When your inpatient is an outpatient
Jean Wendland Porter
Working in the SNF environment as long as I have (don't ask) I have encountered lots of myths, rumors, fables and tales about how therapy should operate in our very limited community. But is our community really limited? Our options for patients and getting the outcomes we want are unlimited. The most unusual yet most common patient we see is the long-term care patient who lives in the facility, but requires skilled therapy. That person is an inpatient in our SNF, yet insurance considers her an outpatient.
How many times have you heard “She just got off therapy and she fell. There's no point in evaluating her again, she's a long-termer”?
That “long-termer” may be someone who had a TIA last night and now her balance is worse. Yes, she's at an intermediate level, but she requires the skills of a therapist in order to address a new balance issue. But what if she “plateaued” in therapy and isn't different? What exactly is plateau? Who determines what that is? Where in the SNF Medicare Manual is that word ever used?
Answers: Plateau is not a thing.
No one can determine the thing that doesn't exist.
The thing that doesn't exist isn't in any manual.
So Mrs. Balance needs another evaluation to determine if there are changes. Is a screen enough? The absolute definitive answer is “maybe.” If Mrs. Balance puts herself on the floor on a regular basis and she has been witnessed doing it and it's documented that this is her behavior, a documented screen should cover it. If any of those things is not true, she needs a PT or OT evaluation.
What about when Mr. Stubborn refuses therapy three days in a row? Everyone knows that means he must be discontinued from therapy, right? (No, it doesn't.) The “Three Days in a Row” rule has never existed. If Mr. Stubborn is skilled and misses three days in a row of any kind of therapy, do an EOT-R assessment. If he's an “Inpatient/Outpatient,” three days in a row of missed therapy doesn't mean anything except he's not charged for those days. If insurance considers an intermediate-care patient to be an outpatient, draw the conclusions that you would for a true outpatient. Mr. Stubborn hasn't shown up to the outpatient clinic for three days. He's probably sick. We'll call him. We'll see him when he gets better.
There's no reason to discontinue therapy because the patient missed three days.
There appears to be a mentality of bullying in our long-term care communities when it comes to attending therapy because the patient can't miss three days with impunity. The bullying can come from any source, even the family. How many times have you heard “Mom, you have to go to therapy to get better. It doesn't matter that you have pneumonia and are on 4 L of O2. You have to go, now get up.”
The bullying can come from the therapists who are often compelled to force patients to get those last few minutes of therapy (we know who we are.) We know that our patients are entitled to and deserve every last minute and every last day of therapy. But we must accept that sometimes they're just not up to it. They might miss three days.
I have been consulting at a facility where a long-term patient was given a cut letter. Her goals haven't been met. She shows potential to achieve the goals and the therapists are willing to adjust her goals to exceed her Prior Level of Function. But the cut letter was given because she missed three days, and they're sticking with that date because their agency has told them the “three missed days rule” is etched in stone.
How does that benefit anyone? Yes, she's a long-termer, but she's also an outpatient. Would you tell a true community-dwelling outpatient that her goals haven't been met but she's all done with therapy because of a rumor you heard about that third missed day?
My advice to my colleagues who are following and believing and accepting these “rules” that don't make sense and don't benefit anyone, especially the patient, is look to the source. Find the documentation in the Medicare SNF Manual or on the cms.gov website. Chances are that if the notice you get during your search shows “0 results available,” the thing you believed is nothing but a tall tale. Do what's best for your patients, and get to know the regulations that benefit them and optimize their care.
Jean Wendland Porter, PT, CCI, is the Regional Director of Therapy Operations at Diversified Health Partners in Ohio.