Minute management and the MDS: smart therapy delivery is based on PPS experience.

Once upon a time, therapy reimbursement and scheduling were two different worlds. It mattered little when Mrs. Smith received her therapy--there was no intense focus on exactly how many minutes she received or in what time period they occurred. "If a patient missed a day, he may only have been seen four times that week instead of five--"it wasn't a big deal," says Stacie Flynn, MPT, master clinician and team leader in physical therapy at Schuyler Nursing Center in Schuyler, Nebraska.

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Then came the Prospective Payment System (PPS) and a new paradigm: Minutes mattered--a lot. Confronted with strict new rules about what qualified for payment, therapists focused much more on time with the patient. Gone were the team meetings and periodic resident screenings. "We were also cut back from doing a lot of facility things, like marketing and committee meetings," says Flynn. "Our focus was on ensuring that our patients received the appropriate number of minutes of therapy."

But with five years of PPS experience has come a collective sigh of relief. Both facilities and therapists have learned to live with minute management. "I think the facility and the staff are more comfortable now--we survived the change and we can relax a little," says Flynn.

Flynn says she now goes to meetings every day to communicate with the executive director, nursing, and other department heads. She and other therapists even take part in promoting the therapy program. "And we're back to giving a high priority to screening residents in the building to watch for decline," she notes.

As with all things, experience is a great teacher. "Facilities have really refined their systems for communication between therapy and nursing and for minute management," says Mark Besch, vice-president of clinical services for Aegis Therapies. "Early in PPS we saw rehab backing off on how aggressively they treated patients. Now we see a more clinically appropriate approach to treatment minutes planning, and we see a division of patients throughout the RUG categories between high and low."

As therapists and nurses have learned to manage minutes on the MDS, several strategies have emerged involving:

1. Admissions. Make sure patients who have therapy needs bring therapy orders from the doctor with them when they are admitted. "If the residents don't come with therapy orders, and you can't get orders from the doctor for two or three days, that can inhibit getting your therapy minutes into the MDS," says Flynn. Nursing and therapy can team up to make this happen. "Our nursing staff is so aware now," adds Flynn. "Admissions asks the hospital discharge planner to make sure the patient comes with therapy orders. That helps speed the process and provide the necessary medical services to the patient in a timely manner."

2. Assessment Reference Date (ARD). Capture the true needs of the patient by having the MDS nurse and therapists collaborate on setting the proper reference date for the first MDS assessment. For example, a facility may habitually use day five as its assessment date. But for a patient admitted on Friday afternoon who is too exhausted to receive therapy until Monday, it would make more sense to use grace days up to day eight, so that therapy from Monday through Friday could be included. If the day five were used, the reference days would be Friday through Tuesday--which would result in three days without therapy, hardly capturing the patient's true needs. "Grace days are there for this exact situation," says Besch. "You should be reimbursed for the services you are going to deliver."

3. Proper evaluation. Evaluate patient needs first, then fit the minutes required into a RUG category. For example, Aegis Therapies uses a "Scope of Practice Grid" that enables the therapist to evaluate the patient's

areas of deficit before deciding on the therapy treatment plan. "It's a tool that assists the therapist to see deeper into the patient's abilities," explains Besch. "We want to treat residents as individuals and plan their minutes based on their needs."

4. RUG categorization. Coordinate all three disciplines of therapy to establish the minutes required to treat the resident, then establish the RUG category. "We don't want to restrict the therapist to the minimum," says Besch, "but we often see a lack of communication between therapists in coordinating therapy and considering the RUG requirement. In short, we want the total number of minutes delivered to our patients to be 'on purpose,' based on the patients' needs, and to be a result of coordinated planning."

5. Ongoing communication. As treatment progresses, make sure all therapists talk to each other in terms of managing minutes and that they keep nurses informed. "We have a planning tool book where we put our projected goals," says Flynn. "I look at that book every day and we have weekly meetings to make sure the plan is appropriate and to determine whether we need to increase or decrease minutes." It's particularly important to keep nursing informed of changes in minutes. "If we were tapering down patients to three times a week and if restorative nursing wasn't in place, then the MDS could default and the patient wouldn't qualify for Part A," explains Flynn. "Also, you need to manage changes in reference dates, especially if the patient is sick and can't come to therapy, so as to keep the MDS accurate."

6. Therapy staff education. Train new staff in the minutes required for each patient. It is important that all staff understand the importance of providing the minutes of therapy that are in each patient's care plan.

7. Mutual respect. Build a bridge of understanding between nursing and therapy through communication. Each needs to trust that the other has valid reasons for its behavior and is doing what is best for the resident. "I don't always understand nursing's plan of care or their reasoning," says Flynn. "Nursing doesn't always understand the therapy plan of care or our reasoning. Sometimes it's just a different perspective. Once we communicate and build the understanding, we build trust in each other."

PPS, so threatening at first, has been tamed. "A critical point in MDS and rehab success is coordination between the disciplines and a commitment to minute management," says Besch. When nursing and therapy communicate frequently and effectively, they create the most accurate MDS, and the facility receives the most accurate reimbursement.

RELATED ARTICLE: Skilled Nursing Facility Care Map

Care mapping is the process of plotting the long-term patient's Medicare Part A stay in order to most effectively use SNF resources to achieve optimum patient care outcomes and an appropriate discharge plan. Rehab therapy should have input into the initial and ongoing development of the care map. As the care map is developed by the Medicare Part A assessment team as a whole, the MDS assessment nurse can set the ARD at the most opportune date to capture the necessary medical and treatment data for input into the MDS assessment. The setting of the ARD will be more objective within the context of the care map, because it will be based on documentation and input from the SNF care team. The type of MDS assessment (comprehensive, full, OMRA, or SCSA) is also determined by the information used to develop the care map.

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RELATED ARTICLE: A Consultant's Observations

Gary Phillips is an associate with BKD, one of the leading public accounting and consulting firms in the United States, and assists some 150 SNFs and swing-bed hospitals in several states with their financial, cost reporting, and reimbursement issues. Along the way, he has seen his share of costly MDS oversights hitting unsuspecting facilities in the pocketbook. He offers several observations:

* "Setting the ARD for the Medicare five-day assessment at day five sounds logical, but can be very expensive. Often the patient is not able to participate in a high level of therapy services upon admission to the SNF because he has been in the hospital. That can cause him to be classified into the lower payment level of rehab. In a case such as this, the better ARD to choose might be day two or three. More hospital time would be included in the seven-day look back, so more medical data from the hospital could be incorporated, classifying the resident into the higher non-rehab RUG."

* "Quite often, if there is a decubitus ulcer, it's not appropriately communicated by the hospital to the nurse at the SNF. This could have a negative impact on RUG classification."

* "The RAI Manual specifically instructs facilities to do an Activities of Daily Living (ADL) assessment on a newly admitted resident over a 24-hour period to determine the amount of assistance that will be needed. Let's say 'Mrs. Anderson' is able to feed and clothe herself independently during the daytime, but needs a great deal of assistance overnight to get to the bathroom safely. If her ADL assessment were done during the day only, the SNF would miss out on the opportunity to bill adequately for the help she needs from nursing staff at night. I recommend that a flow sheet be set up for the CNAs to record how often they are needed to assist residents to assure their safety, thus ensuring sufficient reimbursement."

* "I think it is preferable that CNAs perform ADL scoring, rather than therapists. From my perspective, patients particularly want to perform well for therapists, on grounds that 'I'll be able to get out of here and get back home all the sooner.'"

Phillips (whose "ideal" care map for maximum RUG utilization for resident care and reimbursement is exemplified in the figure) acknowledges that the PPS is "an extremely complicated system, and makes it difficult for nurses without proper training to find out how to determine the best RUG grouping for the patient. Yet I'm amazed that government has developed a system that, when you benefit the patient the most, you get paid the best."