Even though swing beds were authorized more than three decades ago and close to 90% of eligible hospitals take advantage of them, questions and confusion remain over how they can be used and how to appropriately document their use.
In fact, says Carolyn St. Charles, Chief Clinical Officer for HealthTechS3, only a very small percentage of hospitals with swing bed programs get it exactly right. Which means most hospitals are either leaving revenue opportunities on the table, risking regulatory scrutiny or both.
St. Charles will present a webinar later this month to review some of the most frequent areas of confusion related to swing bed programs, including the following:
Swing Bed: It’s more than therapy
The Social Security Act (the Act) permits certain small, rural hospitals to enter into a swing bed agreement, under which the hospital can use its beds, as needed, to provide either acute or post-acute skilled care. And while rehabilitative therapy, either physical or occupational, , are among the most common types of post-acute skilled care provided (wound care and antibiotic therapy are another), there are plenty of other good reasons to swing a patient.
Skilled care can include teaching and training activities.
“Teaching and training activities constitute skilled services when they require skilled nursing or skilled rehabilitation personnel to teach a patient how to manage their treatment regimen,” St. Charles says.
Examples of teaching and training activities include:
- Teaching self-administration of injectable medications.
- Gait training and teaching of prosthesis care for a patient who has had a recent leg amputation.
- Teaching patients how to care for a recent colostomy or ileostomy.
- Teaching patients how to care for and maintain central venous lines, such as Hickman catheters.
- Teaching patients the use and care of braces, splints and orthotics, and any associated skin care.
- Teaching patients the proper care of any specialized dressings or skin treatment.
- Training a patient with COPD on managing their oxygen in relation to exercise or activity.
Direct skilled nursing services are another that sometimes get overlooked as possible swing bed admissions. Examples of these include:
- Intravenous or intramuscular injections and intravenous feeding.
- Enteral feeding that comprises at least 26 percent of daily calorie requirements and provides at least 501 milliliters of fluid per day.
- Naso-pharyngeal and tracheotomy aspiration.
- Treatment of decubitus ulcers, of a severity rated at Stage 3 or worse, or a widespread skin disorder (Heat treatments which have been specifically ordered by a physician as part of active treatment and which require observation by skilled nursing personnel to evaluate the patient’s progress adequately.
- Care of a colostomy during the early post-operative period in the presence of associated complications.
What’s more, skilled care may be provided to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.
The Plan of Care: The Achilles heel of swing bed programs
Once you’ve established that a swing bed admission is merited, the next hurdle is justifying and documenting the need for skilled care in the patient’s medical record, including in the multi-disciplinary plan of care.
“The plan of care must be developed by a multi-disciplinary team and must be specific to the reason the patient was admitted,” St. Charles says. “Additionally, Medicare says that the plan must be measurable and time-limited. In other words, the plan has to say what needs to be done, by when and how is it going to be measured.
“The most common mistake Swing Bed programs make is that they don’t identify short-term and long-term goals and then they don’t make them measurable and time-limited,” St. Charles says.
Examples of measurable, time-limited goals: “Patient will receive 14 days of antibiotic therapy” or “Patient will walk 100 feet with a front-wheel walker within one week.”
“Physical therapy is usually pretty good about those goals, while nursing often struggles,” St. Charles says. “Nursing is used to writing nursing care plans, but not goals that are measurable and time-oriented.
Missing the mark on length of stay
A final area of confusion for swing bed programs is when to discharge patients. St. Charles says she sees many swing bed patients that are discharged before they are really ready, and then are readmitted either to acute care or back to swing bed.
“A lot of facilities will discharge a patient as soon as a patient meets their therapy goals,” she says. But that’s really an outpatient construct that doesn’t always apply.”
“If a patient needs a few more days to make sure they can sustain their progress and have a safe discharge plan, additional days would be appropriate as long as the patient still needs a skilled level of care,” she adds. “The key is to document WHY the patient needs the additional time in the swing bed and how it relates to the overall plan of care, including safe discharge”
Tune into the webinar, Swing Bed Requirements: Lifting the Fog, at noon on Friday, Sept. 24 for more insights on swing bed regulatory requirements and areas of confusion. Reserve your spot today.