Is your rehab unit managed care-ready? How to build on advantages SNFs already have.

As managed care becomes an increasingly important "player" in long-term care, many nursing home-based subacute programs are finding that they already have what the typical managed care organization (MCO) is looking for - lower-cost, high-quality services delivered with an outcomes-oriented approach to care.

SNFs also have a wider latitude than typical rehabilitation providers with respect to the types of patients they can admit. For example, while patients admitted to an acute care-based rehabilitation program are required to have a specified number of hours of rehab per day, the nursing home-based program can admit patients who require far less intensive, and less frequent, therapy.

Nevertheless, there are other factors to consider before joining managed care at the negotiating table:

* Determine the costs of patient care. It is essential that you have a system in place for determining the current direct (patient care) and indirect (plant maintenance, housekeeping, laundry, etc.) costs of patient care on your rehab unit, and for capturing those costs. Being unable to judge whether or not a proposed contract will cover those costs will, of course, place you at a distinct disadvantage when it's time to negotiate.

* Develop an effective prescreening tool. While some facilities may have the luxury of an admissions coordinator who actually goes to referring hospitals to prescreen prospective rehab patients, the more typical SNF scenario involves collecting preadmission information over the phone from a discharge planner whose first priority is to make the discharge as soon as possible.

To make sure you're ready for those telephone inquiries, your admissions coordinator should have, at his or her fingertips, a prescreening tool that will determine, as accurately as possible, the likely costs of that patient's care prior to admission, and will allow you to compare those costs to the MCO's per diem rate. The tool should include questions about dressing changes, medications and any other procedures that will affect follow-up care.

It's also important to get this information from the "right" person. The floor nurse who has actually been caring for the patient will almost always be able to provide more complete information than the discharge planner.

* If you haven't already, begin looking at gathering outcomes data. As you have no doubt heard by now, MCOs are intensely outcomes-oriented, and outcomes data - such as those derived from the FIM (functional independence measure) scoring method commonly used by rehab departments - provide tangible evidence of the quality of care you provide and the successful outcomes you produce.

* Consider a shared risk contract for your therapy department. If you contract out for rehab therapy services, it may be prudent to enter into an agreement in which the contracting agency assumes a portion of the financial risk.

The "Salary Equivalency" Question

The concept of salary equivalency is a product of HCFA's efforts to get a handle on reimbursement rates for therapists. Under the proposal, therapists (speech, occupational, respiratory, etc) would be reimbursed at the lower rates received by physical therapists. HCFA is reviewing a Final Regulation on this at this writing.

Obviously, it is in contracted therapy services that the impact of salary equivalency will be felt and, already, we're seeing more nursing homes hiring their own therapy staffs in anticipation of this. If a facility is being reimbursed X number of dollars for therapy services, regardless of whether that therapist is providing four or eight hours of therapy services per day, hiring a staff therapist under the facility's direct control would seem to be a more efficient, cost-effective option.

This implies a more aggressive utilization of the therapist's skills in the nursing facility - in other words, expanding the utilization of their services beyond that typical of the Medicare A patient caseload and taking full advantage of therapists' knowledge and expertise. The possibilities range from the relatively ambitious - therapy services provided in an outpatient clinic and/or home health program - to ensuring cost-effective utilization of everyday services (i.e. "good medicine"). This might include having therapists do screenings for Medicare B patients, and encouraging their active participation in programs related to restraint reduction, positioning, wound care, and restorative nursing, to name a few.

Conclusion

As a former director of nursing, I know that "capturing the true costs" of care can be a struggle: making sure that everyone is identifying costs, that nurses on the floor are charging items appropriately, that cost data are clear and complete is, for many, a new challenge. Struggle or not, however, it is important to begin in order to establish a baseline.

It is also important to make sure that everyone, especially nursing and therapy, is working together as a team to produce meaningful outcome measurements - a concept that, fortunately, seems to be well understood in the long-term care setting.

All of this may sound like a great deal of hard work - and it is. However, managed care is forcing providers to scrutinize their service delivery more carefully than ever, and to assess and reassess for more efficient and effective performance. Change is upsetting - but it's not necessarily bad. Being "managed care-ready" may lead to a performance upgrade you never imagined.

Debra Gillett is a consultant with Griffin Management, Inc., a Scottsdale, AZ-based consulting firm for hospital and nursing home subacute care programs.