increased health care services are needed.

2. Increased cultural diversity

A more culturally diverse patient population is requiring providers to establish cultural competency by having improved knowledge of different cultural perspectives on health care and placing value on cultural differences.

3. Increased acuity

Patients are discharged earlier from acute care and admitted to rehabilitation settings. The acuity levels of these patients may lead to medical instability causing hospital readmissions.

4. Increased severity

More medically complex patients are surviving because of increased knowledge and advanced technology. As a result these patients may have more severe deficits.
Patients with less severe deficits are being discharged directly from acute hospital care to home where rehabilitation costs are lower (e.g., home health services).

5. Increased consumer awareness and advocacy

Consumers are more knowledgeable about health care and take an active role in decisions related to their own care. They expect measurable benefits for their health care dollar.

6. Emphasis on Evidence-Based Practice (EBP)*

Patients, payers, and other medical professionals are more frequently questioning the research supporting various interventions. SLPs, like other professionals, must ensure the provision of services supported by the best available evidence and be aware of the principles of EBP.

Impact on Speech-Language Pathologists

The multiple changes noted above have led to complex effects on how speech-language pathologists carry out their job duties. Among these effects, the only constant has been a state of flux, with clinicians forced to rethink their goals and objectives on an ongoing basis. The impact on speech-language pathologists includes shifts in patient service delivery, changes in staffing patterns, and role changes. Discussion of the consequences of these changes in health care on the practice of speech-language pathology in acute inpatient rehabilitation settings follows.

Consequences to Speech-Language Pathologists in Acute Inpatient Rehabilitation Settings

Impact on Staffing Patterns

Staffing patterns across all disciplines are changing as organizations attempt to reduce salary costs, the largest expense item in patient care.

1. Staff numbers are being reduced.

When caseloads fluctuate staff may be asked to work in multiple sites (within the hospital, at satellite programs, and at other affiliated hospitals) to achieve increased efficiency.
PRN, part-time, and contract employees may be used when patient census fluctuates.
Clinicians may be asked to perform duties that traditionally have been considered out of the speech-language pathologist's scope of practice (multiskilling).
Clinicians may need to perform clerical duties due to reduced support staff.

2. The staff skill mix is changing to include speech-language pathology assistants (SLPAs), rehabilitation technicians and aides. However, at this time, CMS does not recognize SLPAs as qualified providers and will not reimburse for services provided by SLPAs.*

3. Productivity expectations are increasing as fewer staff serve the same number of patients.

There is less time for mentoring, including supervision of students and clinical fellows.
There is less time for documentation, planning treatment, staff meetings, and other related patient care activities.

4. Distinct speech-language pathology departments are being eliminated as speech-language pathology programs are reengineered into product-line models. As a consequence speech-language pathologists may report to other disciplines.

5. Bilingual staff and staff who are sensitive to and value cultural differences in patient care are needed to meet the needs of a diverse patient population.

Impact on service delivery

Alternative service delivery models are replacing more traditional models.

1. Group treatment is employed to maximize productivity.

2. Support personnel are utilized for assistance with patient care, when appropriate and reimbursable*. (See ASHA position paper and state practice guidelines.)

3. Variable lengths of treatment sessions are used depending on patients' diagnoses and needs.

Treatment sessions are shortened to 30 or 45 minutes for all patients.
Split sessions, during which two patients each receive a half-hour of individual treatment instead of the traditional hour session are scheduled.

4. The speech-language pathologist works as a team member.

The team develops interdisciplinary goals.
Speech-language pathologists may co-treat with one or more other disciplines.

5. Speech-language pathologists use more computer technology

For providing treatment in the clinic or as a home program
For assessing and treating individuals in geographically distant areas (telepractice)
For increasing efficiency and data management
For accessing information
For communicating with other professionals and with patients and families

Impact on patient management

1. There is an increased emphasis on dysphagia.

2. There is an emphasis on cognitively based communication disorders.

3. A functional approach is being incorporated into treatment.

There is a trend away from working on impairments to working at the level of disability.
Functional, measurable goals are being set.
Clinicians must prioritize treatment areas depending on length of stay and the patient's functional needs.
Clinicians must select treatment techniques that are supported by research findings (evidence-based practice).

4. Increased emphasis is placed on patient and family/caregiver education and training. Appropriate documentation of patient and family/caregiver education and an assessment of their learning are important.

5. Evaluations need to be completed within a short time frame.

Accurate early diagnosis is critical for prioritizing deficit areas
More reliance on informal assessment of functional skills.

6. Speech-language pathology services must meet the needs of linguistically and culturally diverse patient populations.

Recruitment of bilingual staff
Use of interpreter services
Increased knowledge and awareness of cultural differences

Impact on documentation

1. Documentation must meet the standards and guidelines of the regulatory bodies and payers regarding timeliness and content, including patient-family input into the treatment plan.

2. There is an emphasis on developing an interdisciplinary treatment plan with functional goals.

3. With less time available for documentation reports must be:

More concise
More timely
Less narrative and more of a checklist format

4. Covered entities must abide by HIPAA regulations.*

Impact on Outcomes

Increased accountability is necessary using objective, measurable, functional goals.

Clinicians use functional measures for goal development, treatment planning, and documentation of gains.
Facilities use functional outcome data in program evaluation, quality improvement, and marketing.
Payers and regulators use functional measurement data to select providers, determine eligibility for services and make fiscal decisions about care.
A number of standardized measures of functional outcomes (e.g., ASHA-FACS, FIM); and a national outcomes database are available for ASHA members (ASHA NOMS).

Impact on Resources

There are fewer resources for continuing education, materials, and equipment.

Impact on Customer Service

Customers include the patient/family, referring physicians and agencies, other disciplines/ departments within the facility, and the insurance or managed care companies.
Training of staff in the area of customer service is being done.
Patient/family satisfaction is an important outcome measure.

General Roles/Skills

In the face of these multiple challenges, speech-language pathologists must be open to changing roles. In some cases, these shifts will include expansion of current roles. Examples of this type of shift may be an increased focus on counseling and training families, intensification or increased proficiency in data collection for outcome information, or increased facility with computers. In other cases, there may be actual changes in job roles; speech-language pathologists, for example, may assume roles as case managers, rehabilitation directors, or marketers of services.

The question of scope of practice and job boundaries is increasingly pronounced. As noted, speech-language pathologists may be asked to take on tasks not traditionally performed. A decision on what is ethical and quality practice must be made by each clinician, within the context of the ASHA Code of Ethics. Similarly, issues about maintaining quality of care in the face of multiple external demands force some into decision making about what is and is not acceptable practice.

One critical role for all speech-language pathologists is that of advocate. This need for advocacy cuts across many levels. It may involve advocacy for an individual patient to receive appropriate care. It may also require advocating on the behalf of our credentials and qualifications when faced by competition from another discipline with overlaps in scope of practice. We may need to advocate for reimbursement with a payer. In the larger picture, we must all assume responsibility for advocating for our patients and our profession with state and federal legislators, those who have established the new rules that are rapidly changing how we deliver our invaluable services.

Knowledge Base for Clinicians Working in Acute Inpatient Rehabilitation Settings

It is recommended that speech-language pathologists involved in providing services in an acute inpatient rehabilitation setting have knowledge of the following:

Medicare regulations
Medicare guidelines for rehab criteria
Medicaid regulations
CARF accreditation standards
Joint Commission accreditation standards
ASHA PSB accreditation standards
OSHA regulations
HIPAA regulations
Standard precautions
ASHA Code of Ethics
Functional outcome measures
State regulations
Understanding of payment models
Documentation requirements
Continuum of care options for discharge planning
Case management
Continuous quality improvement (CQI)
Competencies required by regulatory bodies and hospitals
Clinical pathways
Supervision of support personnel
Principles of group therapy
Biomedical ethics
Time management skills

Resources

AHA News
Health Forum Publishing
One North Franklin
Chicago, Illinois 60606
1-800-242-2626

Balanced Budget Act , Pub. L.No. 105-3 3 (1997).

CARF Connection
CARF...The Rehabilitation Accreditation Commission
4891 East Grant Road
Tucson, Arizona 85712

Eli's Rehab Report
News & Analysis of Finance, Law, Research & Technology
P. 0. Box 9132
Chapel Hill, North Carolina 27515
1-800-874-9180

Elman, R. J. (1999). Group treatment of neurogenic communication disorders: The expert clinician's approach. Boston: Butterworth Heinemann.

Executive Briefings on Health Care
Opus Communications Inc.
P. 0. Box 1168
Marblehead, Massachusetts 01945
(718) 639-1872
Web sitel: www.opuscomm.com

Joint Commission. (2004). Comprehensive accreditation manual for hospitals . Oakbrook Terrace, IL.

Off the Record, Legislative and Regulatory Updates for AMRPA Members
American Medical Rehab Providers Assn.
3rd Floor, 1601 20th St. N.W.
Washington, DC 20009

Rehab Continuum Report
American Health Consultants
Piedmont Rd.
Building 6, Suite #400
Atlanta, Georgia 30305
404-262-7436

Definition of Terms

Balanced Budget Act of 1997: Law designed to bring U.S. budget into alignment; significantly affected models of payment and delivery of therapy services, including PPS (see reference) models for health care facilities.
Capitation: A fixed amount ("cap") which is paid per enrollee of a health plan to the provider regardless of actual costs. Providers then decide how this amount will be spent, i.e., who will receive services, what services will be rendered, frequency, and duration of services, etc.
CARF (The Rehabilitation Accreditation Commission): Organization that provides voluntary accreditation to various rehabilitation facilities, including hospitals, free-standing units, behavioral health care facilities.
Case Managers: Individual charged with coordinating and monitoring care delivered to patients, with goal of achieving desired outcome within cost constraints. Typically, case managers may be nurses, ancillary health professionals, or individuals specifically trained in case management.
Centers for Medicare and Medicaid Services (CMS): The federal agency responsible for overseeing and administering the Medicare and Medicaid programs.*
Clinical Pathways (critical pathways): A "map" of preferred interventions. Includes timing of initiation of services and length of treatment for various providers; developed around a specific disability (e.g., stroke). Offers a means to monitor outcomes and costs of care and reduce clinical variability.
CPT Codes: Current procedure terminology codes. Standardized mechanisms of reporting services using numeric codes established by the AMA. Codes consist of 5 digits and are used in coding of patient services delivered for billing purposes.
Deemed Status: Status conferred by CMS (see listing) when a health care institution is determined to be in compliance with relevant Medicare conditions of participation through voluntary accreditation through an entity (such as JCAHO) whose standards and survey process are equivalent to those of Medicare.
Disabilities: See impairment.
Discounted Fee-for-Service: A negotiated, reduced fee that is paid to providers, typically after services are rendered.
DRGs or Diagnostic Related Groups: An inpatient or hospital classification system used to pay for hospital stays for specific diagnoses (e.g., head injury). One lump sum is paid the institution to cover all costs of care. The hospital then determines length of stay, services delivered, etc.
Episodic Care: Care delivered by "episode"-defined as a spell of illness, single occurrence of a disability or otherwise.
Evidence-based Practice: Clinical practice based on the integration of: (a) clinical expertise, (b) best current evidence, and (c) client values to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve.*
Fee-for-service: A reimbursement model under which a usual and customary fee is paid to the provider after services are rendered.
ICD-9: International Classification of Diseases. A universal coding method used to document the incidence of disease, injury, mortality, and illness. A diagnosis and procedure classification system designed to facilitate ease and uniformity of data collection. Used to group patients into DRGs, prepare billings, and prepare cost reports.
Impairment: Underlying anatomic, physiologic or disease state which may lead to functional difficulties and handicapping conditions. Example - impairment: stroke; functional problem: expressive language disturbance; handicap: difficulties in social interactions. New terminology: impairment, activity, participation (World Health Organization).
Levels of Assistance: Range of care levels needed and/or provided in long term care facilities and other settings.
Long Term Care: A set of services (medical, rehabilitation, personal care) for people who have lost a degree of functional capacity. May be used narrowly to refer to institutions providing care to these people (e.g., skilled nursing facilities).
Managed Care Model: Model of payment and service delivery based on a capitated (see reference) or discounted fee-for-service arrangement. Designed to integrate cost containment into delivery of care.
Minimum Data Set: Assessment and referral tool used in skilled nursing facilities to assist in delivery of individualized, appropriate care. Used to derive Resource Utilization Groups (see reference) under PPS in skilled nursing facilities.
Multiskilling: Cross-training of skills. ASHA endorses cross-training or multiskilling of basic patient skills, professional non-technical skills and administrative skills, but not of professional clinical skills (see ASHA 1997 position statement and technical report).
OASIS: "Outcome and Assessment Information Set" tool used to collect data on home care patients, as mandated by and reported to CMS. Data to be used for case- mix adjustment and outcome based quality improvement.
Patient Care Coordinator: Individual assigned to a patient to coordinate various aspects of care within available reimbursement parameters.
Per Beneficiary Limit: "Therapy cap" limitation on cost of Medicare Part B services allowed to be reimbursed for each individual (beneficiary) receiving therapy services.
Per Diem: Reimbursement payment on a daily basis; typically all-inclusive fee.
PRN: Employment on an "as needed" basis.
Product-line Model: A set of services or goods that can be used by or that is experienced by the patient that can be viewed and used as a product measure.
Prospective Payment System (PPS): Payment system that establishes rates before services are rendered.
Provider Networks: An affiliation of providers developed through either formal or informal contracts and agreements. Develops a list for referrals of providers within the network; may contract externally for administrative and financial services to lower joint overhead.
Resource Utilization Group (RUG) Categories: Reimbursement categories used under the PPS (see reference) for skilled nursing homes. Each category determines amount of therapy received. RUG category is derived from the MPS and determines per them payment level.
Subacute Care: Care rendered after acute hospitalization. May be restricted to immediate period after discharge for high medical complexity and rehabilitation intensity patients; or may be used for entire spectrum of care, e.g., skilled nursing care, home care.
Uncompensated Care: Services rendered that are not reimbursed through insurance or patient private pay.
Universal Precautions: A set of precautions designed to prevent transmission of human bloodborne pathogens, such as HIV or Hepatitis B virus when providing health care.

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