This 470 page report offers policies, procedures and tools to 1) improve efficiency and quality while controlling the cost of care in any skilled facility or rehabilitation service, as well as home care, and 2) provide methods and criteria to objectively transition patients across the continuum of care from acute to subacute or inpatient rehabilitation, skilled ambulatory care and, when applicable, custodial care services.

Review criteria/benefit ‘interps’. Stroke and cardiac rehabilitation policies. Numerous forms and Medicare coverage information, Medicare average LOS by DRG for 2006 data. Extensive references. These tools and strategies are survival tactics for managed care contracts and prospective payment systems.

Table of Contents

Introduction – Introduction, UM for extended care services, Medical necessity defined

Post-acute and Extended Care Requirements - Selecting the most appropriate setting, Evaluation definitions, Chronic pain assessment, Outcome management, factors for success, Provider requirements for Medicare HMO contracts, Functional Independence Measures (FIM), Identification/monitoring: Cost factors, Improve operational efficiencies and communication, Length of stay benchmarks, ECS Facility Network, UM Case Management for Skilled Nursing Facility Services, Concerns about SNF admissions?, Centralized extended care service resource and care management, ECS Resource Center Staff Forums and Grand Rounds, Strategic Initiative to Improve Triage Decisions, Telephone Encounter Guidelines and form, Preadmission Screening by the ECF, Preadmission Screening Tool, OASIS, Hospice care in the nursing facility

Case or Care Management - Case Management process; Case Management Program; Case Management Referral Indicators; Target Diagnoses for CM Services; COPD, Parkinson's Disease, Heart Failure, Diabetes, Heparin-Coumadin conversion; HIV, Hip fracture; Mental Health CM: Policy, Depression, Obstetrical CM; CM loads; Case Management Screens; Case Management – new patient screens/triggers; High risk screen examples; Catastrophic conditions report; Planning the continuum of care; Hospitalist program post-discharge transitional management of care; Director of Case Management Services, position description; Case Manager, position description; Discharge Planner, position description; Case Management Department staff responsibilities; Case Management Credentialing Resources; CM Resources, References

Levels of Care - SNF Guidelines: Level of Care assignment, SNF Levels of Care for payment, Skilled Service Reimbursement, example language for agreements, Skilled Services; Scope of services by level, Transitional Care Unit Guidelines; Hospice

Defining Skilled Services - Skilled vs. unskilled nursing services, Physical Therapy Defined, Skilled vs. unskilled physical therapy services, Skilled vs. unskilled occupational therapy services, Skilled vs. unskilled speech therapy services, Speech and Voice Therapy; Authorization guidelines, Skilled vs. non-skilled services criteria, examples; Custodial care

Managing Extended Care Services - Service Standards and Procedures, Hospital Admission Review; LOS, Level of Care, Direct Admissions, Admission process for Extended Care Facility Patients, Voluntary Placement of Custodial Patients; admission from home, ECS ‘Against Medical Advice’ policy/procedure, Transfer from ECF to Acute Level of Care, ECS Clinicians ;best practices’ for continuing care, Transitional Continuity of Care Plan, Discharge Planning, ECF Discharge to home or residential care facility, Transfer from Acute Care to ECF, Podiatry services, Chiropractic services, Speech Therapy

Acute Inpatient Rehabilitation – Introduction, Criteria for admission, Preadmission review for rehabilitation, Rehab criteria, Continued stay review, Discharge status review, Case Mix, Severity Indices and Complexity of Care, Stroke/CVA, Spinal Cord Injury with paraparesis/paraplegia; dorsal/lumbar, Spinal Cord Injury w. paraparesis/paraplegia; cervical, Amputation, lower extremity, Traumatic Brain Injury Fracture of Femur/Hip/Arthroplasty, Pediatric Rehabilitation; Levels of care, Rehabilitation Benchmarks, Rehabilitation Benefits, Cardiac Rehabilitation, guidelines with references

Forms - ‘Patient Care Plan’ Authorization Form, Request for authorization for additional services, Physical Therapy Progress Note/Request for continuation, Referral Authorization, general format, UM form for Home Health, Oxygen and DME, Physical Therapy order forms

Durable Medical Equipment Coverage Guidelines– Definition, Communication devices, Orthotic/prosthetic devices, Neuromuscular electrical stimulators, Therapeutic electrical stimulation, Transcutaneous electrical nerve stimulation (TENS), Percutaneous electrical nerve stimulation (PENS), Shoe inserts to relieve back pain in patients with leg length discrepancies; Therapeutic Shoes, extensive DME list of covered and non-covered equipment

Potpourri - Assessment and Prevention of Falls; Common management issues, Claims review for extended care services, Resistance training for older individuals, Preventive physical activity regimens, Post-Work Injury Evaluation and Hardening, Handicapped Access Guidelines, SNF/Home Health Educational Brochure, example; Legal issues - elder abuse

Quality Assurance and Improvement - Quality Improvement guidelines/outcome studies; Hospital/SNF QA Screens, Rehab Care; QI Indicators, Quality ‘flags’; Measuring satisfaction: post-acute facility care; Medical Record Review; ECS Site Survey Review Tool; Provider alerts to QA Committee representatives; Urgent Complaint Resolution Policy

Home Health Care/Hospice - Introduction, Home Care and Hospice Case Management - policies and procedures; Maternity and Newborn Care Services; JCAHO Emergency Preparedness for Home Care; Home Health/Hospice - Case Management; Homebound criteria; Common reasons for failure of Home Health Case Management, ‘Homebound’ physician-based program, Skilled Home Nursing Care; Home Nursing for Ventilator or C-PAP Patients; Homecare physician visits; Home Care Plan Oversight; Home Health Teaching Coverage (Catheter Care and Feeding Tube Care Coverage, Complex medication regimen supervision, Pressure ulcers – prevention and care, Wound care); Home Health Referrals, Termination of Home Health Care Services, Home Health Aides/Assistants; Caregivers; Home Health Infusion Services; Home Ventilator Management; Oxygen Coverage Guidelines; Home Social Work Services; JCAHO 2004 National Patient Safety Goals; Home Safety Visit Check List; Hospice eligibility and coverage requirements; Hospice Care in the SNF; Karnofaky Performance Scale; Patient Choice/Disclosure for selection of HHA; Care Plan Oversight – Medicare regulations for home health, hospice coverage; North Dakota Health Care Review: Home Health Quality Initiative - links; Resources – Home Health Care Services; Web Sites for Home Health Care, Hospice

Education - Educational materials, introduction; Patient Education Materials - Development, Approval and Review P & P; ‘Self Care’ or ‘Self-management Educational Programs; References/resources – healthcare education programs; Institutional and Home Care Patient Education Programs, Medicare NCD; Diabetes Self-management Training, Medicare coverage; Education as a utilization strategy; Education notes

Addenda

• Medicare average LOS by DRG for 2006
• CMS SNF Manual, Chapter II, Coverage of Services; Minimum Data Set for Patient Transfers; Web sites - links
• ECS Acronyms and Abbreviations – Alphabetical extensive listing
• References – Extensive list of references collated alphabetically by topic