While there is a great deal of focus on the management of post acute patients in the SNF population, many of whom will return to the community, management of long term care patients is equally essential to the provision of services along the continuum of care. According to CMS regulations, long term care patients have a right to function at their highest practicable level, including the delivery of services to slow the progression of decline, as long as these services meet the definition of skilled criteria.
In order to support the initiation of Rehab services for a long term care patient, it is essential that there are nursing notes describing when the changes occurred, under what circumstances they are noted, the frequency with which the symptoms are noted, any interventions attempted by nursing to address the concerns, who was notified of the changes, and any pertinent nursing assessments performed.
The following represents a sample of the multiple areas or starting points for which the patient should be referred to Rehab professionals for additional screening and/or evaluation.
• Balance changes such as loss of balance.
• Furniture walking (holding on to furniture during attempts to walk).
• Falls or unintentional changes in plane.
• Decline in ADL independence; including the need for increased assistance toileting, self feeding, dressing, bathing.
• Decreased trunk control or strength.
• Postural changes; leaning in wheelchair, anteriorly, laterally or posteriorly.
• Coughing, choking, runny nose or watery eyes during meals.
• Decreased oral intake.
• Decreased safety awareness.
• Decreased audible voice.
• Uncoordinated respiration and swallowing during meals.
Rehab will review the nursing notes as part of the screening and evaluation process, and this will become the basis for medical necessity of the Rehab intervention, as well as the onset date on the skilled therapy evaluation. Harmony supports efforts by the nursing team and rehabilitation staff to work in unison to continually monitor the facility residents for any changes requiring screening and/or assessment by a therapist.
From the Desk of our CEO
Harmony Healthcare International