Question

Assessment: The student will apply utilization guideinlines to assist in making decisions for patient care to continue, following a hospital stay, to a orthopedic rehabilitative care by evaluating 5 patient cases and record their decisions on the appropriate worksheet.

Project 8-3: Use Criteria to Evaluate Appropriate Use of Healthcare Services

Presume you are a health plan utilization coordinator. Your responsibilities involve evaluating the medical necessary of services, including admissions to rehabilitation facilities. The utilization guidelines you use to evaluate appropriateness of patient admissions for orthopedic rehabilitative care following a hospital stay for a fractured hip, total knee or total hip replacement are shown below:
Admission Appropriateness Criteria for Orthopedic Rehabilitation
Patient is medically stable at time of transfer:
Patient is free of fever, and
Patient is not ventilator dependent.
and
Patient demonstrates rehabilitation potential:
Capable of participation in a minimum of 3 hours of therapy per day (physical and occupational therapies combined), and
Potential for learning and carryover demonstrated in acute care, and
Requires therapy from two or more disciplines, and
Requires intensity of services not available on outpatient basis
Before approving insurance coverage for post-hospital admission to a rehabilitation facility for orthopedic rehabilitation, all of the above criteria must be met. If one or criteria are not met, you will send the request to the health plan medical director who will be make the final decision as to whether the rehabilitative care will be prior approved for payment by the health plan. The patient and attending physician can appeal payment denials by providing additional information.

Review the five case sc hospital case manager in the case scenario to request insurance authorization for the patient to be transferred to a rehabilitation facility. How would you respond to th to judge whether orthopedic rehabilitation would be medically appropriate for the patient described in the case enarios provided with this project. Presume you have been contacted by the is request? Use the above criteria
If the p atient does not meet one or more admission appropriateness criteria, which criteria are not met? Use the answer sheet provided for the project to document your responses.

Case 1
This 72-year-old bed-ridden female with Alzheimer's disease and other comorbid conditions was admitted to the hospital following a fall at the foster care home where she lives. She suffered a non- displaced fracture of her left hip. Due to the patient's advanced coronary artery disease and other comorbid conditions it was determined by her physician that surgical intervention would not be appropriate. She was kept in traction for six days while her cardiac condition was closely monitored. During the hospitalization, she received physical therapy twice a day to increase her upper extremity strength although she was not able to fully participate in therapy. On day 7 of her hospitalization the patient is ready for discharge and the case manager calls you to request prior authorization of insurance benefits for post-hospital orthopedic rehabilitation.

Case # 2
This 82-year-old female was admitted for an elective left knee replacement. The patient lives independently in an assisted living retirement center although she has a history of difficulties ambulating due to degenerative arthritis in both knees. Her past medical history includes mitral valve replacement at age 76 and laparoscopic cholecystectomy at age 70. She is on multiple medications, including Coumadin, which was stopped seven days prior to surgery. She underwent surgery on the day of admission. Her postoperative course was uneventful except for hard-to-control postoperative pain. Physical therapy was begun on day two of her hospital stay and occupational therapy begun on day three. She was able to participate fully in all therapies. Her ambulation and ability to care for herself slowly improved. The patient is ready for hospital discharge on the 7h postoperative day and the case manager calls you to request prior authorization of insurance benefits for post-hospital orthopedic rehabilitation.

Case # 3
This 62-year-old man was admitted to the hospital for an elective hip replacement. He has a history of alcoholism, chronic obstructive pulmonary disease, and degenerate joint disease. Prior to admission, he lived independently with his wife of 32 years. The patient underwent surgery on the day of admission. His postoperative course was complicated by pulmonary congestion requiring respiratory therapy treatments. Despite this complication, he was able to begin physical and occupational therapy 24 hours postoperatively. On the 4th hospital day, the patient developed pneumonia for which he was given IV antibiotics. This complication caused him to miss three physical therapy treatments. By the 9t postoperative day, the patient was afebrile and able to ambulate 10 feet with assistance and perform some routine self-care activities. His physician orders discharge on the 9h postoperative day with plans for continued physical and occupational therapy post-discharge. His physician documents that patient can fully participate in the therapies. The case manager calls you to request prior authorization of insurance benefits for post-hospital orthopedic rehabilitation.

Case # 4
This 37-year-old man was admitted to the hospital for an elective right knee replacement. He had undergone replacement of his left knee six months earlier. Knee replacements were needed because of the patient's severe degenerative arthritis. The patient has a history of smoking and recurrent bronchitis, but no other comorbid conditions. The patient underwent surgery on the day of admission. Physical therapy was begun 24 hours postoperatively. By day 5, the patient was able to ambulate independently 20 fee using crutches. His physician ordered continued physical therapy post-discharge. The patient is ready for discharge on the 6th day of his hospital stay and the case manager calls you to request prior authorization of insurance benefits for post-hospital orthopedic rehabilitation.

Case 5
This 51-year old female was admitted to the hospital for an elective right knee replacement for degenerative joint disease. The patient has a past history of Type I diabetes and obesity. She was admitted the night before surgery. Her surgery was uneventful and physical therapy was begun 24 hours postoperatively. On day 3 of her hospitalization, she spiked a fever to 101.2 degrees Fahrenheit and was found to have pulmonary atelectasis. Respiratory therapy treatments and IV antibiotics were started. Due to her decreased endurance, she was only able to tolerate brief periods of assisted ambulation. Her physician ordered a nutritional consultation and diabetic teaching. Six days following her surgery, her strength began to return and by the 9th day, she was able to participate in physical therapy three times a day for 45 minutes and occupational therapy once a day to improve her self-care skills. Her diabetes was under control. On the 11th hospital day, her physician feels the patient is ready for discharge with plans for continued rehabilitative services. The case manager calls you to request prior authorization of insurance benefits for post-hospital orthopedic rehabilitation.

Case #1 This patient would be medically appropriate for admission to a rehabilitation facility for orthopedic rehabilitation. This patient would not be appropriate for admission to a rehabilitation facility for orthopedic rehabilitation for the following reason(s):

Answer 1

Case 1. This patient would not be appropriate for admission to a rehabilitation facility for orthopedic rehabilitation for the following reason:

She is suffering from Alzeimer's disease so she have dementia. She do not have potential to learn and carrying over the demonstrated.

Case 2 : this patient would be appropriate for admission.

Case 3 : this patient would not be appropriate for admission due to following reason

He have degenrative joint disease so might not have potential to participate in minimum 3 hra of therapy per day.

Case 4 : appropriate for admission

Case 5 : she would not be appropriate for admission due to following reason.

She might not have potential to participate 3 hrs per day because suffered from pulmonary atelectasis poat-operatively. She also might need ventilatory support during rehabilitation therapy.