When physical therapists (PT), occupational therapists (OT), or speech therapists (ST) evaluate a patient in a skilled nursing facility (SNF), they document the patient’s prior level of function (PLOF). The status and timeframe to describe PLOF can vary from therapist to therapist. However, usual and customary is the patient’s level of function just prior to the last qualifying hospital stay that supports the SNF admission.
Considerations Regarding Prior Level of Function
Typically, Medicare and other payers would allow therapy if the requirements for skilled, reasonable and necessary care were being delivered, up until the patient return to their PLOF. With the changing healthcare environment that we see today, there are some reconsiderations to discuss with regards to PLOF.
- What if the patient gets to a safe level to return home, and could continue to progress to their PLOF under a less costly provider within the continuum of care? For example, a patient who was an independent community ambulator, was driving her car before she fell and broke her hip. She doesn’t need to stay in the SNF until she has returned to that level. Perhaps she could return home with home health and then transition to outpatient therapy. Therapists can no longer continue to care for a patient to that PLOF in a SNF.
- What if the PLOF, just prior to the last hospitalization, was a recent decline from the patient’s longstanding baseline functional level? In this case, would stopping the rehab at the declined level be wise and safe?
Considerations of transition related to cost should factor in risk and re-hospitalization. A patient who is sent home too early is at an increased risk of a hospital re-admission. A patient who is not safe to get around at home is at high risk for falls and other complications.
How Should the Appropriate Safe Transition Decision be Made?
PTs, OTs and STs have the perfect measurement tools at their disposal to assist in making a transition decision. Using objective standardized tests and measures, the therapist can provide information that will correlate with risk. Lower risk means less chance of a fall and a re-hospitalization because of poor decision making.
Physical therapy typically focuses on a patient’s mobility. There are many standardized tests to measure balance. The Berg Balance test, used for higher level patients, provides a scale from 1-56 with a score above 41 indicating low risk for falls. If a therapist can provide data of the patient’s baseline and progress, current score is currently at medium risk (score between 21-40) and with 2 more days of intensive therapy, and the therapist believes that the patient will achieve low risk level, what is the cost of denying those additional days?
Occupational therapy focuses on activities of daily living. The Barthel Index is a standardized test with a composite score of 10 ADL activities. A sore between 85-100 is usually identified with someone who can live at home alone or in independent living. A score below 60 is indicative of the need for 24-hour care. A score between 61-84 demonstrates the need for some amount of assistance. If the OT can provide Barthel Index updates, this can assist the insurance payor and family with knowing what kind of safe discharge plan and level of assistance is required.
Speech therapists often get involved in the cognitive aspect of care. A patient who has a Berg Balance score in the moderate risk level, but is impulsive and has poor safety awareness and judgment, is at extremely high risk. Combined with physical therapy, the speech therapist can work to improve cognition. The use of standardized tests such as the Montreal Cognitive Assessment Tool (MoCA) or the Brief Cognitive Assessment Tool (BCAT), geared to identify deficits related to Mild Cognitive Impairment (MCI), allow the therapist to focus in on specific training and develop environmental strategies to improve safety. Just like exercising a leg muscle allows it to get stronger, and walking and balance to improve, focus on brain “exercises” and practice of safe routines improves scores on these standardized tests and safer cognitive function.
If a patient has had a recent decline, but has been functioning at a much higher level within the past 6 months, perhaps the therapist should use that level as the more “accurate” PLOF. When a patient is discharged home to a low level, without much reserve, seasoned caregivers will talk about the “slippery slope.” With lack of reserve, any additional small incident causes the patient to quickly slide back down to an unsafe level. This is one reason re-hospitalizations occur.
Positioning for New Payment Models
Moving forward, we know that with the focus on ACO’s and bundled payments, we must be acutely aware of cost. However, the risk of discharge too early, with a re-hospitalization, ameliorates the savings of the early discharge. Therapists should use appropriate standardized testing with all patients, and communicate status and associated risk to the payor and family caregivers. An ounce of prevention is worth a pound of cure! A few extra days in a SNF, to get the patient to a safer level, will be worth the cost in the long run.
