Time to Think Ahead

Lisa Werner, MBA, MS, SLP Director of Consulting Services, Fleming-AOD, Inc.

If you feel like you have finally caught your breath from the changes to the Case Mix Groups (CMGs) that went into effect on October 1, 2019, make sure you don’t plan to rest for long. I was working with a client last week and we included a planning meeting to review the Final IRF-PAI Version 4.0 that was released in early December. The changes will not impact patient care, but they will require forethought and documentation changes as they call for a significant amount of data collection. To put this into perspective: the length of the document is 30 pages, which is up from 18 pages in the current version. Some of the items that were used only for risk-adjustment have been introduced for discharge assessments as well. Furthermore, many questions are related to the social determinants of health and the Drug Regimen Review.

Let’s Take a Closer Look at These Changes The first difference starts on page 3, Section A, where the ethnicity, race and preferred language questions have been added or modified. On the current IRF-PAI, patient race is asked in a different manner. Therefore, you should evaluate whether the expanded questions should be answered by the provider currently assigned to complete the question or if a different provider may have more relevant information. On page 4, a question about transportation has been added. The question aims to determine whether a lack of transportation has interfered with the patient’s ability to manage on a day-today basis. The ethnicity, race and language questions are asked on admission only, but the transportation question is asked at admission and discharge. If these questions are currently built into your EMR and populate eRehabData ® , please do not overlook the modification that will be necessary. I see value in including the page 3 and 4 questions on the case manager’s admission and discharge assessment.

On page 5, Section B, there are new questions that address the patient’s hearing, vision and health literacy. These are asked in addition to the expression of ideas and wants and understanding verbal and non-verbal content questions, which continue to be presented in the same form as we currently see them. The discharge IRF-PAI asks the health literacy question again. This is the only Section B question that is repeated. In many inpatient rehabilitation units and hospitals, the expression and understanding questions are completed by the nurses. Since the new questions about vision, hearing and health literacy are loosely related, the nurse should be able to answer them without adding to their workload. Once again, the new questions will need to be added to the EMR using the exact answers as seen on the IRF-PAI in order to upload to eRehabData ® .

Section C is also changing. The signs and symptoms of delirium question from CAM was included in addition to the BIMs and Staff Assessment for mental status. The current provider assigned to complete the BIMs should also be responsible for the CAM. The instructions indicate that the CAM should be answered in addition to either the BIMs or Staff Assessment. Currently, the Section C items are completed at admission only. Beginning for discharges on and after October 1, 2020, the Section C questions are asked again at discharge.

Section D introduces mood questions. Nine questions about the patient’s mood are asked and scored in terms of presence and frequency. Additionally, there is a question about social isolation. These items may best be answered by a social worker, case manager or nurse depending on your access to services. The Section D items are present for admission and discharge scoring.

The next few items stay the same until we arrive at Section J: Health Conditions. These new questions regarding pain were added to the IRF-PAI in both the admission and discharge sections. To share the responsibility, these questions could be addressed by physical therapy as they are likely asking these questions in the interview already. Make sure the information is recorded in the evaluation and discharge summary using the same answers as listed on the IRF-PAI to ensure ease of data collection.

In Section K, the list of nutritional approaches has been modified to be more specific. Make sure to plan accordingly. The breakdown of this section would not necessitate a change in personnel completing the item, but your EMR might need to be adjusted if this question is answered in the record.

Section N has been expanded to include questions about whether the patient is taking medication in high-risk drug classes, and if there is a documented indication for these medications. Given the complexity of the high-risk drug class questions, discuss the role of pharmacy and the physician in addressing this new item. If nursing has been completing your drug regimen review questions, you might agree that the new questions call for an assessment that goes beyond the nurse’s scope of practice.

Section O was vastly expanded. Make sure to integrate the list of Special Treatments, Procedures and Programs into your EMR. This section should be completed by the patient’s nurse. It is asked at admission and discharge.

On the discharge IRF-PAI, new questions were introduced to validate hand-off of medications to the next provider. The first two questions ask if a current reconciled medication list was delivered to the next provider and, if so, the route of transmission. This section also asks if the provider gave a current reconciled medication list to the patient, family or caregiver and the route of transmission. Since the nurse prepared the discharge paperwork, adding these questions to the discharge process is likely the least intrusive means of gaining responses.

This concludes the summary of changes for the IRF-PAI Version 4.0. Of note, I did not indicate each item that is included on the IRF-PAI and skipped sections that have not been modified. Given the extent of the revisions, I felt that it was important to remind you of how many changes we face so you can start pulling teams together to assign task completion and to anticipate necessary documentation changes. As always, these updates impact patients discharged on and after October 1, 2020, which means you will need to have the documentation changes in place and education completed by the end of August. These questions will be required for Medicare fee-for-service and Medicare Advantage patients beginning with September admissions for stays anticipated to be more than 30 days. More instructions are required to ensure that the intent of the new items is properly captured. I look forward