IRF Weekend Rounding/Coverage

[Ogliodendrocyte]

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For those doing IRF, when you work on the weekend- you round on the unit then go home? If you have an admission do you have drive back in or do you just put in orders from home and document the next day within 24hr timeframe?

 

[RangerBob]

My admits typically arrive in time that I don't have to come back. But putting in orders from home and seeing the pt the next days is totally kosher as long as they're stable (which they should be if they're coming to IRF)

 

[RodofEbullience]

Round, write notes, prep admissions and leave. Admissions will typically start coming in after 1PM so I see them the next day. I have never had to go back into the hospital after leaving in the first place thus far.

 

[Iamnew2]

Round, write notes, prep admissions and leave. Admissions will typically start coming in after 1PM so I see them the next day. I have never had to go back into the hospital after leaving in the first place thus far.

I'm going to piggy back on this ... how do you guys handle irrational patient family demands? Example we have amputee patient that's doing great, medically doing well, therapy wise doing well, has been evaluated by prosthetics and for light weight WC, therapy team told patient and family that they would need a ramp - weeks ago. patient set for dc soon, NP daughter comes all of a sudden and starts threatening legal action because they only recently ordered their ramp and it wont be in until later in the week from proposed discharge date. Patient's dc is on his rand date. She threatens the administration telling them that "by law he can't be discharged" to which I chuckled internally a little bit. Therapy says that they can't get him in the home bc WC won't fit on the steps to his entrance. I find it irrational to keep a patient for several days over rand when he's stable beacuse of his family's ineptitude. The family also apparently thought the hospital would be building their ramp - don't ask me how.
Thoughts?

 

[DMBandFan86]

Pretty normal, a couple of days isn’t the end of the world. Having good outcomes and making people happy is also part of IPR. RAND dates are just averages. People will go over and people will go under.

 

[Iamnew2]

Pretty normal, a couple of days isn’t the end of the world. Having good outcomes and making people happy is also part of IPR. RAND dates are just averages. People will go over and people will go under.

I understand and yes I use rand as a guideline as well but the patient has no medical needs and is already mod I. My concern is that patient will just sit there for a week with pretty much nothing going on

 

[RangerBob]

Pretty normal, a couple of days isn’t the end of the world. Having good outcomes and making people happy is also part of IPR. RAND dates are just averages. People will go over and people will go under.

Agree with this.

However, if family requesting an unreasonable amount of time over, the program director can hand them a Medicare letter saying they’ve met their goals, and CM can talk about SNF/board and care/self-pay.

Regardless, dealing with unreasonable family requesting a lot more time off is the job of the case manager/program director.

 

[DMBandFan86]

Alternatively you could order squad transfer to the home and they would just be homebound at mod-I until the ramp is built. Ultimately the daughter isn’t a decision maker unless the patient is incompetent or defers.

I’m pretty laid back when it comes to these things. I’d rather not have a 1 star review come back just for a few days of overhead. Irrational, maybe. But if they are an amputee patient then likely they will need IPR again in the future and if they choose somewhere else then that can be a lot of lost $.

 

[Iamnew2]

Alternatively you could order squad transfer to the home and they would just be homebound at mod-I until the ramp is built. Ultimately the daughter isn’t a decision maker unless the patient is incompetent or defers.

I’m pretty laid back when it comes to these things. I’d rather not have a 1 star review come back just for a few days of overhead. Irrational, maybe. But if they are an amputee patient then likely they will need IPR again in the future and if they choose somewhere else then that can be a lot of lost $.

How do you justify it with insurance/Medicare? Someone who is ready to go medically and with therapy? Wouldn’t it be considered fraud?

 

[Dansk2011]

Why can't he get up stairs if he is mod I?

More importantly what legal ground would she have? Families threaten legal action all the time. Doesn't mean anything. They could appeal the discharge. That will give them some time but would reiterate that if they lose they are responsible for the costs of the extra days out of pocket.

Could send to a snf for that short period for social reasons until the ramp is built.

1-2 days over rand is fine, but a week seems like a stretch especially if they are mod I.

I don't think it's fraud if they did stay. Could justify "not a safe discharge" if you were really concerned. But the hospital likely won't get paid or may have to pay that money back at some point.

Sometimes it's better to just bite the bullet. It doesn't come out of your pocket at the end of the day.

 

[Iamnew2]

Why can't he get up stairs if he is mod I?

More importantly what legal ground would she have? Families threaten legal action all the time. Doesn't mean anything. They could appeal the discharge. That will give them some time but would reiterate that if they lose they are responsible for the costs of the extra days out of pocket.Could send to a snf for that short period for social reasons until the ramp is built.

1-2 days over rand is fine, but a week seems like a stretch especially if they are mod I.

I don't think it's fraud if they did stay. Could justify "not a safe discharge" if you were really concerned. But the hospital likely won't get paid or may have to pay that money back at some point.

Sometimes it's better to just bite the bullet. It doesn't come out of your pocket at the end of the day.

There is no legal grounds of anything other than getting her way. Patients and family in this population where I work do that regularly because they want things their way. They literally thought we would be building their ramp. They expect the hospital to take them back home etc. We have had families go on vacation and tell us they can’t pick up the patient Until they come back. I’m like what? And technically it does come out of my pocket - if I see the patient i would have to bill - at the same time there’s no med necessity and patient is mod I. So don’t feel great about that

 

[lejeunesage]

For those doing IRF, when you work on the weekend- you round on the unit then go home? If you have an admission do you have drive back in or do you just put in orders from home and document the next day within 24hr timeframe?

Yup. I round on whoever is there, then go home.
I'm on call from home but don't have to go in.
Anyone that comes in after I've left, I see the next day.

 

[PMR’s chill]

I'm going to piggy back on this ... how do you guys handle irrational patient family demands? Example we have amputee patient that's doing great, medically doing well, therapy wise doing well, has been evaluated by prosthetics and for light weight WC, therapy team told patient and family that they would need a ramp - weeks ago. patient set for dc soon, NP daughter comes all of a sudden and starts threatening legal action because they only recently ordered their ramp and it wont be in until later in the week from proposed discharge date. Patient's dc is on his rand date. She threatens the administration telling them that "by law he can't be discharged" to which I chuckled internally a little bit. Therapy says that they can't get him in the home bc WC won't fit on the steps to his entrance. I find it irrational to keep a patient for several days over rand when he's stable beacuse of his family's ineptitude. The family also apparently thought the hospital would be building their ramp - don't ask me how.
Thoughts?

I offer snf. I usually explain that this is short term rehab, if they can’t take care of the patient a snf is a great option.

 

[PainApp2021]

My admits typically arrive in time that I don't have to come back. But putting in orders from home and seeing the pt the next days is totally kosher as long as they're stable (which they should be if they're coming to IRF)

SM would like to have a word with you.. 😆

 

[Iamnew2]

SM would like to have a word with you.. 😆

do you all do Asia exams on your sci patients?or do your therapists do it? I have a new sci patient where the therapists just decided on their own to do an ASIA exam. I was like umm ok. I've never had such independent therapists. is this the norm for you guys also?

 

[PainApp2021]

do you all do Asia exams on your sci patients?or do your therapists do it? I have a new sci patient where the therapists just decided on their own to do an ASIA exam. I was like umm ok. I've never had such independent therapists. is this the norm for you guys also?

I'm a new grad and going into a subspecialty fellowship so I won't be doing SCI... but it depends on the rehab hospital. We covered one hospital that residents did the ASIA and one model system where therapists were very well trained and would do it on their own (but we were still encouraged to do it ourselves).

 

[RangerBob]

SM would like to have a word with you.. 😆

I may just be oblivious, but what does “SM” mean?

 

[RangerBob]

do you all do Asia exams on your sci patients?or do your therapists do it? I have a new sci patient where the therapists just decided on their own to do an ASIA exam. I was like umm ok. I've never had such independent therapists. is this the norm for you guys also?

I’ve seen it done that way-where therapists do it. That's great they're taking the initiative. The more people doing it, the better.

Still--we rarely do ISNCSCI exams--they just take so long. If we were an academic center (or better yet, a VA SCI unit where you have 1-5 admits/week) we could do it and there'd be some educational value. Does anyone really care if T11 on the left is altered to LT and L3 on the right has PP absent? Generally what you really care about are can they feel the bottom of their feet/is proprioception intact, can they generally feel each extremity, are S3-5 intact, and what are their motor scores. SCI researchers are trying to validate an abbreviated ISNCSCI exam because they realize the whole thing is just so impractical--particularly for busy clinic docs.

With that said, most of our patients that are SCI are not the same type of SCI we saw on our units. They're almost always incomplete (we get a few complete SCI, but generally they're young and have intact UE's--otherwise we're really not the right unit for them and they should be at a dedicated SCI center. Even then I still recommend an SCI unit. SCI rehab is very specialized and you really need therapists who work with SCI day-in and out, and on our smaller/more rural unit they just don't get that exposure.

Edit: I should clarify I mean the SCI patients we admit to our community rehab unit are very different/“less-SCI” than the SCI patients we admitted to rehab units during residency

 

[PainDoc2025]

Whats the typical pay for IRF weekend coverage? Or SNF weekend coverage?

 

[j4pac]

I’ve seen it done that way-where therapists do it. That's great they're taking the initiative. The more people doing it, the better.

Still--we rarely do ISNCSCI exams--they just take so long. If we were an academic center (or better yet, a VA SCI unit where you have 1-5 admits/week) we could do it and there'd be some educational value. Does anyone really care if T11 on the left is altered to LT and L3 on the right has PP absent? Generally what you really care about are can they feel the bottom of their feet/is proprioception intact, can they generally feel each extremity, are S3-5 intact, and what are their motor scores. SCI researchers are trying to validate an abbreviated ISNCSCI exam because they realize the whole thing is just so impractical--particularly for busy clinic docs.

With that said, most of our patients that are SCI are not the same type of SCI we saw on our units. They're almost always incomplete (we get a few complete SCI, but generally they're young and have intact UE's--otherwise we're really not the right unit for them and they should be at a dedicated SCI center. Even then I still recommend an SCI unit. SCI rehab is very specialized and you really need therapists who work with SCI day-in and out, and on our smaller/more rural unit they just don't get that exposure.

Rectal exam is incredibly important for both prognosis and treatment strategies. You can probably omit the other details, but that’s likely too important to leave out.

 

[RangerBob]

Rectal exam is incredibly important for both prognosis and treatment strategies. You can probably omit the other details, but that’s likely too important to leave out.

Correct (well--sort of)--that's why I referenced S3-5.

I'd argue the rectal exam is really only useful for prognostication. For treatment you want to know if they have an upper or lower motor neuron bowel. But often even if they have a lower motor neuron bowel, they can benefit from an upper motor neuron bowel program. In my fellowship we typically started with UMN bowel programs for everyone. If it didn't work, then we switch to a LMN bowel program. So the rectal is really not all that helpful for treatment.

I find doing a rectal exam when patients arrive to be very off-putting and embarrassing for them--and at a sensitive time. So we often delay it if we even do it. But typically we get the info we need elsewhere--the patients are reliable at stating if they can feel bowel/bladder filling, have control, if they feel a foley or suppository get inserted, etc. The SCI research backs them up (though AIS-B patients aren't quite as reliable). And my RNs can confirm if a suppository just plops back out, if the patient is incontinent without knowing it, etc. My partner (also SCI fellowship trained) and I find that it's just rarely critical that we do a rectal exam, and typically causes more harm/discomfort for the patient, which is a lousy way to start rehab.

 

[j4pac]

Correct (well--sort of)--that's why I referenced S3-5.

I'd argue the rectal exam is really only useful for prognostication. For treatment you want to know if they have an upper or lower motor neuron bowel. But often even if they have a lower motor neuron bowel, they can benefit from an upper motor neuron bowel program. In my fellowship we typically started with UMN bowel programs for everyone. If it didn't work, then we switch to a LMN bowel program. So the rectal is really not all that helpful for treatment.

I find doing a rectal exam when patients arrive to be very off-putting and embarrassing for them--and at a sensitive time. So we often delay it if we even do it. But typically we get the info we need elsewhere--the patients are reliable at stating if they can feel bowel/bladder filling, have control, if they feel a foley or suppository get inserted, etc. The SCI research backs them up (though AIS-B patients aren't quite as reliable). And my RNs can confirm if a suppository just plops back out, if the patient is incontinent without knowing it, etc. My partner (also SCI fellowship trained) and I find that it's just rarely critical that we do a rectal exam, and typically causes more harm/discomfort for the patient, which is a lousy way to start rehab.

I agree (to a degree). It may not the best thing to do after an introduction. I don’t think that a valuable medical evaluation does harm. These are adults, and the significant majority just want good care. I don’t think that every patient needs one, but I can’t tell you how many times I regret just not doing it out of concern of the patients modesty. And aside from checking a patients skin and tone, is there really an aspect of the exam on inpatient that is as valuable?

 

[RangerBob]

I agree (to a degree). It may not the best thing to do after an introduction. I don’t think that a valuable medical evaluation does harm. These are adults, and the significant majority just want good care. I don’t think that every patient needs one, but I can’t tell you how many times I regret just not doing it out of concern of the patients modesty. And aside from checking a patients skin and tone, is there really an aspect of the exam on inpatient that is as valuable?

By tone I’m guessing you mean MMT? Or spasticity?

Much of the exam isn’t really that important. Like do we really care a patient has a +Babinski after a stroke? Of course they do… But taken together the whole is greater than the sum of the parts as it paints the clinical picture.

Sacral sensation/function is critical in an SCI patient. And may very well be more important to tone or skin. Whether a formal ISNCSCI exam is indicated vs abbreviated exam combined with patient history/discussion with other team members who are also doing that same exam (but typically for a functional purpose, like administering a suppository) may vary though. At a unit like ours without many “true/classic” SCI patients, the latter is typically the route we go.

Most of the time when I’m doing a full ISNCSCI exam, it’s on consult/newly admitted patient that I actually think needs to be transferred to a dedicated SCI unit/VA SCI unit.

 

[JFS]

Whats the typical pay for IRF weekend coverage? Or SNF weekend coverage?

Interested if anyone has some insight on this

 

[Iamnew2]

N

Interested if anyone has some insight on this

typically there is no SNF weekend coverage. IRF depends. I would say 1500 if employed, if collections prob more.

 

[Iamnew2]

N

typically there is no SNF weekend coverage. IRF depends. I would say 1500 if employed, if collections prob more.

When one of your patients becomes mod I, do your therapists tell you? say a patient's CMG is on x date, patient becomes mod I 5 days before CMG, when do you discharge them?
In most prior practices for me, the therapists would come and ask if they could make patients mod I in room, etc.
I discharge within 2 days max unless something comes up, or there is a medical issues, or disposable issue.
Therapists where I work now don't seem to understand this concept, and make patients mod I and at times don't tell me sometimes - I have cracked down on this many times telling them hey once a patient is mod I it's time to go unless medical issues, etc.
How do you guys handle this?