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Mystery Solved: Which Patients Are Good Candidates For Acute Inpatient Rehabilitation?

Occupational Therapy Environment, Saint Luke's Hospital, WA

For most physicians who practice inpatient medicine, acute inpatient rehabilitation facilities are mysterious places with inscrutable admissions criteria. This is partly because physical medicine and rehabilitation (PM&R) has done the poorest job of public relations of any single medical specialty (Does anyone know what we do?), and also because rehab units have been in the cross hairs of federal funding cuts for decades. The restrictive CMS criteria for inpatient rehabilitation have resulted in contortionist attempts to practice our craft in an environment where clinical judgment has been sidelined by meticulous ICD-9 coding.

But I will not bore you with the reasons behind our seemingly capricious admissions criteria. Instead I will simply tell you what they are in the simplest way possible. After much consideration, I thought it would be easiest to start with the contraindications to acute rehab – I call these “red lights.” If your patients have any of these, then they will not qualify for transfer to the acute inpatient rehab unit. I followed the absolute contraindications with relative contraindications (you guessed it, “yellow lights”) – these patients require some clinical and administrative judgment. And finally, I’ve listed the official green lights – the diagnosis codes and medical necessity rules for the ideal inpatient rehab candidate.

I hope that these rules demystify the process – and can help discharge planners, rehab admissions coordinators, and acute care attending physicians alike help to get the right patients to acute inpatient rehab.

RED LIGHT (Patient does not meet criteria, admission is not currently indicated):

  1. Inability to Participate: Patient cannot tolerate 3 hours of therapy per day.
  2. Unwillingness to participate: The patient does not wish to participate in PT/OT/speech therapies and/or shows no evidence of motivation in previous attempts to perform therapy
  3. Poor rehabilitation potential: The patient’s functional status is currently no different than their usual baseline. (Confirmed by previous history, medical records, or reliable source.)
  4. Dementia: The patient has a chronic brain deficiency that is not expected to improve and makes carryover of training unlikely or impossible.
  5. Doesn’t need help from at least 2 different rehab disciplines: The patient must demonstrate likely benefit from working with at least 2 of these: PT, OT, Speech.
  6. Acute illness or condition: The patient has an acute illness/condition requiring medical intervention prior to transfer to an acute rehab facility – these include:
    • septicemia (infection with fever and elevated white count)
    • delirium (medication effect, dehydration, infectious, toxic-metabolic)
    • unstable vital signs (severe hyper or hypotension, severe tachy or brady arrhythmia, hypoxia despite oxygen supplementation)
    • acute psychotic episode (including active hallucinations or delusions)
    • uncontrolled pain (the patient’s pain is not sufficiently controlled to allow participation in therapy)
    • severe anemia
    • extreme fatigue or lethargy due to medical condition
  7. Procedure or workup pending: The patient is in the middle of a work up for DVT, cardiac disorder, stroke, infection, anemia, chest pain, bleeding, etc. or is about to undergo a procedure (surgery, imaging study, interventional or lab test) that could alter the immediate course of his/her medical/surgical management.

YELLOW LIGHT (The patient may not be a good rehab candidate, clinical/administrative judgment required regarding admission):

  1. Possible poor rehabilitation potential: The patient’s prior level of function (PLOF) is likely low or similar to current level, however there is no clear documentation of the patient’s PLOF. It is unclear if aggressive rehabilitation will substantially improve the patient’s functional independence.
  2. Unclear benefit of ARU versus SNF: The patient is unlikely to avoid future placement at a skilled nursing facility. Would it be in the patient’s best interest to transfer there directly?
  3. Mild dementia or chronic cognitive impairment: The patient has carryover challenges but is able to participate and follow directions. There may be family members who could benefit from PT/OT/Speech training so they can take the patient home and be his/her caregiver(s).
  4. Unclear safe discharge plan:  The patient lives alone or has no family support or has no financial means to improve their living conditions or their home is unfit for living/safe discharge or patient refusing SNF but qualifies otherwise.
  5. Insurance denial: The patient’s insurer declines their inpatient rehab stay. Physiatrist may attempt to overturn decision or facility may wish to take patient on a pro bono status.  Uninsured patients may be candidates for emergency Medicaid. Facility must decide if they will lobby for it.
  6. Severe behavioral disorders (unrelated to acute TBI): Verbally abusive, violent, inappropriate or disruptive to other patients.
  7. The patient meets medical necessity criteria for acute inpatient rehab but their impairment is not represented by one of the 13 impairment categories approved by CMS. (E.g. medical debility, cardiac impairment, pulmonary disease, cancers, or orthopedic injury without required comorbidities). Admission may depend upon individual facility’s case mix and its current annual compliance rate with 60% rule.

GREEN LIGHT (The patient is a good candidate for acute inpatient rehab if they have no red or yellow lights, meet criteria for medical necessity AND meet the impairment categories listed below):

MEDICAL NECESSITY DEFINITION:

Acute inpatient rehabilitation services are medically necessary when all of the following are present:

  • Individual has a new (acute) medical condition or an acute exacerbation of a chronic condition that has resulted in a significant decrease in functional ability such that they cannot adequately recover in a less intensive setting; AND
  • Individual’s overall medical condition and medical needs either identify a risk for medical instability or a requirement for physician and other personnel involvement generally not available outside the hospital inpatient setting; AND
  • Individual requires an intensive inter-disciplinary, coordinated rehabilitation program (as defined in the description of service) with a minimum of three (3) hours active participation daily; AND
  • Individual is medically stable enough to no longer require the services of a medical/surgical inpatient setting; AND
  • The individual is capable of actively participating in a rehabilitation program, as evidenced by a mental status demonstrating responsiveness to verbal, visual, and/or tactile stimuli and ability to follow simple commands.  For additional information regarding cognitive status, please refer to the Rancho Los Amigos Cognitive Scale (Appendix B); AND
  • Individual’s mental and physical condition prior to the illness or injury indicates there is significant potential for improvement; (See Note below) AND
  • Individual is expected to show measurable functional improvement within a maximum of seven (7) to fourteen (14) days (depending on the underlying diagnosis/medical condition) of admission to the inpatient rehabilitation program; AND
  • The necessary rehabilitation services will be prescribed by a physician, and require close medical supervision and skilled nursing care with the 24-hour availability of a nurse and physician who are skilled in the area of rehabilitation medicine; AND
  • Therapy includes discharge plan.

13 Diagnosis Codes Approved by CMS for Acute Inpatient Rehab

1. Stroke

2. Spinal cord injury

3. Congenital deformity

4. Amputation

5. Major multiple trauma

6. Fracture of femur (hip fracture)

7. Brain injury

8. Neurological disorders, including:

• Multiple sclerosis

• Motor neuron diseases (Guillain Barre, ALS)

• Polyneuropathy

• Muscular dystrophy

• Parkinson’s disease

9. Burns

10. Arthritis: Active polyarticular rheumatoid arthritis, psoriatic arthritis, and seronegative arthropathies

resulting in significant functional impairment of ambulation and other activities of daily living;

11. Vasculitis: Systemic vasculidities with joint inflammation resulting in significant functional impairment of ambulation and other activities of daily living

12. Severe or advanced osteoarthritis (osteoarthrosis or degenerative joint disease) involving two or more weight bearing joints (elbow, shoulders, hips, or knees but not counting a joint with a prosthesis) with joint deformity and substantial loss of range of motion, atrophy of muscles surrounding the joint, and significant functional impairment of ambulation and other activities of daily living

13. Knee or hip joint replacement, or both, during an acute care hospitalization immediately preceding the inpatient rehabilitation stay and also meets one or more of the following specific criteria:

  • The patient underwent bilateral knee or bilateral hip joint replacement surgery during the acute care hospital admission immediately preceding the IRF admission
  • The patient is extremely obese with a Body Mass Index of at least 50 at the time of admission to the IRF or
  • The patient is age 85 or older at the time of admission to the IRF.

References:

http://www.anthem.com/medicalpolicies/guidelines/gl_pw_a051177.htm

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/InpatRehabPaymtfctsht09-508.pdf

http://www.gpo.gov/fdsys/pkg/FR-2013-08-06/pdf/2013-18770.pdf

Fit Family Challenge 2013: Ten Tips For Fast, Healthy, And Affordable Meals

I’m very excited to be the nutrition coach for the Boys & Girls Clubs’ Fit Family Challenge again this year. In surveying the finalist families, I discovered that the two most important nutrition issues on their minds were cooking speed and food affordability. Far down the list were things like food allergies, weight loss, and nutrition basics.

Contrary to popular belief, healthy eating doesn’t have to be expensive. A new study showed that a healthful diet only costs an average of $1.50/day more than an unhealthy diet, and the additional cost is mostly related to the expense of leaner protein sources. So with a little bit of shopping savvy, you can change your family’s nutrition without breaking the bank.

Since busy moms and dads are always looking for ways to provide fast, nutritious meals for their children, I thought I’d provide some tips for doing so on a budget. These are strategies that I also use when I’m traveling across the country, working long hours at hospitals with only a microwave and small refrigerator available, and very little time for meal prep. If your day is frantic, and you don’t have much time to cook, then these tips are for you! (I’m not saying we’re going to win any culinary awards for these meals, but they are very practical. Please use your own favorite herbs and spices for flavor. I have added links throughout this post to show you examples of products I’ve used and like – but there are many other good ones out there!) :-D

1. Tupperware. Make sure you have lots of plastic storage containers (Tupperware or other brand) and baggies in various sizes. You can reuse the containers and portion out food into single serving sizes in advance. Don’t worry about finding containers that are “BPA-free” – they may cost more and fifty+ years of scientific studies (reviewed by the U.S. Food and Drug Administration) have determined that they are safe for microwave use and food storage.

2. Prepare meals ahead of time. Set aside one day a week where you will fill containers and baggies with single serving sizes of 1) protein, 2) fruits/veggies, 3) nuts/fats, and 4) complex carbohydrates. Each meal should include one of each. Snacks can contain two or three of the four groups. Each family member can quickly grab portions for their meals, lunch boxes, or snacks, and you can make up plates for dinner by reheating them in the microwave.

3. Fast protein. Pre-cooked, grilled chicken or turkey strips can be found in the refrigerated or frozen section of your local discount store. Four ounces of grilled chicken is a good serving size, and make sure you choose the chicken without sauce or chemical flavorings as your healthiest option. One serving takes about a minute to reheat in the microwave. Other great sources of protein include plain Greek yogurt (a serving is 1 cup), protein powder (whey, egg, or vegan sources), pre-packed hard-boiled eggs, canned tuna or fish in water, smoked salmon, and low-fat cheese sticks.

If you have a stove and 4-8 minutes to spare, quick-fry pork chops, lean beef, fish fillets, or egg beaters (plain, liquid egg whites in a carton are even better) with low-fat shredded cheese with a few chopped veggies can make a great omelet that’s fast and affordable.

You can make egg whites in a microwave (spray a microwave container with a little bit of pure olive oil cooking spray) and cook for one and a half minutes per serving. Top with salt, pepper, cheese, and maybe a little ketchup if you like that. Super fast, super healthy.

In a pinch, beef, pork, and natural turkey jerkies are very portable protein sources. However, they can be expensive, and you must look for the all natural varieties (not the jerky full of salt and chemicals at various truck stops across the country).

4. Fast fruits & veggies. Fruits are pretty easy because you can chop them up or peel them quickly, but if you don’t want to chop them too far in advance, pre-made fruit cups are a little more expensive, but very convenient. Make sure you choose the fruit that is packed in its own juice, not syrup.

As far as veggies are concerned, some can be enjoyed raw (celery, carrot sticks, lettuce, tomatoes etc.) but others need cooking. The fastest way to cook most fresh veggies is to steam them in a microwave. Stores now pack veggies (such as green beans, broccoli, and snow peas for example) in “steam-in bags” where you can just puncture the bag with a fork and then microwave the veggies for a couple of minutes. If you’re buying veggies in bulk, you can purchase  ”Zip n’ Steam” bags and use those instead. I’ve used these bags for everything from butternut squash to corn on the cob. They lock in all the vitamins and minerals that you may loose in a boiling or canning process.

Otherwise, frozen veggies are very convenient and are pre-chopped. Canned vegetables are also rich in vitamins (though they tend to lose the water soluble A&B vitamins so you’ll need to get those from your fruits or a squeeze of lemon in your water) and very easy to heat and are affordable.

5. Fast fat. Mostly, what I mean by healthy fats is nuts, seeds, and vegetable oils (especially olive). Fats are rarely cost-prohibitive and it doesn’t take much to “prepare” them. Healthier nuts and nut butters are plain (no sugar or salt added). Avoid candy-coated nuts, sugary spreads, or trail mixes that have “yogurt-covered” anything or chocolate added. Go easy on the dried fruit as it is a simple sugar. Cook with olive oil or olive oil spray when you can. Limit your animal fat intake (butter, high-fat cheese, lard, bacon) as it is not as healthy for you as vegetable sources.

6. Fast complex carbohydrates. I’m a big fan of brown rice. It’s very inexpensive and reheats well with a little moisture in the microwave. You can purchase the rice dry (this is the most affordable way, but you’ll need to cook up a big batch once a week), or pre-cooked in microwavable bags or containers. Brown rice grits, corn grits, cream of wheat, and oats all make quick, microwavable portions of carbs. Whole grain tortillas take 15 seconds to heat in the microwave and can be used as a wrap or side-dish. Whole grain breads, sugar-free whole wheat cereal, canned beans, hummus, and sweet potatoes (not in syrup) are all fast and affordable.

7. Drink water. It’s free, it’s everywhere, it has no calories. Water is the healthiest fluid source available, so make use of it. To save money, you can re-use plastic water bottles by refilling them with tap water. If your tap water doesn’t taste great, a squirt of fresh lemon or lime juice (along with keeping it colder) should solve the problem. Sugary sodas, juices, and energy drinks should be limited. Club soda, sparkling water, or diet sodas are a better choice if you are craving carbonation. Skim milk, almond, rice, or soy milk are healthy options as well.

8. Buy in bulk. So now that we have broken down the healthy, affordable diet into its four components and fluids – it’s time to stock up! Buying large quantities of your favorite non-perishable items can save money. Consider cost-sharing with another family, coupon-clipping, and price-shopping. Some items that you normally don’t think of as frozen goods actually store very well in the freezer – bread, tortillas, nuts, and bananas for example can last for months in the freezer. For a review of the best grocery items to buy in bulk, see this slide show.

9. Skip the organic food. Organic products are very expensive and do not provide a significant nutritional advantage over regular foods. You may wish to buy organic food to support your local farmers or because the items are fresher-looking or their packaged goods may have fewer preservatives or added ingredients, but don’t spend your last penny on organic foods because you think it’s the only way to keep your kids well-nourished. As far as reducing your potential exposure to pesticides, organic foods may reduce pesticide exposure by 30%, not exactly the “pesticide-free” level that some would lead you to believe. Most experts (including the FDA) agree that the amount of potential pesticide residue found on fresh fruit and vegetables is too low to pose a significant risk human health. Washing fresh produce with soap and water, or removing the skin, can further reduce levels if you have concerns.

10. Don’t waste money on vitamins and supplements. Although it seems like a good idea to provide your children with extra vitamins in pill-form, the majority of U.S. children and adults (according to large CDC nutrition studies) are not deficient in any vitamin or mineral. Our fortified food sources, even with sub-optimal diets, are doing a surprisingly good job of getting us all the nutrition we need. If your doctor has determined that you or a family member has a nutritional deficiency, then please follow their advice regarding supplementation. As for herbal supplements, be very careful of those since recent studies have shown that they often don’t contain the active ingredients on their labels and may even contain harmful allergens instead.

There are probably many other terrific ideas that you’ve discovered on the path to feeding your family quickly and affordably. Please share them on the blog so we can expand our creative meal planning together! I’ll be thinking of the Fit Family finalists as I enjoy my brown rice and green pepper chicken fajitas in my hospital microwave this week!

Are Plastic Products Safe? Educational Webinar Reviews The Science

Concerns about plastic safety have been growing over the years, and the media has stepped up its efforts to expose potential dangers associated with plastic compounds such as bisphenol A (BPA) and phthalates. The problem is – there is very little scientific evidence linking plastic to human harm, and no credible evidence that our current typical exposures to BPA poses any health risks at all (so say the health agencies of the United States, Canada, the European Union, and Japan). But that’s not a very exciting story, is it?

Instead, what we often hear in the news is that microwaving our plastic containers or drinking from plastic water bottles could be dangerous to our health… and that BPA-free containers are better for baby. But where did the media come up with these ideas? I asked Dr. Chuck McKay, a toxicologist and emergency medicine physician at the University of Connecticut, to explain how safe levels of exposure (to various chemicals) are determined, and how to know if news reports are based on scientific evidence. I hope you’ll listen in to this educational Webinar.

Some of my favorite take-home messages from the Webinar include what I call “just becauses”:

1. Just because you can find a substance in your urine doesn’t mean it’s harmful. (Asparagus anyone?)

2. Just because an animal reacts to a substance, doesn’t mean that humans will. (How often have you caught a cold from your dog?)

3. Just because extreme doses of a substance can cause harm, doesn’t mean that tiny doses also cause harm. (Consider radiation exposure from riding in an airplane versus being near ground zero of a nuclear strike).

4. Just because something has a theoretical potential to harm, doesn’t mean it will. (Will you really be attacked by a shark in 2 feet of water at your local beach?)

5. Just because someone conducted a research study doesn’t mean their findings are accurate. (Do you really believe the Cosmo polls? There’s a lot of junk science out there!)

For an excellent review article of the high-quality science behind plastic safety, please check out this link. In the end, there are far more important health concerns to worry about than potential exposure to plastic compounds. And throwing out all your plastic containers may not even reduce your exposure to BPA anyway… A recent study found that people had higher concentrations of BPA in their urine when they followed a plastic-free, organic diet! Their exposure was actually traced to ground cinnamon, coriander, and cayenne pepper. Who knew?

National Nurses United Supports The Occupy Wall Street Movement

Lillian Wald was a famous nurse activist and writer. She’s my role model. Lillian stood up for the little guy by providing health care to the poor, and she advocated for social justice during the Gilded Age. For those of you who may not know, the Gilded Age was a time of great wealth for a fortunate few in America. You might call these people the original 1%. Wall Street bankers and robber barons were buying politicians and running amok while building vast fortunes off the backs of the working poor. Sound familiar? It’s funny how history has a way of repeating itself.

I believe that Lillian Wald, the founder of public health nursing, would support the Wall Street Occupation if she were alive today. Lillian didn’t wring her hands when someone needed help. She got her hands dirty. I bet she would be encamped with the protesters, caring for the sick and blogging about Occupy Wall Street events. Nurses working the frontlines at the Occupy Wall Street protest rallies report that Read more »

*This blog post was originally published at Nurse Ratched's Place*

Niche Science And Targeted Medicines Vs. “Magic Bullets”

Maybe you read the other day in The New York Times that the pharmaceutical industry has a problem. Big blockbuster drugs like Lipitor are going off patent and the industry leaders don’t have new blockbusters showing promise to replace them. So the big companies search for little companies with new discoveries and they consider buying them. Industry observers think the days of $5 billion-a-year drugs to lower cholesterol or control diabetes may be past for awhile, and the companies will have smaller hits with new compounds for autoimmune conditions and cancer.

When I saw my oncologist for a checkup yesterday — the news was good — we chatted about the article and the trend toward “niche science.” We welcomed it. We didn’t think — from our perspective — the world needed yet another drug to lower cholesterol. We need unique products to fight illnesses that remain daunting, some where there are no effective drugs at all. For example, my daughter has suffered for years from what seems to be an autoimmune condition called eosinophilic gastroenteritis (EGID). Her stomach gets inflamed with her own eosinophil cells. They would normally be marshaled to fight a parasite in her GI tract but in this case, there’s nothing to attack. So the cells make trouble on the lining of the stomach and cause pain and scarring. Right now, there’s no “magic bullet” to turn off these cells. My hope is some pharma scientists will come up with something to fill this unmet need.

In the waiting room before I saw my doctor at the cancer center in Seattle I overheard a woman on the phone speaking about her husband’s new diagnosis of pancreatic cancer. I was sitting at a patient education computer station nearby. When she was finished I introduced myself and showed her some webpages to give her education and hope: pancan.org and our Patient Power programs about the disease. She was grateful. I did tell her — and she already knew — that there was no miracle drug for pancreatic cancer and that it was a usually-fatal condition. But that there were exceptions and, hopefully, her husband would be one. Of course, wouldn’t an effective medicine be best? Read more »

*This blog post was originally published at Andrew's Blog*

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

Click here for a musical take on over-testing.

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