Structuring Team Conference to Justify Medical Necessity Lisa Bazemore, MBA, MS, CCC-SLP

Weekly Team Conference Purpose:  The purpose of the conference is to problem solve the most effective way to meet the patient’s needs. Assess the individual’s progress or the problems impeding progress Consider possible resolutions to problems Reassess the validity of the rehabilitation goals initially established

Weekly Team Conference Attendees:  Medical Director/Treating Rehab Doctor  Case Manager and Social Worker  Treating PT, OT, ST  Treating Nurses  Neuropsychologist  Therapeutic Recreation Specialist  PPS Coordinator or Program Director  Coder  Nutrition  Pharmacy

Weekly Team Conference What To Do:  Open the conference with a recap of the week including: Case Manager report-  Prior level of function and planned discharge disposition Medical Director report-  Medical needs that were addressed  Tests ordered and outcomes

Weekly Team Conference What to do next:  Discuss current situation: strengths, barriers, and plan for next week including reports from: Physician Therapists Nurses Social worker/case manager  Identify strategies for removing the barriers to discharge  List team’s goals for addressing barriers to discharge and specifically state why the patient needs to stay in the hospital for another week

Weekly Team Conference What to do next:  Recap the list of ICD-9 codes. Add codes to the list from information conveyed during the meeting  Ensure that the physician documentation matches the report given during the conference to ensure proper coding  Set a discharge plan

Weekly Team Conference What NOT to do:  Fill out the functional portions of the form during the conference. Come to the meeting with the form mostly completed Fill in only new information gathered during the meeting  Functional indendence measure review each functional item Instead focus on progress and barriers You should be reporting the level of assistance with each task on the scoring form

Weekly Team Conference What NOT to do:  Plan the discharge based on the Medicare expected length of stay This indicator is meant to be an average not a guideline

Weekly Team Conference Rules:  What every good team should do. Be knowledgeable of the patient so you can adjust the plan of care appropriately. Aim for 8-10 minutes per patient. Be solutions based. Seek contributions from all team members. Assure that documentation supports continued physician, nursing, and therapy involvement.

Weekly Team Conference Success Elements:  How the good team measures their success. You came prepared and everyone could knowledgably discuss the patient’s care. Each patient’s case took 10 minutes or less to complete. The weekly conference form is completed sufficiently to justify the continued stay of the patient. Significant goals from the previous week’s conference are discussed and updated. You developed collaborative solutions to eliminate or minimize remaining barriers to discharge.

Weekly Team Conference A more in depth look at the process:  Report on the major areas of performance for each patient being discussed.  Review active medical conditions  Report elements including functional performance and medical status over the past hours

Weekly Team Conference Specifically consider:  Consistency in the patient’s performance  Progress made compared to team conference goals from the previous conference  Barriers Pain Endurance Adjustment issues Impulsivity and awareness Balance Cognition Nutrition and elimination Sleep/rest patterns

Weekly Team Conference Address key areas when functional deficits impact the patient’s ability to go home.  Examples of key areas: Transfers-Bed, Toilet, Shower  PT, OT, Nursing Lower body dressing  OT, Nursing Toileting, Toilet Transfers, Bladder and Bowel Management  OT, Nursing Problem solving  OT, ST, Nursing Skin integrity  PT, OT, Nursing Adjustment to disability  Psychology, SW, OT, Nursing, TR

Weekly Team Conference Address the discharge plan:  Discuss the discharge plan and functional ability required to achieve this plan.  Identify key barriers to the patient achieving the plan of care.  Set team goals that will support the discharge plan.  Modify the discharge plan (as needed).  Estimate the length of stay.

Weekly Team Conference What is a team goal?  Something that all team members will work on together.  It supports the key discharge goal and discharge plan.  Individual disciplines have short term goals that support it.  It is a necessary step to moving the patient along their path to discharge.

Weekly Team Conference Example:  The physician would like to remove a patient’s foley catheter. To do this successfully the team will need to work together on the goal of bladder continence. PT-Transfers, strength, balance OT-Toileting, toilet transfers Nursing-Bladder program, post void residual scanning ST-Memory, problem solving strategies

Length of Stay Management

How do you establish a length of stay?  Specific patient needs  Pathways or protocols  eRehabData facility averages  National and regional benchmarks  Medicare CMG length of stay

Length of Stay Management Review your goals:  Keep your patient’s discharge goal in mind  How much time will it take to achieve the goals? Medical Nursing Rehabilitation therapy  When will family teaching be initiated and how long will that take?

Length of Stay Management How does this measure up?  Does your clinical plan fall within benchmarks?  If yes, good job.  If no, evaluate treatment plan, discharge plan, coding and scoring.

Do You Have a Problem? Analyze the Facility Report  Transfer Patients: Percentage of patients that are discharged to another Medicare bed  Acute care  SNF  LTACH  Another IRF  Discharge Destination: Breakdown of discharge locations for the patient’s served

Do You Have a Problem Analyze the Facility Report  Averages: Two benchmarks: Weighted and unweighted Onset days: Different instructions by RIC Length of stay considerations Functional independence measure scoring data-  Admission Totals  Discharge Totals  Functional Independence Measure Change  Motor subscale at admission

Do You Have a Problem Analyze the Facility Report  Individual Functional Independence Measure Items: Admission, discharge, change, and follow-up Explains difference between facility totals and benchmark totals First glance at isolating functional independence measure scoring errors

Measuring Goal Attainment Goal setting is important!  Patient metrics page reports admit, discharge, goal, and gain.

Strategies Goal Attainment:  Emphasize goal revision on the plan of care. Keep your eye on the goal.  Use your team to discuss barriers and strategies impeding progress.  Begin setting team goals in the weekly team conference.  Determine a method to communicate current status and goals regularly through a functional status board, stand-up meetings, and/or team conference.

Team Conference Documentation of Team Conference:  Level of function at admission  Discharge goals  Medical needs  Nursing needs  Functional status by functional independence measure areas or major functional areas representing function across 24 hours  Include multiple weeks on a team conference form to allow you reflect progress  Include barriers to discharge  State weekly team goals  Identify strategies for attaining the goals  State discharge plan and estimated length of stay

Team Conference Examples and Mock Conference