Top 5 Differences between Acute Care and Outpatient OT

Top 5 Differences between Acute Care and Outpatient OT

 

Currently I am making a transition to Outpatient. I have done a little outpatient OT in the past and 17 years of Inpatient and Acute Care from Pedi to Geriatrics, Neuro to Burns.... Outpatient is a different animal.

 

The main differences are:

1. Scheduling
2. Billing and Coding
3. Documentation
4. Patient Type (Acuity and Diagnosis))
5. Outcomes Measurement

Scheduling

In Acute Care there are so many factors that can influence your time. Patients are ill, they leave the floor for testing. In our case we made an extensive list of patients that the therapists would see. If the patient was unavailable you may check back, otherwise you proceed.

 

In Outpatient there is a much more regimented pattern. Blocks of time are in 1/2 hour for treatments and 1 hour for evaluations. It is possible to get the patient from the waiting room, see the patient and write the note in a 1/2 hour but just barely. If there are any delays to the schedule it is very difficult.

 

There would surely be ways to make the process for both more efficient.

 

Billing and Coding

In Acute Care we are paid by DRGs or Diagnostic Related Groups. Essentially, if some one has a pneumonia with no modifiers you get one rate. There is a tremendous benefit to this if your facility recognizes the benefits of rehab for decreasing Length of Stay - LOS. The more Rehab, the shorter LOS, the more money for the facility. However; many places did not figure this out and Acute Cares may be somewhat understaffed as a result.

 

In Outpatient we are tied to the myriad Insurance Company Demands. The history of Outpatient includes a little bit of fraud, so... everyone suffers and a lengthy process to justify treatment ensues. Now, there were a few bad apples but everyone is required to dedicate a lot of time to making sure the payers believe rather than treating the patients. Necessary evil? Or unfortunate consequence of a few bad apples. Anyway, we document ICD9 codes, E-Codes and Now G-Codes, just to make sure it's okay.

 

Authorization in Outpatient is an unfortunate waiting period after the evaluation while the Insurance Company decides if you merit treatment. Usually you do, but certain insurances take more than a week to tell you. Unfortunately, that week can be the most painful of weeks.

 

In our facility Acute billing is electronic for the therapists but only because I wrote the database that did it. In Outpatient it's on paper and gets added by administrative support people.

 

Documentation

In Acute Care many facilities have gone to Computer Based systems, we have. We write an Eval with separated data in a database. This generates as report that can be pasted into Cerner. Later this year we will be going to Epic which may have a lot of clicks and limited reproducibility but we shall see.

 

In Outpatient there are significant concerns due to the billing and coding process and the need to have Doctors specifically sign the plan of care. Also, an authorization must be sent with the Doctors reviewed POC to the insurance company to seek the Authorization I mentioned above. 

 

Patient Type (Acuity and Diagnosis)

In Acute Care therapists see the sickest of the sick. Patients who need to stay in hospital need to have a lot of care given to them. Also, the culture of hospitals often leads to patients spending much too much time in bed. Bed rest is terrible for most conditions (maybe preterm labor can justify it and the others are for very short periods of time, like just after a procedure).

 

In outpatient, the great majority are ambulatory. They have a few focused injuries and if the Doctor ordered care for any particular one we can work on it. The body and function is divided and specialists are called for a careful review of the body part the Doctor referred for. I have an inclination to want to review and treat the whole person. In this case sometimes I can't.

 

This doesn't make much sense sometimes as we are trying to get people better and more functioning. I think this is the challenge to expand the care of patients to their ultimate needs rather than what they remembered to ask for in the Doctor's office. Also, with the minimal recognition of OTs roles many Shoulder and Elbow patients are referred to PT and not OT. If we're going to go by that unfortunate divide the body system we should at least adhere to it.

 

Outcome Measurement

In Acute Care this is currently pretty limited. The DRG system has devoted resources towards monitoring Length of Stay or LOS. The focus is on getting people out, back home and not returning within 30 days for any reason. The measurement around these values is somewhat patchy but can be done with effort.

 

In Outpatient there has been a lot more effort on developing and using outcome measures. Currently, I am writing a tool to help administer, score and report on the DASH - the Disability of the Arm, Shoulder, Hand Scale. This scale nicely gives a score out of 100. It looks like a disability score but not officially. It has a lot of great ideas for helping guide the functional components of treatment.

 

I think the outcomes measures would be a big help.

 

Summary

Overall there are many key differences between acute care and outpatient OT. There are several others and I'd love to hear your ideas and experiences about them in the comments below.