SUCCESSFUL REHAB MANAGEMENT IN LONG TERM CARE
RehabPerspectives
WINTER 2005
Measuring
Therapy’s
Outcomes
Measuring Up
Looking in the Clinical Mirror
The Facility Perspective
S p e cial ad ver t ising s e c t io n sp o ns o re d by
MEASURING THERAPY’S OUTCOMES
Stepping Up to the Plate
ith this third issue of Rehab Perspectives,
we explore the importance of measuring a
patient’s progress during rehabilitation therapy. That
seems like a pretty basic concept. Our society measures most things: student learning, professional
competence, even the ability to drive a vehicle.
Yet historically, when it comes to rehabilitation,
we talk in a fuzzy language: Mrs. Smith is “better,” she has made “significant progress,” she has a
“higher quality of life.”
Although those words are heartening and the impact on the patient’s life might have been significant,
they may not be enough. We must have a standardized, quantifiable measure to prove that Mrs. Smith’s
functional abilities have moved from point A to
point B as a result of rehab intervention.
In other words, we must have credible outcomes
data to support what we do. Outcomes measurement
is important clinically in improving services, it is
an exceptional facility marketing tool, and it will
almost certainly become the backbone of future
reimbursement.
Aegis has stepped up to the plate to hold our
therapy departments accountable for the services our
patients receive. With more than ten years’ experience delivering contract therapy to nursing homes
and eldercare venues, and currently serving more
than 1,000 facilities nationwide, we are committed
to a leadership role in the rehab industry and to high
standards in resident treatment. We’re proud of our
outcomes measurement, using the Rehabilitation
Outcomes Measure, and our reporting tools. With
outcomes reports, everyone wins—patient, family,
facility, physician, referral source, and clinician.
So enjoy this issue of Rehab Perspectives as we take
you on a tour of outcomes measurement. Fasten
your seat belt, it’s an exciting ride. Aegis is your
rehab resource.
Best regards,
Contents
03 Measuring Up
What are outcomes and why are they important?
05 Looking in the Clinical Mirror
Outcomes as a tool for refining intervention
06 The Facility Perspective
Outcomes as documentation of quality
RehabPerspectives
For more information on these articles, contact Aegis Therapies at:
Aegis Therapies
3960 Hillside Drive, Suite #204
Delafield, WI 53018
Toll Free: (877) 877-9889
Phone: (262) 646-1760
Fax: (262) 646-5634
www.aegistherapies.com
Produced by the Nursing Homes/Long Term Care Management special projects team:
K.T. Anders, Editor and Writer
Martha Schram
President
Aegis Therapies
Richard Peck, Managing Editor
Eric E. Collander, Art Director/Designer
Mary McCarthy, Production Manager
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MEASURING THERAPY’S OUTCOMES
Measuring Up
What are outcomes and why are they important?
S
o why is the word “outcomes” creating a buzz in rehabilitation
therapy these days? After all, everyone knows what outcomes
are. Following her hip replacement, Mrs. Winterbottom goes
into therapy, and after treatment she is able to walk. Great
outcome. The nursing facility did its job, and Mrs. Winterbottom tells
everyone what wonderful therapy she received. The story is warm and
fuzzy and makes everyone feel good.
But real therapy outcomes are more than anecdotal stories and testimonials. Real therapy outcomes mean the benefit of therapy is actually
measured on a national scale using hard data and benchmarked statistics
over hundreds of thousands of patient records. Real outcomes are about
reports customized to each patient and facility that relate measured
functional gains to length of stay and the efficiency of therapy services
from a variety of perspectives.
In other words, real therapy outcomes could reveal that Mrs. Winterbottom was rated at 0.5 for gait when she began therapy. After 21
days of treatment, she was rated at 3.0, which placed her above the
national average for similar hip replacement patients. Further reports
might reveal that the entire facility has a higher intensity of treatment
(reflected in a higher percentage of the upper RUG categories) with
shorter lengths of stay than the national average and that their patients
are discharged to higher levels of independence and are much more
likely to return home.
With this outcome information, the facility now can prove it did its
job and justify the level of therapy provided. Mrs. Winterbottom is right
on when she tells everyone what wonderful therapy she received.
“We are in an age of increasing responsibility to justify what it is we
are doing,” says Audrey L. Holland, PhD, Regents Professor Emeritus
at the University of Arizona. “There is a need to gather evidence to suggest that treatment is beneficial and economically feasible. Outcomes
measurement is beginning to make a difference.”
Today’s healthcare is all about gatekeepers—people who control access
to the patient and/or to reimbursement. “Whether to the physician, the
family, the federal government, or even the nursing staff, we must be
able to prove our impact in some measurable way,” says Bill Goulding,
director of outcomes and appeals management for Aegis Therapies.
“When we simply say that someone has increased his independence
and ability to dress his upper body, that’s meaningful to the patient,
but it’s not measurable. Gatekeepers need some justification to proceed
with the plan of therapy.”
as principal at SeniorMetrix in Boston, has been involved in studies on
the cost-to-outcomes relationship on a national level. “The point is to
use that measure in a large enough scale so that compared data can be
created between providers. If each therapy develops its own measure, the
problem is that you can’t go outside the use of that measure to compare
your patients’ outcomes with national or regional standards.”
For example, suppose Sunny Mountain Nursing Home has developed
its own measurement scale. When our Mrs. Winterbottom tries to evaluate care at Sunny Mountain compared with care at Shady Forest Home
in order to decide which facility to enter, the numbers mean nothing to
her, especially if Shady Forest, too, has its own measurement scale.
Similarly, referral sources looking at the two facilities would have no
idea how their patients would fare either by diagnosis, length of stay,
or functional level at discharge. “One of the biggest problems with
outcomes is that you must have a measure with interrater reliability,”
says Goulding. “If someone in Dubuque scores a patient at 2.5 level,
someone in Boston should be able to evaluate the patient on the same
scale and arrive at exactly the same score.”
For that to happen, a scale must have reliability and validity. Several
scales are currently in use, each with its own pros and cons. The Functional Independence Measure (FIM) is probably the most widely used
scale in rehabilitation, certainly in acute rehab settings.
But according to Professor Holland, the FIM doesn’t quite do the job
for long-term care. “The Rehabilitation Outcomes Measure (ROM),
marketed by Accu-Med Services (www.accu-med.com), is a better
scale for nursing homes than the FIM,” she says. “It is more refined,
covers more areas, and asks more questions. It’s much more specific in
dealing with questions of language cognition, for example. And it will
become an even better scale as it is more broadly used.”
One advantage of the ROM, according to Mark Besch, vice-president of clinical services for Aegis, is that it is specific to skilled nursing
How Do You Measure?
Outcomes objectively document the level of functional abilities assigned
at the time of admission and the level of those abilities upon discharge.
But how do you measure that level? “From a theoretical standpoint, any
measure that is valid and reliable works,” says Reg Warren, PhD, who,
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MEASURING THERAPY’S OUTCOMES
“The government wants suggestions on payment structure, and one of
the alternatives is for Medicare to pay X number of dollars for rehab
for particular diagnoses,” explains Goulding. “I don’t know how a
therapy company that doesn’t have outcomes data will know if it can
survive with that.”
facilities. “When balancing dollars and treatment worth, it’s important
to look at data from the same setting and from the same regulatory
environment,” he says. “The FIM scale is the largest overall, but it is
not all post-PPS data and not all skilled nursing facility data.”
Another advantage of the ROM is the ability to measure the abilities
the patient will need after therapy discharge. For example, if patients
are going home, it’s important to measure their ability to do light
housekeeping, prepare meals, and manage finances. If patients are
remaining in the nursing home, the ability to bathe, dress, transfer,
etc., is uppermost.
Mary Spooner, director of operations for Beverly Healthcare for
Ohio, is sold on the ROM. “It’s industry-specific, it captures the bulk
of the diagnoses we are dealing with, and it drives quality,” she says.
All Beverly facilities use the ROM.
Aegis has built a data bank of more than one million outcomes records
for its patients in skilled facilities that can compare ROM scores and data
across many variables, including patient age, acuity (days post-onset),
initial disability, ICD codes, general diagnostic group, length of stay,
and discharge setting. “To my knowledge, it is the largest post-PPS
outcomes database in the country,” says Goulding.
The Cost/Value Balance: The Future of Outcomes Data
The “Holy Grail” of outcomes data, according to Goulding, is to be able
to prove that therapy is a good investment, that it reduces the burden of
care and thus the financial burden on the healthcare system. He likens
outcomes information to those old-time balance scales with a basket
on each side of a fulcrum. “On one side is the cost, which is extremely
measurable: for example, $3,000 worth of physical therapy,” he says.
“On the other side is the benefit or outcome. How much outcome balances the dollars? That’s been hard to measure.”
How much therapy a patient should receive, how long he/she should
be in a particular post-acute setting, and what kind of functional change
should be expected are topics that Dr. Warren explores for his healthcareplan clients at SeniorMetrix. “Standards are now beginning to develop,”
he says. “It’s important to have a uniform standard of functional change
across therapies and across settings, and associate reimbursement with
that measure. Quality and outcomes are disconnected in the current
RUGs payment system. It is the linking of those two that will be important strategically for nursing homes in the future.”
A step toward that goal is the comparison of therapy outcomes with
MDS data. The goal is to see if nursing documents less labor, and
therefore less labor cost, in caring for a patient because of therapy the
patient received. For example, gains made in occupational therapy could
be matched with nursing to see if the patient’s ADL skills are getting
better. Goulding notes that Aegis is beginning to compare its therapy
outcomes with those of the Beverly Enterprises database. “There are
many uses for outcomes,” he says. “But the one that will really make a
difference is the one that can prove that improvement in therapy equals
reduction in cost or what is sometimes called ‘burden of care.’”
What else is ahead for outcomes data? “I envision that outcomes
reporting will eventually be part of the Medicare system,” predicts
Dr. Warren. “Medicare-risk lives are projected to triple in the next
five years, and that means 12 million Medicare members will be under
managed care plans. Most of them will require some form of outcomes
associated with their payment.”
And that means that the buzz about outcomes may become a very
big noise indeed.
Training and Certification
Of course, a scale means nothing unless those who administer it are
thoroughly trained in its use. “There has to be some certification process,”
explains Besch, “so that people can prove that they clearly understand
the scale and that everyone uses it in the same way.”
For example, he notes that Aegis therapists go through three hours of
intensive training in which they observe and rate how patients perform
various functional tasks. After completing training, they take an examination to determine how well they understand the rating scale.
“The test is the same for everyone who uses ROM around the country,”
says Besch. “It is discipline-specific, so PT, OT, and Speech must each
achieve a certain score for each discipline. It’s all about making sure
that when the therapist is presented with a clinical situation, he or she
can understand how to translate that into the measure.”
The Value of Outcomes to the Industry
Outcomes reports will play a vital role in upcoming changes in government regulation of healthcare. “Medicare Part B therapy caps are
primarily aimed at guarding against overutilization, so outcomes data
would be very beneficial for regulators,” says Goulding. “Therapy
caps also force efficiency, and that’s what outcomes are all about. I’m
hoping that by providing outcomes information, we can be proactive
and give the government data that I’m not sure it has—that is, to tell
them what it costs to provide nursing and therapy care for patients by
diagnostic group.”
In fact, Sen. Blanche Lincoln from Arkansas recently met with leaders
of Aegis Therapies to ask for information to help with making decisions
on therapy caps. “She wanted more than anecdotal testimonials on
the effectiveness of therapy,” reports Goulding. “She wanted outcomes
information to back them up.”
Outcomes data will also allow a nursing facility to predict the impact
of reimbursement regulation on its bottom line by providing data on
length of treatment, functional gains, cost of therapy, and cost to the
home in terms of nursing labor costs. For example, the need to justify
rehabilitation is more intense for Medicare Part B patients than for
those Part A patients who have just been released from the hospital.
How the ROM Scale Works
Using the Rehabilitation Outcomes Measure (ROM) scale,
therapists score a patient’s level of function in several areas
at admission and at discharge, using a scale from 0.0 to 3.0
in half-point increments. A 0.0 means the patient is totally
dependent upon staff, an extreme burden of care for the
healthcare system. A 3.0 means the patient is totally independent and is a minimal burden of care. “The description of
each level is very detailed, creating consistencies across the
scale whether you are talking about bathing, stair climbing,
or toilet hygiene,” says Bill Goulding, director of outcomes
and appeals management for Aegis Therapies. “That’s why
the rating can be standardized.”
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MEASURING THERAPY’S OUTCOMES
Looking in the
Clinical Mirror
Outcomes as a tool for refining intervention
lla Onitskansky, Aegis Therapies district manager for Ohio and
West Virginia, sits at her desk printing the outcomes reports
for the therapy departments at the 17 facilities in her district.
Before her are individual patient’s scores on the Rehabilitation Outcomes Measure (ROM) scale and facility reports aggregated
by length of stay, therapy minutes, overall patient gains, and discharge
locations.
“I love these reports,” she says. “I can look at the evaluation and
discharge scores of patients in each of my facilities and see those areas
in which functional gain scores have greatly improved and which areas
need work. That helps me with training.”
For example, on this day, Onitskansky notices that certain patients
haven’t made anticipated gains at two facilities. “I can see that in one
of my buildings, the therapist needs further training in dementia,” she
says. “Another needs training in stroke therapy. With outcomes information, I can strategize and put appropriate training resources where
they are needed most.”
The polar, or “spider,” graph (below) is one of Onitskansky’s favorite
report tools, customized for each therapy patient. It dramatically shows
the patient’s ROM scores at admission compared with the ROM scores
at discharge. With it and the accompanying Patient Overview Report,
therapists can quickly see the results of their interventions.
“I feel that outcomes reporting has an impact on clinical care,” says
Onitskansky. “With this kind of quantifiable result, the therapist can
see what has been done. Sometimes therapists go from patient to patient
and we don’t have time to look back and really see what we can do better.
With the reports and ROM scores, the information is right there.”
She cites an example of one physical therapist who noticed that outcomes scores fell when her assistant provided therapy. “That made us
research the problem,” says Onitskansky. “We brought in extra training
to help the therapist.”
By slicing and dicing data, outcomes reports can present a patient’s
ROM score from several different perspectives. “The idea is to isolate
what might have driven the outcome,” says Mark Besch, Aegis vicepresident of clinical services. “Was it a staffing issue or a function of
comorbidity or age? Or perhaps patients are coming to us further postonset. Outcomes information tells us where
to look for answers.”
Hard numbers on patient
improvement give staff a
window into the positive
changes they are making in
patients’ lives. “Since
we’ve begun measuring outcomes, our
staff has become more
enthusiastic about patient progress,” notes
Mary Spooner, director
of operations for Beverly Healthcare for Ohio.
“That’s a big boost for morale
and job satisfaction.”
Outcomes data are a key component of evidence-based practice. “It’s
important for us as an industry and
for our profession to prove that we are
doing a valuable job,” says Onitskansky.
“Not just by storytelling, but also by having
a measurable outcome.”
l
0.0 Total assistance
2.0 Standby assistance
0.5 Maximum assistance
2.5 Modified independence
1.0 Moderate assistance
3.0 Total independence
1.5 Minimal assistance
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MEASURING THERAPY’S OUTCOMES
The Facility Perspective
Outcomes as documentation of quality
S
uppose you are a discharge
planner at Lakelovely Hospital and you’re seeking a
facility for Mrs. Smith, who
is recovering from a stroke. Information from the Beachside Home lists
average length of stay, functional gain
scores for stroke patients based on a
national scale, and the percentage of
patients discharged to home. The
nursing home across town, Cloudview, provides personal testimonials
about its rehab but has no objective
data on how long therapy would last
or how effective it might be. Which
facility would you choose?
Creating a Marketing Advantage
Quality that can be documented is a
powerful marketing tool. “You may
think that you have great outcomes
for your hip fractures, but that’s just
a feeling,” says Mike Beckwith, senior
sales manager for Aegis Therapies.
“With outcomes reports, a facility
can compare its gains for fracture
patients with those of other facilities
in the area.” Hard numbers provide a
distinct marketing advantage.
In his highly competitive metro market, Joel Kelsh, administrator
for Providence Place in Minneapolis, relies on his outcomes data. “Presenting outcomes data shows I’m progressive and committed to being a
leader,” he says. “That’s the message I want to send out.”
At Beverly facilities, too, outcomes data have proven invaluable. “Our
Rehabilitation Outcomes Measure [ROM] reports quantify our quality
and progress,” says Mary Spooner, director of operations for Beverly
Healthcare for Ohio. “They enable us to let our managed care insurance
companies know how we are doing, let our patients and families know
how we are doing, and let our referral sources know how their patients
have improved. They give a specific, measurable report to the physician.
I don’t know why more facilities aren’t using outcomes.”
It may be that the word just isn’t out yet. Denise Norman, district
manager for Aegis Therapies for northern Illinois, says hard information
about outcomes is not widespread. “My customers say, ‘Yeah, yeah, I’ve
heard about outcomes before,’ but they’ve never really seen anything,”
she says. “If the facility hasn’t had a company that provides outcomes
information, it doesn’t know what it is missing.”
But seeing is believing. “What wows them is when we show them
the proof of what we’re doing,” says Norman. “Once the facility sees
these reports, we get nonstop requests from the administrator and the
marketing team. They say, ‘Can you pull up that information for me?
I’m going to meet with this doctor today,’ or ‘I’ve got a hospital meeting
next week.’ Hopefully people will come to expect outcomes reporting
as a standard of care.”
Boosting Demand for Rehabilitation
Data on outcomes are an effective means of transforming the image of a
nursing facility from a warehouse for the elderly to a place for rehabilitation and discharge back to the community. “Providers have a ‘census’
mind-set,” explains Gary Phillips, operations consultant for BKD, a
consulting firm in Springfield, Missouri. “They’ve been taught that if they
keep their beds full, they will be profitable. We even hear some physicians
say, ‘Well, these are old people; we’re not going to rehabilitate them.’”
But Phillips says showing outcomes reports to physicians often results
in obtaining their full cooperation for the higher level of rehabilitation
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MEASURING THERAPY’S OUTCOMES
a facility wants to perform. That, in turn, enhances a facility’s image.
“Instead of competing with community-based services, skilled nursing
facilities should position themselves as part of the continuum of care,”
he says. “If they can rehabilitate patients and discharge them to a lower
level of care, customer satisfaction increases dramatically.”
Justifying Rehab Levels
With outcomes data to back up treatment, high RUGs categories needn’t
be a red flag for Medicare, according to Aegis’ Beckwith. He cites one
facility that was concerned about performing aggressive rehabilitation.
“But in this particular case, outcomes data revealed that the facility
actually had more acute patients, length of stay was shorter, and more
patients were discharged to home than the average facility,” he says.
Outcomes also showed that the gains patients made in therapy were
actually higher than the average facility. “The facility had no idea,” says
Beckwith. “Nobody knows that kind of information unless you have
an outcomes program to show it.”
Empowering Staff
Positive feedback is a powerful incentive for staff. Data on the number
of discharges to home and standardized scores on patient gains are feelgood statistics that indicate quality interventions. “It’s very motivational
and uplifting for the staff,” says Norman. “To be able to prove what
happened in care is helpful for the quality assurance team.”
Creative Uses for Outcomes Data
“Look at Me Now” Cards
Show-and-Tell Tours
Transform outcomes statistics into a statement of personal
functional gain with a “Look at Me Now” card showing a photo
of the patient at time of discharge and a visual graph of ROM
scores at time of admission and at time of discharge. “It’s a
great way to report individual patient outcomes back to the
referring physician, the discharge planner, the case manager,
and even the family,” says Denise Norman, district manager
for Aegis Therapies for northern Illinois. Confidentiality isn’t
an issue, since the recipients have been in on the patient’s
medical condition from the start. Within those parameters,
“The card is a good marketing tool, and it’s ‘warm and fuzzy’
for the family,” says Norman. “It shows that we care about
people and that outcomes aren’t just numbers.”
Use outcomes information during tours for potential residents
and family to assuage the fear that the nursing home is the
“last stop,” with no option to return home. “You can literally
pull the outcomes information of patients with the specific
diagnosis of the potential resident while on a tour and show
that patients with that diagnosis received X number of days
of therapy and X% of them returned to the community,” says
Mike Beckwith, senior sales manager for Aegis Therapies.
“That’s a great selling tool.”
Bragging Brochures
Strut your stuff with statistics. “If the nursing home brochure
reports that in 400 hip replacement patients, 350 have been
able to walk without a walker within 25 days and 85%
have returned home, that‘s going to impress someone
whose mom is looking for postsurgical care,” says Bill
Goulding, director of outcomes and appeals management for Aegis Therapies. “Another nursing home may
not be able to give such specific information.”
Foot-in-the-Door Openers
Keep your facility front and center in the minds of referral sources by providing them with frequent outcomes
reports, whether in person or even by mail. “Facilities
that have been in the community for a long time often
have nothing new to say to referral sources,” says
Beckwith. “With an outcomes report, you have a great
reason to keep in touch. It’s hard to argue that you are
a nuisance when you are dropping by with the good
news on the progress of their patients.”
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