Even if Medicare payments for rehabilitation were less favorable, an integrated and effectively managed continuum of rehabilitation services can be very appealing financially for health systems. The full continuum of rehabilitation includes acute, post-acute and outpatient, and each level--if effective--can improve the system's margins on other services.

CONTINUUM BARRIERS

Unfortunately, few health systems have dedicated the necessary resources to optimizing their rehabilitation continuum. Most systems exhibit some of these rehabilitation effectiveness inhibitors:

1. Rehabilitation silos. Fragmented reporting responsibilities are major barriers to an effective rehabilitation continuum. In some hospitals, the responsibility for inpatient, outpatient and the distinct-part rehabilitation unit is assigned to different administrative personnel. For example, inpatient rehabilitation may report to a VP for patient services; the rehabilitation unit may report to the COO; and outpatient unit may report to a director of outpatient services. This segmentation often becomes more complex in health systems, where the rehabilitation unit might report to a post-acute or extended care administrator, while inpatient and outpatient rehabilitation report to administrative personnel in each of the system's hospitals. These reporting practices lead to disparate admissions and operating policies, and missed opportunities to leverage staff, DME purchasing and other common areas.

2. Separate and uncoordinated admissions. When each of the rehabilitation components within a system has its own admissions personnel and procedures, hospital case managers and physicians have difficulty referring patients to rehabilitation. This is particularly true when more than one hospital in a system has an acute rehabilitation unit and an outpatient rehabilitation program.

3. No rehabilitation continuum. A coordinated rehabilitation continuum permits the health system to optimize patient care, outcomes and financial performance. While most hospitals have a long way to go before their information systems are adequate for an optimal rehabilitation continuum, much can be done through shared personnel and procedures to connect admissions and discharges between and among acute and subacute rehabilitation, home health and outpatient rehabilitation.

4. Missed opportunities for efficiency. As acute rehabilitation prepares for Medicare PPS, a critically important lesson can be learned from SNFs that were subjected to PPS in 1998: The most efficient provider wins. When rehabilitation components in a system are fragmented, efficiency suffers as procedures and operations are unnecessarily duplicated and opportunities for leveraging staff are unnoticed.

5. Unexplored options for outpatient outreach. Coordinating outpatient services throughout a health system provides a platform for expanding outpatient rehabilitation services. Many health systems are finding that a distributed network of outpatient rehabilitation centers in physician office buildings, assisted living facilities, wellness centers, senior centers and even in shopping malls provides financial returns and familiarity for families and patients. The intent is that satisfied outpatient rehabilitation users and their referring physicians will use other health system services in the future.

A CONTINUUM STRATEGY

There is no single best model for an integrated rehabilitation continuum. An organization's model should reflect the system's size, location, governance and market conditions. There are, however, several steps and strategic initiatives that apply to most hospitals and health systems.

1. Clear goals. While most health organizations are aware of the importance of an organizational vision, administration often skips the step of defining the goals for an integrated rehabilitation continuum.

One major health system in the Southeast with three acute hospitals, a rehabilitation hospital, a SNF, home health agency and outpatient rehabilitation services recently completed a plan for an integrated rehabilitation continuum. The CEO articulated the goals as follows:

* A fully utilized rehabilitation hospital

* A continuum of rehabilitation services that serve the community and have a high degree of continuity

* A leadership model that drives rehabilitation

* Market domination in rehabilitation

* Satisfied physicians who believe that rehabilitation services in all components are meeting their needs and are customer-friendly.

2. Rightsizing acute and subacute rehabilitation. As market conditions, health care practices and payment structures change, the demand for acute and subacute rehabilitation should be reassessed. Shorter lengths of stay and more alternative post-acute care settings have negatively impacted the occupancy of many acute rehabilitation hospitals and units. Before downsizing a unit, however, the hospital or health system should determine if there are opportunities to generate referrals from other physicians, hospitals or managed care organizations. The organization also should find out whether there is a demand for specialty niches in acute rehabilitation that will help fill the unit or hospital, such as ventilator weaning programs with a rehabilitation focus, specialty programs for progressive neurological problems or comprehensive programs for traumatically brain injured patients. Conversely, a market assessment may find a demand for more acute rehabilitation beds, particularly for Medicare patients if SNFs have reduced their Medicare beds.

Likewise, a health system's skilled nursing facility should determine the continued efficacy of its subacute rehabilitation program in light of market conditions and PPS. While some may find that increasing Medicare beds responds to market demand and results in volume-related efficiencies, others may need to consider reducing the number of Medicare beds and the subacute rehabilitation program.

3. Executive committee and coordinating council. Instituting a rehabilitation executive committee and a coordinating council makes sense for most health systems. The executive committee serves as the governing body with accountability for the rehabilitation continuum. Its composition includes the COO, senior rehabilitation executive(s) and a senior executive from finance, human resources, information management, marketing, managed care and medical affairs.

The coordinating council comprises rehabilitation-related directors and may include service center directors, admissions director, marketing, reimbursement/ billing director, case management coordinator, nursing director, home health liaison and outpatient scheduler. Its purpose is to maintain and coordinate program development, implement a budget and report to the executive committee regarding program goals and objectives, reimbursement, budgeting, staffing, etc.

4. Centralized admissions, marketing and billing/reimbursement. Creating a single admissions coordinator for acute rehabilitation units and subacute rehabilitation settings can significantly increase the timeliness and appropriateness of admissions. An important part of this process is the development of detailed criteria, specifying the patient types that can be admitted without further review. Upon receiving or generating a referral, the admissions coordinator completes a brief assessment within 24 hours. If the patient's condition meets one of the automatic admission criteria for acute or subacute rehabilitation, the patient can be transferred immediately. If a patient's medical condition requires a review, then a decision must be made within the next 24 hours.

Likewise, centralizing outpatient scheduling for all settings allows for more timely appointments and more effective use of resources. If one outpatient setting cannot accommodate a new patient, the system can offer another one with an immediate appointment.

To optimize the effectiveness of centralized admissions and to ensure that patients receive care in the most appropriate setting, the system should clearly state the following for each level of care:

* Patients served

* Clinical and non-clinical needs met

* Admissions and discharge criteria

* Financial, licensing issues/restrictions

* Acceptable lengths of stay.

Centralizing rehabilitation marketing and billing/reimbursement functions also can increase operational efficiency. A unified marketing approach also allows for branding of rehabilitation services, so that the health system's reputation can provide a halo effect for the rehabilitation services and vice versa.

6. Standardized rehabilitation practices. The more rehabilitation components a health system has, the more opportunity there is for duplication of resources and compliance problems. By standardizing rehabilitation practices whenever possible across the continuum, a health system can improve quality, outcomes and efficiencies while decreasing costs and risks of noncompliance with federal or state regulations.

7. Optimizing access for outpatient rehabilitation. Proprietary enterprises have jumped in to close the service gap in the outpatient rehabilitation marketplace. Many health systems have missed an opportunity to be prominent players in outpatient rehabilitation as they've established physician referral patterns to particular outpatient centers and managed care organizations have narrowed their networks.

Some communities still have opportunities to target specific patient groups requiring outpatient rehabilitation, such as seniors. The decision to expand outpatient sites or services should be predicated on a careful analysis of outpatient rehabilitation demand in specific geographic areas. If focusing on seniors, a market assessment should consider opportunities in existing facilities where outpatient rehabilitation could constitute an additive service.

In addition to the obvious outpatient service sites geared to the aging, such as assisted living facilities, senior housing campuses, senior centers and wellness centers, consider providing outpatient rehabilitation in the physician group offices that have large Medicare practices. While potential fraud or abuse issues must be reviewed in developing the arrangement, there can be multiple advantages, like shared space and support services, and patient convenience.

Outpatient rehabilitation services also may be offered in locations that provide other hospital outpatient services, such as pain or arthritis management, infusion therapy or dialysis centers.

IMPLEMENTING A PLAN

While hospitals may be able to develop and implement a plan for an integrated rehabilitation continuum within 12 months, for health systems the process typically takes more time--three to six months to complete a plan that has buy-in from all stakeholders and one to two years to implement all components of the plan.

But invariably, health systems that undertake this endeavor find it well worthwhile.

Dr. Kathleen M. Griffin is national director of Post Acute and Senior Services for Health Dimensions Consulting Group, Benedictine Health System, Scottsdale, Ariz. She is also an ADVANCE editorial advisor.