Managing Inpatient Rehab Facility (IRF) Transitions

Identifying When Inpatient Rehab Facility (IRF) Transitions Are Necessary

When reviewing costs in an ACO REACH or MSSP ACO contract, the skilled nursing facility (SNF) Part A days is always an area to review for ways to shift the utilization to home health for patients who can be managed at home for their rehabilitation. However, more and more often another layer of care that many ACOs are struggling to manage is inpatient rehabilitation facility (IRF) stays.

Acute Illness Treatment Increases

Inpatient rehabilitation facilities (or hospitals) have increased presence in the last few years with more partnerships with acute hospitals for short term acute illness treatment. Additionally, with the SNFs continuing to have staffing concerns that relate to the new staffing ratios that were mandated for SNFs in 2023, IRFs are a simple fix for discharge planners looking to clear their beds. Added to this equation is the fact that the primary care providers who are participants in the ACO are often not the provider seeing the patient at the short-term acute hospitals and not involved with determining the post-acute plan of care for the patient that they are managing, or at minimum they will be held responsible for the costs of care.

IRF Regulation Updates

The regulations for IRF  were significantly updated in the fiscal year (FY) 2010 final rule.  In the webinar CMS presented in November 2023, the steps to approving a patient for admission and discharge are detailed but not the diagnoses that are expected to result in a possible need for IRF treatment. In the Medicare Benefit Policy Manual Chapter 1 – Inpatient Hospital Services Covered Under Part A, the regulation on admission and duration of treatment state the following:

A patient can only be expected to benefit significantly from an intensive rehabilitation therapy program provided in an IRF, as required in section 110.2.3, if the patient’s IRF medical record indicates a reasonable expectation that a measurable, practical improvement in the patient’s functional condition can be accomplished within a predetermined and reasonable period of time. In general, the goal of IRF treatment is to enable the patient’s safe return to the home or community-based environment upon discharge from the IRF.

Yet in reviewing claims from ACO REACH and MSSP ACO files, many patients are not using IRF to return home but rather as a step in post-acute care either before or after an SNF Part A stay. Additionally, many ACOs are finding the admission diagnoses are more frequently for critical illness myopathy and deconditioning than for the more well-known neurological, amputation, and complex orthopedic care that was the usual in past years. One example, like many that I’ve found, is a patient who was inpatient acute hospital for heart failure for 6 days. The patient then went to a SNF for a Part A stay totaling 95 days (with a few inpatient acute stays during the 95 days of care) before returning IP at an acute care hospital. The patient then transferred to an IRF for the diagnosis of weakness for 11 days and over $16,000. The patient then had a two-week additional inpatient stay at an acute hospital before returning to another SNF for their final days of life, with hospice care for only three days. 

IRF Utilization and Costs for ACOs

How can ACOs get a better grip on IRF utilization and costs? It does take some effort and attention, but it can be better managed with some basic steps:

• Connection to a Health Information Exchange (HIE): an HIE will allow for providers to be aware of where the patients is in the acute and post-acute care journey and be proactively involved in discharge planning.
  
• Contracting with hospitalists as part of your ACO network: having a hospitalist or two at your main hospitals and ensuring your patients being admitted are assigned to your provider can allow your team to have care quality as well as appropriate utilization of care as considerations in discharge planning.
  
• Care navigators: having care navigators from the ACOs work closely with the acute care hospital discharge planners can help guide care delivery locations to facilities – or home health companies – that the team has identified as high performing partners. Working with the IRF team to review the treatment plan and predicted length of stay can improve coordination of care.
  
• Contracting with post-acute providers: if your team notes that there are trends of increased use of IRF and/or long lengths of stay at SNF, consider contracting with one or more facilities to be partners in the shared savings aspects of ACO REACH and MSSP ACO programs.

While IRFs are a necessary layer in the post-acute care landscape, the increased use and spend without seeing positive outcomes for patients can be low-value care. IRFs are not going anywhere, so learning to identify patients who need – and do not need – this level of care is key.

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Author:

Carol Javens, RN, BSN, CHPN | Account Manager, Acclivity Health Solutions