Care Coordination Competency

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Across
  1. 3. Process to ensure smooth transitions to home or next level of care
  2. 4. Older scoring system replaced by Section GG for functional assessment
  3. 5. A meeting of the interdisciplinary team to coordinate care and discharge plans
  4. 6. Three words used in the cognitive patterns assessment
  5. 7. The assessment tool used in inpatient rehab to collect patient data for CMS
  6. 11. First day of skilled therapy services, used for CMS tracking
  7. 12. Entered in caretool flowsheet if activity not attempted due to medical condition or safety concern
  8. 15. A secondary diagnosis that can increase CMG weight if it meets tiering criteria
  9. 17. Requirement that patients receive at least 3 hours of therapy per day, 5 days per week
  10. 18. Helper provides verbal cues a as patient completes activity. Assistance may be provided throughout the activity or intermittently.
  11. 19. Written record required to support therapy intensity and skilled need
Down
  1. 1. A physical or cognitive deficit affecting a patient’s ability to perform ADLs
  2. 2. Documentation required within 48 hours prior to IRF admission to support medical necessity
  3. 5. Payment group assigned based on diagnosis, function, and comorbidities
  4. 8. Completed within 24 hours of IRF admission to validate appropriateness
  5. 9. Process of ensuring medical necessity and preventing denials
  6. 10. IRF-PAI section that measures functional status and outcomes
  7. 13. Key part of rehab care planning, focuses on patient’s expected functional outcomes
  8. 14. Classification of comorbidities that increase reimbursement (low, medium, high)
  9. 16. CMS rule requiring that at least 60% of patients have qualifying rehab conditions