acuity of patients

[sistasoul]

I work on a rehab unit that is attached to a hospital but is separate from the hospital in that even when we get patients from our hospital they are considered new admissions. We use the same pharmacy, radiology, etc. It seems that many patients are really sick when we get them and some even have to be sent back as acute patients. A lot of them are confused and have dementia, etc. Some are well into their 90's. I do not understand how these patients actually qualify to be able to do 3 hours of physical and occupational therapy a day. I find that it is almost like being back on the medical surgical floors with the exception of not having all of the IV's and without a hospitalist. I find the patients to be a lot "heavier" then even when I worked on an orthopedic/neurological med surge floor- and those patients were all heavy.

Does anyone else experience these types of patients who probably are not all that appropriate for 3 hours of rehab?

[TheCommuter, BSN, RN]

Does anyone else experience these types of patients who probably are not all that appropriate for 3 hours of rehab?

Yes. Our marketers fill our facility with inappropriate admissions during times of low census to keep profitable heads in those beds.

As long as the 105-year-old with end-stage dementia and cachexia still has Medicare dollars to milk, we'll be admitting him although he won't benefit from 3 hours of intensive therapy per day.

[WittySarcasm, BSN]

This sounds much like my rehabilitation unit. We have patients that are not correct for the therapy that we expect them to do. Many times we have to return them back for medical conditions that they should have never have been sent over to us. I can remember getting the cancer patient that should have gone to hospice then with us where we were constantly taking his vitals. Or the patient that's been wheelchair bound for 2 years and we were teaching him to walk. Yeah...I found as long as they have insurance saying yes, we'll get them.

[Boog'sCRRN246, RN]

Yes. Our marketers fill our facility with inappropriate admissions during times of low census to keep profitable heads in those beds.

As long as the 105-year-old with end-stage dementia and cachexia still has Medicare dollars to milk, we'll be admitting him although he won't benefit from 3 hours of intensive therapy per day.

Your marketers don't worry about RAC audits with these types of patients? I've been on both sides of the bed, so to speak. As a floor nurse, I hated low census because I had to float; as a rehab liaison, I hate low census because it's an automatic assumption that I'm not doing my job, but I absolutely won't admit a patient who is a RAC audit waiting to happen just to fill beds. As you know, Medicare has very strict criteria to meet for inpatient rehab, and it's about to get even stricter. I can't say we haven't admitted a few inappropriate patients at times, but it's not the norm, and usually not intentional.

[TheCommuter, BSN, RN]

Your marketers don't worry about RAC audits with these types of patients?

Apparently not. My workplace is located in a large metro area and must compete with many other rehab facilities for new admissions. Therefore, keeping heads in our beds is an uphill battle.

The nicer, newer facilities tend to receive the patients who are appropriate for the intense three hours of daily therapies. The old, antiquated facilities (read: my workplace) must scrape the bottom to attract whatever patients they can get.

[sistasoul]

What is an RAC audit? Is it a readmit to an acute floor? It seems unreal lately with some of these patients. We just had a patient code last week. Another two sent to inpatient where they both died. Very confused patients where we have had to use net beds for them because we just did not have the staff to watch them and keep them safe. All of this has happened in the last 2 to 3 weeks.

[Boog'sCRRN246, RN]

What is an RAC audit? Is it a readmit to an acute floor? It seems unreal lately with some of these patients. We just had a patient code last week. Another two sent to inpatient where they both died. Very confused patients where we have had to use net beds for them because we just did not have the staff to watch them and keep them safe. All of this has happened in the last 2 to 3 weeks.

A RAC (recovery audit contractor) is a gift from the Medicare gods {dripping sarcasm}. It is a program designed by CMS to identify and correct overpayment of Medicare claims. For inpatient rehab, it happens a lot when Medicare feels a patient's care could have been provided at a lower level of care (i.e., SNF). If the audit is not successfully appealed, the money paid to the hospital must be returned and then the patient ends up getting a HUGE bill. To make it even better, this audit usually happens 2-3 years after the patient has discharged.

There's a fine line between appropriate/inappropriate patients for inpatient rehab. The medical necessity criteria means they have to be acutely ill, but stable enough to tolerate the therapy. You'll always run the risk of having a patient code; I've seen a patient development brain stem herniation (complete with Cushing's triad) after being on the rehab unit for several days and actively participating in therapy. Had another patient develop cardiac tamponade. It does keep things interesting.

[StefiNurse]

Whats the future for the LTC setting??How can nursing revise ,reevaluate,and reform the skilled setting to of course improve it..And why is the stats of California the only state that has a mandated Nurse/Patient ratio in this country?? Why has that not been syndicated?? I just don't understand... Uhh my LTC rants!!!

[TheCommuter, BSN, RN]

why is the stats of California the only state that has a mandated Nurse/Patient ratio in this country??

California's nurse/patient ratio law applies only to acute care hospitals. It does not apply to LTC facilities or SNFs in the state.

[StefiNurse]

Wow...that's so unreasonable... I just don't understand why this can't be widely available... To all facilities..Especially LTC/Skilled due the likeliness of our Pts being of course high acuity..