住院康复机构医疗必要性标准

本立场声明的目的, 其中包括康复护理标准,确定住院康复机构的医疗必要性和文件, is to establish and present a set of appropriate guidelines that define the criteria of 24 hour availability of rehabilitation nursing with specialized training or experience in rehabilitation for determination of medical necessity 在住院康复机构.

Introduction

使独立康复医院或急症护理医院的康复单位被列为住院康复设施, they must meet the requirements specified in Title 42 Code of Federal Regulations (CFR) 412.23(b)(2), as well as other regulatory requirements and are paid under the IRF prospective payment system (PPS). Numerous fiscal intermediaries (FIs) monitor and determine if an IRF met the requirements specified in 412.23(b)(2). IRF care is only considered by Medicare to be reasonable and necessary under 1862(a)(1)(A) of the Social Security Act if the patient meets all of the requirements outlined in 42 CFR §§412.622(a)(3)、(4)和(5).

修订了医疗保险福利政策手册, 2010年1月生效,2014年1月生效, 在医疗记录中包括证明IRF住院是合理和必要的文件, 重点是入院前筛查, 入院后医师评估, 护理的总体计划和入院顺序.

决定接受一个病人到IRF是复杂的,基于多种因素, including policy, regulatory standards, 评估每个受益人的个人护理需求. In 1982, 医疗保健融资管理局(HCFA), 现在的医疗保险和医疗补助服务中心, identified Conditions of Participations (CoP) that had to be met in order to be classified as an IRF.

The inpatient rehabilitation facility (IRF) benefit is designed to provide intensive rehabilitation therapy in a resource intensive inpatient hospital environment for patients who, 因为他们的护理需求很复杂, medical management, 和康复需求, 需要并可以合理地预期受益于住院和跨学科团队的方法提供康复护理.

In addition, 以使IRF患者被认为是合理和必要的, there must be a reasonable expectation that these criteria are met at the time of admission:

  1. 患者需要多种治疗学科(物理治疗)的积极和持续的治疗干预, occupational therapy, 语言语音病理学, 或假肢/矫正器), 其中一个必须是物理或职业治疗.
  2. The patient requires an intensive therapy program; under industry standard, 这通常是每天三个小时的治疗, at least five days per week; however, in certain, 证据确凿的案件, this therapy might consist of at least fifteen hours of therapy within a seven consecutive day period, 从进入IRF的那天开始.
  3. 病人需要康复医师的指导, defined as a licensed physician with specialized training and experience in inpatient rehabilitation. (The requirement for medical supervision means that the rehabilitation physician must conduct face-to-face visits with the patient at least 3 days per week throughout the patient’s stay in the IRF to assess the patient both medically and functionally, 以及根据需要调整治疗过程,以最大限度地提高患者从康复过程中获益的能力).
  4. 可以合理地期望病人积极参与, 并显著受益于, 强化康复治疗计划.

Interdisciplinary services are those provided by a treatment team in which all of its members participate in a coordinated effort to benefit the patient and the patient’s significant others and caregivers. Interdisciplinary services, by definition, cannot be provided by only one discipline. Though individual members of the interdisciplinary team work within their own scopes of practice, each professional is also expected to coordinate his or her efforts with team members of other specialties, 以及病人和病人的重要的其他人和照顾者. 跨学科团队的目的是培养频繁, structured, 并在各学科之间建立书面沟通, prioritize, 达到治疗目标.

At a minimum, the interdisciplinary team must document participation by professionals from each of the following disciplines (each of whom must have current knowledge of the patient as documented in the medical record at the IRF):

  • A rehabilitation physician with specialized training and experience in rehabilitation services;
  • 受过专门训练或有康复经验的注册护士;
  • A social worker or a case manager (or both); and
  • A licensed or certified therapist from each therapy discipline involved in treating the patient.

The criteria for IRF are subject to Local Coverage Determination (LCD) policies meant to help FIs define medical necessity for beneficiaries within a specific geographic area. lcd和IRF医疗必要性标准因代理而异,已成为分配卫生保健资源的主要工具.

The 皇冠6686官网 (皇冠6686会员登录) is pleased to provide this position statement to CMS regarding the criteria of 24 hour availability of rehabilitation nursing with specialized training or experience in rehabilitation for determination of medical necessity in an IRF and recognizes that CMS has a central role to play in improving rehabilitation care of individuals with chronic illness and physical disabilities. 皇冠6686会员登录是一个5个以上的专业护理专业协会,000名专业护士, 谁负责确定康复护理执业范围和制定专业康复护理执业标准. 皇冠6686会员登录's mission is to promote and advance professional rehabilitation nursing practice through education, advocacy, collaboration, and research to enhance the quality of life for those affected by disability and chronic illness.

以下是皇冠6686会员登录的立场声明, 皇冠6686官网主要建议的摘要, 然后是建议的基本原理.

Position Statement

The 皇冠6686官网 (皇冠6686会员登录) believes that the recovery from an acute episode of illness or injury depends on adequate medical treatment and early identification of needs for rehabilitation care. 皇冠6686会员登录认为irf是高质量连续护理的一部分,个体可以在生命的任何阶段从康复护理中受益. 皇冠6686会员登录认为,是否需要强化康复的决定应该更多地取决于患者的损伤或疾病(损伤)的影响, functional deficits, 可实现的目标)而不是诊断.

Rehabilitation nurses, 通过专业知识和专业技能, 促进和维持病人的机能水平. Although the proportions of skill mix of licensed and unlicensed staff must be appropriate and determined by the number of patients; levels of intensity of the patients for whom care is being provided; contextual issues including architecture and geography of the environment and available technology; level of preparation and experience of those providing care and accreditation standards, 皇冠6686会员登录认为,设施必须雇用康复护理(CRRN)认证的注册护士,以改善患者的进展, 从而缩短逗留时间,从而降低成本. 康复护理认证是对专业实践中知识和技能的专业认可. It is 皇冠6686会员登录’s belief that IRFs must utilize the expertise of a CRRN for the supervision, orientation process, competency evaluation, 以及员工的教育.  皇冠6686会员登录 believes that the expertise of a certified rehabilitation registered nurse must be available in the assessment, implementation, and evaluation of a rehabilitation program to meet the needs of the rehabilitation population being served. Ultimately, 皇冠6686会员登录 believes that accountability and coordination of cost-effective quality rehabilitation care is best accomplished by registered nurses who have been educated and certified in the rehabilitation specialty.

康复护士, 个人容易接触到, families, 团队成员和其他相关方, 通过专业教育, expertise, 以及关心慢性病和残疾患者的兴趣, 是成功康复计划的关键伙伴吗. 皇冠6686会员登录认为,当康复护士发挥领导作用,并与康复团队成员合作时,康复效果最大化.

皇冠6686会员登录 believes that the 2014 Standards and Scopes of Rehabilitation Nursing Practice should be implemented and evaluated to improve the quality of care for rehabilitation patients. 皇冠6686会员登录 supports the development and implementation of a standard patient assessment screening tool across the post acute care continuum based on patient needs that will measure the effectiveness of post acute care and provide outcome data to determine the appropriate post acute care setting at the appropriate time thus improving both quality of care and continuity of care in a cost effective manner. Lastly, 皇冠6686会员登录 believes the documentation of the rehabilitation professional registered nurse should reflect the need for specialized rehabilitation nursing and should include the identification of relevant International Classification of Functioning, 残疾与健康组成部分和领域将为衡量健康和残疾提供标准语言和框架.

Recommendations

皇冠6686会员登录 recommends CMS:

  1. Include and define the criteria of availability of rehabilitation nursing with specialized training or experience in rehabilitation for determination of medical necessity 在住院康复机构,
    • 将定义纳入 具有专业知识的全科康复护士 和注册康复护士,以定义具有专业训练或康复经验的康复护理,
    • 康复护士通过自学获得并保持现有的护理实践知识和能力, educational programs, certification and by adhering to the rehabilitation nursing scope and standards of practice,
    • 把这个方向, education and competency evaluation of the specialized rehabilitation professional registered nurse must be provided by a certified rehabilitation registered nurse (CRRN) to ensure quality care and to meet the needs of the rehabilitation population being served,
    • 在IRF中加入CRRN以供评估, implementation, 以及评估康复计划以改善病人的病情,
    • 说明文档必须支持这种需求, 提供24小时以上的康复护理, 7 days a week.

基本原理与建议

Demographics

Demographic shifts towards an increase in the population of elderly in the United States indicates a substantial increase in the number of people experiencing physical or mental impairments and the proportion of the population at risk of developing a physical or mental impairment that affects their functional ability. 65岁及以上的人口比例将从2005年的约12%增加到2030年的近20%(美国人口普查局), 2013). 这种转变将影响医疗保健行业的经营方式. Aging consumers with a disability will require services from various health care agencies, resulting in a sharp increase in the need for quality rehabilitation and disability-related services.

Recent military conflicts have added many more individuals to the population who need rehabilitation services affecting both military and civilian rehabilitation service providers. 康复护士有专业知识,必须跟上康复保健的新治疗和进展, polytrauma, 还有创伤后压力综合症.

Setting

康复可以在各种环境中进行,包括通过医疗保险家庭健康福利(包括临终关怀)在家中进行。, 在门诊治疗机构, 在技术熟练的护理机构, 在综合门诊康复机构(CORF), 在住院康复机构,  在长期护理医院(LTCH)或在家庭保健.

康复护士的目标与作用

Rehabilitation nursing is a specialty practice within the profession of nursing and involves the diagnosis and treatment for individuals and groups to actual and potential health problems related to altered functional ability and lifestyle. The goal of rehabilitation nursing is to assist individuals with disability and/or chronic illness in restoring, maintaining, 促进最大限度的健康. Rehabilitation professional registered nurses possess specialized knowledge and clinical skills necessary to provide care for people with physical disability and chronic illness; manage complex medical issues, 为患者/护理人员提供持续教育, 运用护理程序进行实际护理, 与跨学科康复团队的其他成员合作, document effectively to ensure the fulfillment of legal and reimbursement requirements, 成为护理人员和学生的资源和榜样,  and utilize evidence-based practice findings for clinical practice and participate in nursing research studies. 康复护理角色包括照顾者, patient educator, counselor, care coordinator, case manager, patient advocate, consultant, researcher, 管理员或经理, and expert witness.

业务范围和标准

康复护理实践标准, 符合美国护士协会(ANA)(2015)的定义, purposes, 以及标准和指导方针的框架, 并建立在ANA(2015)护理:范围和标准的实践, describes a competent level of professional nursing care and professional practice common to all rehabilitation professional registered nurses engaged in clinical practice. The Standards of Practice describe a competent level of nursing care as demonstrated by the nursing process, 专业表现标准描述了专业角色中胜任水平的行为,包括与实践质量相关的活动, education, 专业实践的评估, collegiality, advocacy, collaboration, ethics, research, resource utilization, and leadership (ANA, 2015). These rehabilitation nurses are expected to adhere to the standards of rehabilitation nursing practice and engage in professional role activities appropriate to their education, position, 练习设置(皇冠6686会员登录, Standards and Scope, 2014.

具有专业知识的全科康复护士

专业护士谁实践康复护理作为一个通才可能在各种机构和社区设置功能. The role a nurse assumes depends on basic nursing preparation; specialized formal or informal education; and clinical experiences with individuals and the families of those individuals who have disabilities, 潜在的障碍, or chronic illness. 目前的康复技术和治疗需要独特的知识和技能,可以通过自学和继续教育项目获得. 高质量的继续教育项目可以通过皇冠6686会员登录和它的许多地方分会以及许多有康复护士的机构获得.

康复护士 exemplifies a specialized knowledge and skill set that is comprehensive and broad in scope with roots in both professional nursing and rehabilitation functional care concepts. 除了进行专门的护理, the rehabilitation nurse spends a significant amount of time reinforcing patient learning from other disciplines. It is essential that all professional registered nurses practicing rehabilitation nursing possess the basic knowledge and skills that enable them to collect appropriate assessment data for each rehabilitation patient; identify significant problems; establish appropriate diagnoses; and set short and long term goals and identify outcomes that reflect an understanding of the impact of the disability or chronic illness on the planning, delivery, 以及在现有经济资源范围内对护理进行评估.

注册康复护士(CRRN)

Certification in rehabilitation nursing (Certified Rehabilitation Registered Nurse [CRRN]), which may be obtained through the Rehabilitation Nursing Certification Board (RNCB), 验证这些知识和技能的获得. Nelson and colleagues’ (2007) landmark study found an inverse relationship between the percentage of nurses certified in rehabilitation nursing and length of stay (LOS). Specifically, a 1% increase in CRRNs on the unit was associated with an approximated 6% decrease in LOS. This finding supports the value in recruiting and retaining nurses with specialty certification, 以及支持现有员工努力获得认证. Preparation for the certification examination is supported by a wide range of educational products by 皇冠6686会员登录 and other quality preparation classes offered through the 皇冠6686会员登录 chapters, 私营机构和康复保健组织.

Rehabilitation Team

康复取决于团队方法. The collaborative rehabilitation team model facilitates care in a coordinated and cost-effective manner. The rehabilitation professional registered nurse’s role on the rehabilitation team is vital. 康复小组的成员各不相同, 取决于练习环境和残疾, 但患者和家属/护理人员始终是团队中必不可少的核心成员.

Documentation

The rehabilitation professional registered nurse documents relevant data in a retrievable format. Documentation must support the need, availability and provision for rehabilitation nursing care. Documentation should serve as evidence for the ongoing provision of rehabilitation nursing care within the context of the rehabilitation team in meeting the patient’s rehabilitative needs. 

文件应包括以下内容,但不限于:

  • 康复诊断、疗程、护理计划及预期结果
  • 疾病和共病管理
  • 初级预防和促进健康
  • 预防继发性并发症
  • Bowel and bladder management goals; progress in bowel and bladder continence or regulation following an injury that impacts such functions
  • 皮肤护理管理包括身体定位和压力重新分配, wound care, 以及皮肤损伤的预防
  • 药物治疗和疼痛管理
  • 加强自我照顾和行动能力
  • 日常生活技能的功能方面
  • 心血管、肺和自主神经管理
  • 营养和生活方式的适应
  • Safety (precaution education and carryover); ongoing assessment of safety, 不仅包括身体上的限制, 还有记忆等认知功能, judgment, 和解决问题的能力
  • 吞咽预防和补偿技巧
  • Energy conservation
  • 亲密和性
  • 角色变化、社会心理表现和适应技术
  • Family involvement
  • Aftercare including community resources, equipment, emergency services and external support systems
  • 病人的目标是实际的,现实的和个性化的

Goals and interventions that integrate and demonstrate carryover of techniques from therapy to increase the functional status and lessen the burden of care should also be evident in the medical record.

Consideration should be given as to how the medical and functional components of the rehabilitation patient are inter-related and should be documented from the rehabilitation nursing perspective.  Education of the patient and family/caregiver are inherent within rehabilitation nursing; evidence of ongoing patient and family/caregiver education for the above mentioned topics should be documented by the rehabilitation professional registered nurse in the medical record.

CMS requires that the IRF patient assessment instrument (IRF-PAI) is included in the IRF medical record. Because the information in the IRF-PAI must correspond with information provided in the medical record, 护理文件是至关重要的,以支持照顾负担的医疗和功能复杂的病人.

规程之间频繁冲突的文档, widely fluctuating patient abilities throughout a 24 hour period based upon changes in medical stability, pain, 耐力或认知, or failure to progress as planned should be explained and a realistic plan to address the problem(s) identified. 出院计划的文件应在护理计划的早期指出.

国际功能分类, 残疾与健康(ICF)是世界卫生组织(WHO)制定的国际分类系统的一部分。. ICF关注的是 human functioning, providing a unified, 有助于描述受健康状况影响的功能组成部分的标准语言和框架. 虽然它不是一个评估工具, it does allow the collection of data as to how people with a health condition function in their daily life rather than focusing on their diagnosis or the presence or absence of disease. 《皇冠6686会员登录》描述了个人在健康和与健康有关领域以及在环境和个人因素范围内的状况. 

The ICF is WHO's framework for measuring health and disability at both individual and population levels. 它已经在40多个国家进行了跨文化适用性测试. The ICF integrates the social and environmental aspects of disability and health and provides a framework that is equally applicable for mental and physical disorders. Thus, 它有巨大的潜力作为一个共同的全球框架来组织和交流皇冠6686官网人类功能的信息.

Conclusion

Rehabilitation is a continuous process and patients rehabilitate themselves through the influence of a comprehensive approach to care provided by the rehabilitation professional registered nurse. 达到最佳效果, today’s rehabilitation professional registered nurses need to be cognizant of patients’ needs and desired outcomes, 对成本控制的关注, 以及在持续护理过程中提供的服务选择. 在接下来的几十年, 患有慢性疾病和残疾的人数预计将上升. 这一转变将增加对康复专业注册护士的知识和专业知识的需求. 这些提供卫生保健的康复专业护士需要符合现有的最高统一国家标准, ensuring that the continued health and safety of the public are protected and that the care provided is cost-effective in the most appropriate setting and of the highest quality.

With a core purpose to promote and advance professional rehabilitation nursing practice, 皇冠6686会员登录 developed this position statement to provide CMS and FIs with guidelines that could assist in standardizing the language of the LCDs and assist in further defining the criteria of 24 hour availability of rehabilitation nursing with specialized training or experience in rehabilitation for determination of medical necessity in an IRF. 皇冠6686会员登录 appreciates CMS's continuing efforts to ensure that Medicare beneficiaries have access to high quality care in the most appropriate setting and 皇冠6686会员登录 encourages CMS and other insurers to utilize these guidelines in support of continuing efforts to recognize the value of intensive inpatient rehabilitation professional nursing in ensuring safe, 高质量标准.

References

美国护士协会. (2014). 护理:执业范围和标准 (3rd ed.). 银泉,医学博士:作者.

美国护士协会. (2010). 护理专业的认可, 专科护理执业范围声明的批准, 专业护理实践标准的认可. 银泉,医学博士:作者.

皇冠6686官网. (2014). 康复护理执业标准及范围 (6th ed.). Glenview, IL: Author.

皇冠6686官网. (2015). 康复护理专业实践:一门核心课程 (7th ed.). Glenview, IL: Author.

医疗保险和医疗补助服务中心. 医疗保险福利政策手册, 第1章A部分涵盖的住院医疗服务(修订179, 01-14-2014), pg. 23-29. Retrieved from http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c01.pdf.

医疗保险和医疗补助服务中心. GPO访问电子 Code of Federal Regulations. 第42篇:病死率公共卫生, 第412部分住院医疗服务的预期支付系统, 附属部分b -医院服务受住院病人运营成本和住院病人资本相关成本支付系统的限制或排除, § 412.23 .排除的医院:分类. Retrieved from http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Downloads/pp368-486.pdf.

Nelson, A., Powell-Cope, G., Palacios, P., Luther, S. L., Black, T., Hillman, T., et al. (2007). 住院康复环境中的护理人员配置和病人结果. 康复护理,32(5), 179–202.

美国人口调查局. (2013). 2012年全国人口预测. Retrieved from http://www.census.gov/population/projections/data/national/2012.html.

Other Resources

皇冠6686官网. 康复护士角色描述 (Brochure).

皇冠6686官网. 康复护士发挥作用 (Brochure).

皇冠6686官网. Factors to Consider in Decisions about Staffing in Rehabilitation Nursing Settings (Position Statement).

医疗保险和医疗补助服务中心. (2013). 住院康复机构预期支付系统. Available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/InpatRehabPaymtfctsht09-508.pdf.

康复设施认可委员会. (2008). 医疗康复标准手册和解释性指南. Tucson: CARF.

医学研究所报告(2003). 使美国成为可能:评估康复科学与工程的作用. Available at http://books.nap.edu/catalog/5799.html

Approved by the 皇冠6686会员登录 Board of Directors September 2008; revised March 2014; revised March 2017

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