Weekly Team Conferences
Lisa Bazemore, MBA, MS, CCC-SLP
Weekly Team Conference
• Purpose:
 The purpose of the conference is to problem
solve the most effective way to meet the
patient’s needs.
• Assess the individual’s progress or the problems
impeding progress
• Consider possible resolutions to problems
• Reassess the validity of the rehabilitation goals
initially established
Weekly Team Conference
• Attendees:
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Medical Director
Case Manager and Social Worker
Treating PT, OT, ST
Treating Nurses
Neuropsychologist
Therapeutic Recreation Specialist
PPS Coordinator or Program Director
Coder
Weekly Team Conference
• What To Do:
 Open the conference with a recap of the week
including:
• Case Manager reportPrior level of function and planned discharge
disposition
• Medical Director reportMedical needs that were addressed
Tests ordered and outcomes
Weekly Team Conference
• What to do next:
 Discuss current situation, barriers, and plan for next
week including reports from:
• Physician
• Therapists
• Nurses
• Social worker/case manager
 Identify strategies for removing the barriers to
discharge
 List team’s goals for addressing barriers to discharge
and specifically state why the patient needs to stay in
the hospital for another week
Weekly Team Conference
• What to do next:
 Recap the list of ICD-9 codes. Add codes to the list
from information conveyed during the meeting
 Ensure that the physician documentation matches the
report given during the conference to ensure proper
coding
 Set a discharge plan
Weekly Team Conference
• What NOT to do:
 Fill out the functional portions of the form during the
conference.
• Come to the meeting with the form mostly
completed
• Fill in only new information gathered during the
meeting
 Review each functional item
• Instead focus on progress and barriers
• You should be reporting the level of assistance with
each task on the FIM scoring form
Weekly Team Conference
• What NOT to do:
 Plan the discharge based on the Medicare expected
length of stay
• This indicator is meant to be an average not a
guideline
Weekly Team Conference
• Rules:
 What every good team should do.
• Be knowledgeable of the patient so you can adjust
the plan of care appropriately.
• Aim for 8-10 minutes per patient.
• Be solutions based.
• Seek contributions from all team members.
• Assure that documentation supports continued
physician, nursing, and therapy involvement.
• Allow the scribe time to get it all down.
Weekly Team Conference
• Success Elements:
 How the good team measures their success.
• You came prepared and everyone could
knowledgably discuss the patient’s care.
• Each patient’s case took 10 minutes or less to
complete.
• The weekly conference form is completed
sufficiently to justify the continued stay of the
patient.
• Significant goals from the previous week’s
conference are discussed and updated.
• You developed collaborative solutions to eliminate
or minimize remaining barriers to discharge.
Weekly Team Conference
• A more in depth look at the process:
 Report on the major areas of performance for each
patient being discussed.
 Review active medical conditions
 Report elements including functional performance and
medical status over the past 36-48 hours
Weekly Team Conference
• Specifically consider:
 Consistency in the patient’s performance
 Progress made compared to team conference goals
from the previous conference
 Barriers
• Pain
• Endurance
• Adjustment issues
• Impulsivity and awareness
• Balance
• Cognition
• Nutrition and elimination
• Sleep/rest patterns
Weekly Team Conference
• Address key areas when functional deficits impact the patient’s
ability to go home.
 Examples of key areas:
• Mobility
PT, OT, Nursing, TR
• Transfers-Bed, Toilet, Shower
PT, OT, Nursing
• Lower body dressing
OT, Nursing
• Toileting, Toilet Transfers, Bladder and Bowel Management
OT, Nursing
• Problem solving
OT, ST, Nursing
• Skin integrity
PT, OT, Nursing
• Adjustment to disability
Psychology, SW, OT, Nursing, TR
Weekly Team Conference
• Address the discharge plan:
 Discuss the discharge plan and functional ability
required to achieve this plan.
 Identify key barriers to the patient achieving the plan
of care.
 Set team goals that will support the discharge plan.
 Modify the discharge plan (as needed).
 Estimate the length of stay.
Weekly Team Conference
• What is a team goal?
 Something that all team members will work on
together.
 It supports the key discharge goal and discharge plan.
 Individual disciplines have short term goals that
support it.
 It is a necessary step to moving the patient along their
path to discharge.
Weekly Team Conference
• Example:
 The physician would like to remove a patient’s foley
catheter. To do this successfully the team will need to
work together on the goal of bladder continence.
• PT-Transfers, strength, balance
• OT-Toileting, toilet transfers
• Nursing-Bladder program, post void residual scanning
• ST-Memory, problem solving strategies
Length of Stay Management
Length of Stay Management
• How do you establish a length of stay?
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Specific patient needs
Pathways or protocols
eRehabData facility averages
National and regional benchmarks
Medicare CMG length of stay
Length of Stay Management
• Review your goals:
 Keep your patient’s discharge goal in mind
 How much time will it take to achieve the goals?
• Medical
• Nursing
• Rehabilitation therapy
 When will family teaching be initiated and how long will
that take?
Length of Stay Management
• How does this measure up?
 Does your clinical plan fall within benchmarks?
 If yes, good job.
 If no, evaluate treatment plan, discharge plan, coding
and scoring.
Do You Have a Problem?
• Analyze the Facility Report
 Transfer Patients:
• Percentage of patients that are discharged to another
Medicare bed
Acute care
SNF
LTACH
Another IRF
 Discharge Destination:
• Breakdown of discharge locations for the patient’s served
Do You Have a Problem
• Analyze the Facility Report
 Averages:
• Two benchmarks: Weighted and unweighted
• Onset days: Different instructions by RIC
• Length of stay considerations
• FIM scoring dataAdmission Totals
Discharge Totals
FIM Change
Motor subscale at admission
Do You Have a Problem
• Analyze the Facility Report
 Individual FIM Items:
• Admission, discharge, change, and follow-up
• Explains difference between facility totals and benchmark
totals
• First glance at isolating FIM scoring errors
Measuring Goal Attainment
• Goal setting is important!
 Patient metrics page reports admit, discharge, goal, and
gain.
Strategies
Goal Attainment:
 Emphasize goal revision on the plan of care. Keep your eye on
the goal.
 Use your team to discuss barriers and strategies impeding
progress.
 Begin setting team goals in the weekly team conference.
 Determine a method to communicate current status and goals
regularly through a functional status board, stand-up meetings,
and/or team conference.
Next Call: April 1, 2008 at 1:00 EST
Lisa Bazemore, MBA, MS, CCC-SLP
[email protected]