Are high rehab RUG scores really for you?

Judy Smith, GNP, RN, is the owner of Clinical/Operational Innovations, a Denver, Colorado-based consulting firm specializing in nontraditional care delivery models in long term care. Scott Jolley, CPA. is the owner of Pinnacle Healthcare Consulting in Salt Lake City, which specializes in Medicare reimbursement issues.

AS LONG TERM CARE PROFESSIONALS SCRAMBLE To FIND strategies to survive under PPS, many have been attending more seminars than they can count. These always include sessions like "Completing the Minimum Data Set (MDS)" and "Resource Utilization Group (RUG) Scoring." With conventional wisdom suggesting that the higher the rehab RUG score, the higher the reimbursement paid to the facility, conversations at workshops buzz with ways to achieve the highest score.

These conversations inevitably raise several questions. One, are providers still operating in a cost-based reimbursement mode? Two, have providers completed the essential paradigm shift that recognizes that the lowest-cost provider of many rehabilitative interventions is not therapy but nursing? And three, as outside therapy contractors become less prevalent and staff nurses become more involved in rehabilitative treatments, how can facility managers ensure that higher costs are not incurred, care is not jeopardized, and already overburdened nurses are not given more than they can handle?

Nurses need to get better at identifying patient problems. To encourage this, most facility managers need to change their care delivery systems to refocus nurses on "hands on" care. Nurses must also be reeducated to provide more outcomes-oriented rather than task-focused care.

Unfortunately, nurses in skilled nursing facilities all too often fail to recognize unstable or potentially unstable medical conditions. Patients are given daily therapy that is poorly tolerated, resulting in acute episodes. These not only hurt the patients but may necessitate costly trips to the emergency room, for which the facility may be held financially responsible.

What's more, if problems are not accurately identified from the start, interventions that impact the RUG score, such as medication changes, physician visits, IVs, injections, and oxygen, are not prescribed. Additionally, if unstable medical conditions such as dehydration or cardiac arrhythmias are not prevented or treated, or if pain is poorly managed or depression is not treated, the patient will not achieve his or her highest functional potential.

If the desired outcome is not being achieved, perhaps it's time to reexamine the perceived problem and the goal and appropriateness of the intervention. For example, is it always appropriate to provide skilled therapy if such problems exist, or would it be best to wait until the patient is stabilized medically? Alternatively, after the patient is medically stabilized, might the ADL deficit have resolved itself without any therapy?

Consider the case of a patient whose diagnoses include exacerbation of congestive heart failure and atrial fibrillation, degenerative joint disease, depression, history of malnutrition, osteoporosis, history of deep vein thrombosis, and undiagnosed urinary incontinence. This patient, whose ADL score is 8, needs the assistance of one caregiver to transfer, ambulate, dress, and toilet because of inactivity during this acute illness.

Nursing diagnoses and treatments might include (but would not be limited to) the following:

Diagnosis: Unstable (or potentially unstable) cardiorespiratory status related to recent exacerbation of congestive heart failure and atrial fibrillation.

Treatments: Monitoring of fluid intake and output, daily weights, vital signs and a cardiorespiratory assessment every shift, IV fluids and/or medications daily, oxygen administration, and daily physician order changes.

Diagnosis: Impaired mobility and self-care deficit related to weakness from inactivity and degenerative joint disease (considered a common "wear and tear" disease of the elderly).

Treatments: Range of motion, ambulation, dressing and toileting assistance by nursing, and pain management.

If 500 minutes of skilled therapy were provided in addition to the above interventions in an attempt to score the patient in the highest rehab category, the RUG score would be RVA, with an unadjusted federal per diem payment in the amount of $261.12. After paying the cost of therapy (assume cost of therapy to equal 70 percent of therapy labor component, or $81.28), the facility would be left with $179.84 to provide the essential treatments listed above.

However, let us consider a more enlightened approach. If therapy were not provided at this time, the RUG score would be SE2 with a federal per diem of $218.97 and the $81.28 per day cost of therapy would not be incurred. Thus, the facility would realize $39.13 more per day to provide the treatments listed above. After appropriate nursing care had stabilized this patient and prevented the complications of bed rest and inactivity, it is reasonable to assume that the patient would gradually recover to the prior level of ADL functioning without therapy.

Similar rate disparities exist in the other therapy categories, resulting in increases in the net contribution to the facility of between 8 and 41 percent. Of course, the difference will be greater if the cost of providing therapy treatments is more than 70 percent of the therapy component.

It is important to note that the treatments needed by this patient are definitely within the scope of nursing practice and constitute appropriate treatment. The cost-based system of the past encouraged all rehabilitative treatments to be done by therapists, for reasons that had to do with cost, not care. Busy nurses, frustrated by expectations to assist in all areas of operations in addition to nursing care, eagerly relinquished these treatment interventions, but they are certainly capable of taking them on again.

Based on what we've seen in SNFs nationwide for the past five years, it seems that long term care nurses continue to deliver care in a way developed many years ago to meet the needs of much lower-acuity, ICF-type residents. Certainly, few SNFs have adequately prepared for the more restrictive payment system imposed by PPS. As in the example above, they often persist in pursuing higher-cost therapy treatments while restricting or overlooking necessary, less costly nursing and medical interventions. Most importantly, nurses are not enabled to assess high-acuity patients and intervene appropriately. As a result, data captured by the MDS for reimbursement is inaccurate and patients do not receive appropriate care.

Assessing problems accurately and prescribing nursing and medical treatments more appropriately yields crucial benefits, including:

* Documented improvement in patient outcomes

* Lower cost of care, in most cases

* Better reimbursement achieved by more accurate, timely MDS completion and more accurate claims processing with fewer denied claims

* Reduced legal exposure from inaccurate documentation of patient conditions.

By refocusing on care delivery methods that achieve more accurate assessments and provide more appropriate intervention, providers can realize improved patient outcomes. What's more, if you do what is clinically appropriate for each patient rather than try to achieve the highest rehab RUG score for everyone you admit, your facility should wind up doing better financially under prospective payment.