Rehabilitation Medicine Administration: The Australian National Diagnosis Related Groups - Essay Example

Health care is interestingly complex. Every nation has a health care system under which health care services are disseminated. In this respect, various processes and operations are involved with diverse outcomes. It is not guaranteed that a particular process would produce similar outcomes for a certain patient case. It is with this that management of healthcare is complicated and continued development is vital. Rehabilitation, of which this document is focused, is an episode of health care. It refers to a process that allows an individual to achieve his or her optimal physical, mental, and/ or social level of functioning. What is more, rehabilitation may involve provision of care under the following circumstances: It is given to individuals with disability with expectations of positive gains, and more so on improving the functioning of the person, It is done through a specialized unit in terms of staff and infrastructure under the guidelines of the Commonwealth Department of Health and Aged, It is done by a multidisciplinary team that is clinically managed by rehabilitation professional. A rehabilitation episode can also be qualified by the following: A documented or an individualised evaluation (primary or periodic) of functional capacity through the utilization of credible functional evaluation procedures. A rehabilitation plan that is multidisciplinary but individualised with appropriate time lines and goals. In a rehabilitation unit, it is vital for the leader to understand that each and every patient is unique. In this respect, classification of patients would be useful where factors such as resource utilization, patient health status and the required intervention would play the greater part in this classification. Acute care as well as sub-acute and non-acute care episodes presents varying challenges. One is payment and funding criteria that would ensure quality provision of care is maintained. The pioneering Diagnosis Related Group (DRG) classification, although it is useful with acute care, it proves inadequate for the sub-acute and non-acute care. Consequently, the Australian National Sub-Acute and Non-Acute patient (AN-SNAP) Casemix Classification emerged as an appropriate measure of the sub-acute and non-acute care. It is useful in management and funding of rehabilitation services provision. Casemix classification has the advantage of allowing healthcare institutions to “make more informed decisions on the best and most appropriate use of their resources” (Brook, p.1). The Diagnosis Related Groups (DRGs) There are a number of casemix classifications. The Australian National Diagnosis Related Groups (AN-DRG) emerged in the mid-1980s. With DRGs, the care and diagnosis of a patient who has been discharged from a health institution are recorded as principal or secondary diagnosis. This “diagnostic recording” enables health centers to comprehend the nature of acute health care (Brooks, p. 2). DRGs approach classifies “acute inpatient hospital episodes” (Eagar, p. 1). It is worth to note the three fundamental guidelines for DRG system: It is a must for the DRG’s diagnostic clusters to be clinically acceptable; Resource homogeneity must be exhibited in each DRG. Particular episodes with a DRG ought to map to the particular DRG as opposed to several DRGs. In addition, composite audit procedures and coding rules make sure that the above outlined guidelines are adhered to. Nonetheless, International Classification of Diseases (ICD) and the profile of DRG play a very vital part in adherence to these guidelines. Each and every health system exhibits its unique DRG. The Diagnosis Related Groups would be used in funding. It would be set as follows: The diagnosis of every patient episode would be recorded as outlined in ICD. Subsequently, the information that is specific to patient would be coded to DRG A DRG weighting is set. The factors considered in coming up with the weight include each DRG resource consumptions as compared to others. Weighted separation, which represents an event of a discharged patient, would be determined by multiplying the weight of every DRG with their total number. Outliers are acknowledged when the length of stay is abnormal. Funding is then determined through WIES and price multiplication. Nonetheless, the sub-acute as well as the non-acute inpatient episodes requires a different approach since DRG is inadequate in classification of these kinds of episodes. According to a plan by the Casemix Implementation Project Board 1993, three areas are vital in addressing inpatient episodes: classification, pricing and payments. Moreover, various strategies are essential in management of rehabilitation services (Eagar, p. 1): Establishment of classification approaches for rehabilitation, Development of relevant cost weights, Promoting to managers, clinicians, and industrial units the use of “casemix accounting, information collection and budgeting” in clinical management. Several studies have demonstrated the inadequacy of the DRG system. Smith and Firm, 58; Lee et al; Webstar; and Hindle agree that the Diagnosis Related Groups is unsuitable for non-acute and sub-acute care classification. Furthermore, there is consensus that by merely testing the data items already available from regular collection of national morbidity would not be relied upon to yield a practical alternative classification. In this respect, therefore, although key diagnosis of patient can foretell the cost of care on acute episodes, the clinical diagnosis is not principal when it comes to non-acute and sub-acute cases. The limitations of Diagnosis Related Groups Casemix classification and the need for inclusion of additional aspects in casemix classification led to the development of the National Sub-Acute and Non-Acute Casemix Classification (SNAP). National Sub-Acute and Non-Acute patient Casemix Classification The SNAP includes rehabilitation, geriatric psychiatry, sub-acute geriatric medicine, and palliative care episodes. Only the rehabilitation episode type is of significance in this study. Rehabilitation episodes types The AN-SNAP classification includes both overnight and ambulatory episodes; the ambulatory episode type includes Same day, Outpatient, Community episodes. Overnight Rehabilitation episode The overnight episode type is classified into 32 classes. FIM is the standard measure of function. It is worth to note that only stroke and burns episodes utilize the FIM Cognition Sub-Scale. Furthermore, only three out of the 32 classes have a long length of stay: Class 218 (Spinal Injury; FIM Motor is 14-46); Class 202 (Spinal Injury, Neurological, Brain Injury and Major Multiple Trauma (MMT); FIM Motor is 13); and Class 212 (Brain Injury; FIM Motor is 14-28). The Burns and Stroke episodes are grouped together because Burns profiles are similar to Stroke episodes. Note that the FIM Discharge score was not qualified as satisfactorily powerful cost predictor. Elsewhere, only a few cases of rehabilitation episodes have a clear-cut deviation. In particular, the long-term spinal injury case that is dependent on ventilator is notable. The following dependent variables feature in overnight rehabilitation episodes: FIM motor scale, FIM cognitive sub-scale, Length of Stay, Functional Impairment Code, Assessment Only, and Age. Ambulatory rehabilitation episodes The Ambulatory episode includes 15 classes, out of which 11 are treatment classes while 4 are assessment classes. The dependent variables used include the following: The Sole Practitioner or Multidisciplinary episodes, Functional Impairment Code, Treatment episodes or Assessment Only, and Medical only or not. In same day episodes, no considerable differences are notable in cost between the impairment codes used in grouping the 3 classes. Therefore, it was not necessary to classify the classes further. Note that FIM is not an appropriate measure of outcome ambulatory classifications. Fig. 1: The structure of SNAP classification - Overnight Rehabilitation Fig. 2: The structure of SNAP classification - Ambulatory Rehabilitation Trends in rehabilitation care There are four main issues that arise when rehabilitation trends are considered (Centre for Health Service Development p. 8). One, there is an increasing demand for rehabilitation care with the aging population. Two, Secondly, ambulatory rehabilitation demand seems to be increasing, and it is possible that some can be substituted for overnight care. Three, “consultation-liaison services” that are strongly established within the public segment, “are not similarly established in the private sector”, and therefore do not qualify for the payment funds. Last, there are no signs clinical practice changes are resulting to decrease in the inpatient length of stay. Meeting the budgetary targets: approach and strategies The governing body direction to have a 10% reduction in operational costs should not have come at a later time. The indication that the organization is over budget is based on a comparison between adverse casemix cost data and other rehabilitation services management benchmarks. It is worth to note that the use of casemix in management and funding of rehabilitation services is more powerful than many other approaches (Brook 100). The AN-SNAP classification in use in our case is the most appropriate. It features 38% of variance in rehabilitation case type. Moreover, there is considerable diversity in the cost of sub-acute and non-acute care. A 30-fold variation in episode cost exists between the least expensive and the most expensive class in the AN-SNAP overnight classification and a 5-fold difference in per diem cost. As well, the diversity in the cost of sub-acute and non-acute care of ambulatory service is substantial. There is a 48 fold variation in episode cost and a 5 fold variation in per diem cost between the most expensive and the least expensive class in the ambulatory classification. Note that variance exists in care cost episode in the same class due to co morbidity, case complexity, social issue as well as other factors not monitored in benchmark classification. This document recommends several approaches to ensure the rehabilitation activities fall within the targets. First, it would be essential for the organization to make the review of patients’ data a procedure; the documented cases should be considered. Therefore, the cost of the care episodes should be established and compared to the episodes weight so as to lead in determining the source of the excess expenditure. It is vital to consider both internal and external factors. Some of the external factors that are beyond the control of the organization include economic variations. Inflation is one such factor. It is essential that there is timely collection of patients’ data, especially at the time of admission. This is beneficial in performance review, funding purposes, and in alteration of the service provision. AFRM rehabilitation indicators would be utilized to assist in rating and benchmarking the performance. Moreover, consumer participation would be promoted and addressed appropriately with the aim of acquiring valid and first hand data. It should be a priority for the organization to ensure that the rights of patients such as consent, privacy, and complaint are respected and the responsibilities addressed appropriately. The recognition of the consumer as the most vital component in the rehabilitation center will help in addressing several other vital issues. Costs reduction Cost reduction would be vital in meeting the organization’s budgetary goals. It would be essential to establish areas that would be operated with lesser budgetary allocation as well as utilizing expensive operations when it is really necessary. In this regard, expensive investigative procedures like MRI would have to go through strict authorization that has weighed all alternatives. External services would be monitored and evaluated to ensure the desired value is maintained at the minimum cost. In addition, outsourcing would be a solution to acquiring certain services that would be expensive if the organization managed them directly. Such services could include accountants and auditors, typists, and cleaners. Technology could be used to substitute some staffs. It is true that sufficient staffing is appropriate for clinical efficiency. Nonetheless, the roles played by some staff could be covered by technological aids such as in physiotherapist and in ADL. Therefore, only the vital positions would have the relevant personnel. Consequently, cost of staffing would be minimized immensely. Length of stay The length of stay is one aspect that is directly related to overall cost and should be managed wisely. Immature and unnecessary transfer of patients into the rehabilitation services would be discouraged. The strategy would minimize the length of stay for patients. In this respect, it would be beneficial for the organization to consider ‘sub-rehabilitation’ services that would explore into the needs of patients under different clinical care as opposed to rehabilitation care. These services could include care review, opinions, and education to care givers and patients as well as early interventions. The aim would be to reduce complications in the events of transfer into rehabilitation services, and consequently reduction in cost of the patients’ episode. Of importance is that these additional services should generate revenue. Education and training of the staff, more so, nurses and doctors should be a priority in management of medical care. Acute cases are delicate and should be handled delicately. Therefore, it should be within the capacity of the rehabilitation center to handle cases such as pneumonia, deep vein thrombosis, bladder, and bowel cases. What is more, systems for early detection of medical complication should be in place. In this respect, relevant clinical checks should be performed to reduce cases of complications, while ulcer development and DVT cases could be managed by waterlow pressure ulcer risk assessment scale and DVT prophylaxis respectively. The organization should incorporate a policy that would ensure that patients do not overstay in the rehabilitation services. In this respect, community and home-based rehabilitation are considered as alternatives. Therefore, it would be possible to early-discharge patients, but when it is appropriate to do so, and place them into community-based care. The mechanism for this transfer would be well strategized to eliminate small issues that may result to greater consequences. For instance, the destination homes would be established on for a long-term relationship, where factors such as reliability and quality of care would determine the homes. It would be the responsibility of the rehabilitation organization facilitators to make sure there is update information on these community homes. Work cited Brook C, Casemix Funding for Acute Hospital Care in Victoria, Department of Human Services Victoria. Centre for Health Service Development 1999, A National Classification System and Payment Model for Private Rehabilitation Service s, viewed on January 1, 2008, , 2001. Casemix Implementation Project Board 1993 Eagar K et al., The Australian National Sub-Acute and Non-Acute Patient (AN-SNAP) Casemix Classification: report of the National Sub-Acute and Non-Acute Casemix Classification Study. Centre for Health Service Development, University of Wollongong. 1997. Eagar K, The Australian National Sub-Acute and Non-Acute Patient (AN-SNAP) Casemix Classification. Australian Health Review, Vol. 22, No 3, 180-195, 1999. Herring Health and Management Services, Report on the Evaluation of a Trial of Blended Payment Model for Private Rehabilitation Services, viewed on January 1, 2008, , 2001. Lee, L.A., Eager, K.M. & Smith, M.C. Subacute and non-acute casemix in Australia. MJA Vol 169 Supplement 22-25, 1988. Sandstrom, R., Mokler, P.J. & Hoppe, K.M, Discharge destination and motor function outcome in severe stroke as measured by the functional independence measure/function-related group classification system, Arch Phys Med Rehabil 79(7): 762-5, 1998. 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