Reduced Utilization in Skilled Nursing
Warren R., Wirtalla C., Leibensberger, A. (2001) Preliminary observations on reduced utilization in skilled nursing facility rehabilitation. American Journal of Physical Medicine and Rehabilitation; 80:626-633
Study 1
Objective: identify initial differences in therapy utilization between cost-based and PPS (RUGS) based reimbursement for skilled rehabilitation
Design: 506 PPS outcomes matched and compared to 271 cost-based (pre-PPS) outcomes. Matching based upon impairment grouping, age, days post onset and admission FIM score.
Results: Utilization for RUGS group higher than allowed by assigned RUGS category. Regardless of payment type, patients with mid-range admission FIM scores received more therapy than those with high or low admission scores. Compared to the cost-based cohort, PPS patients had a similar SNF LOS, received less total hours of therapy, experienced less FIM gain, but were discharged to community at a similar rate.
Conclusions: Lower therapy utilization rates under PPS may be associated with lower function at discharge from skilled setting.
Relevance: Health Plans should be monitoring therapy hours provided in the skilled setting
Study 2
Objective: describe the influence of an outcomes based case management model on cost of skilled rehabilitation in a staff model HMO
Design: cohort of 493 HMO results using an outcomes based model (physical therapist providing predicted functional outcomes and LOS at admission) were compared to 272 matched records from a traditional case management model (no predictive data used).
Results: HMO cohort had significantly shorter LOS (1.8 day reduction) with identical outcomes in terms of function at discharge and dc to community rates.
Conclusions: Outcomes based models can eliminate unnecessary utilization while maintaining appropriate clinical outcomes.
Relevance: Health Plans should consider the use of an outcome based model to improve results of their case management processes.
