Inpatient rehabilitation facility

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  Inpatient rehabilitation facilities (IRFs) are hospitals that specialize in intensive rehabilitation.

  
  
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  IRFs provide the most intensive therapy and the greatest variety of rehabilitation services. These may occur in general rehabilitation units or in dedicated brain injury units that are within acute care facilities or part of freestanding postacute hospitals.

  
  
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  Medicare has established these following regulatory requirements for IRFs:

  
  
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  A rehabilitation physician must review and approve each patient, and the patient must meet these criteria:

  
  
  
  
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    Require close medical supervision by a rehabilitation physician to manage medical conditions and require specialized rehabilitative nursing expertise to support participation in an intensive rehabilitation therapy program.

    
    
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    Require the active and ongoing therapeutic intervention of multiple therapy disciplines, including physical therapy (PT), occupational therapy (OT), speech language pathology (SLP), or prosthetics and orthotics and at least one therapy discipline must be PT or OT.

    
    
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    Require an intensive rehabilitation therapy program uniquely provided in IRFs and must tolerate 3 hours of rehabilitation therapy per day at least 5 days a week or at least 15 hours of intensive rehabilitation therapy within a consecutive 7-day period, beginning with the date of admission.

    
    
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    Be sufficiently medically stable to benefit from IRF services.

    
    
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    Provided services may result in a measurable and significant improvement in the patient’s condition within a reasonable time frame.

  
  
  
  
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  A postadmission physician evaluation to verify that the patient’s preadmission assessment information remains unchanged or documentation of any changes must be completed within 24 hours of admission.

  
  
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  Individualized overall plan of care must be completed by the rehabilitation physician within 4 days for each patient, emphasizing the interdisciplinary approach to care provided in IRFs.

  
  
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  Interdisciplinary team meetings are required at least once per week throughout the IRF hospitalization.

Long-term acute care hospital

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  Long-term acute care hospitals (LTACHs) take care of medically complex patients who require longer inpatient hospitalizations.

  
  
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  Although LTACHs provide rehabilitative therapies, their primary focus is on medical and nursing care of complex conditions.

  
  
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  Medicare mandates the length of stay (LOS) to be greater than 25 days on average, reflecting the expectations of medical complexity.

  
  
  
  
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    Medical complexity includes the need for respiratory therapy because of ventilator or tracheostomy dependence, prolonged ventilator weaning, intensive respiratory care, parenteral feeding, dialysis, complex wound care, or multiple intravenous medications or transfusions.

  
  
  
  
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  Additionally, a 3-day intensive care unit LOS at the acute care hospital immediately preceding LTACH admission or 96 hours of mechanical ventilation services during the LTACH admission is required by Medicare for admission.

  
  
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  There is no Medicare requirement for the amount of rehabilitation therapy at LTACHs.

Skilled nursing facility

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  Skilled nursing facilities (SNFs) provide skilled nursing and rehabilitation care at a less intensive and more variable level than IRFs.

  
  
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  SNFs provide PT, OT, and SLP therapy and skilled nursing services.

  
  
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  SNFs must designate a physician to serve as medical director who is responsible for implementation of resident care policies and coordination of medical care in the facility.

  
  
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  A physician must visit every 30 days for the first 3 months of stay and every 60 days thereafter.

  
  
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  Medicare patients must have had a 3-day qualifying stay in an acute care hospital within the preceding 30 days and need skilled nursing and/or skilled therapy services.

  
  
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  There is no requirement for a specific number of hours of therapies per day.

  
  
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  Medicare covers SNF services on a short-term basis up to 100 days in a benefit period ( Table 17.1 ).

  
  
  
  

  TABLE 17.1

  
  

  Medicare Coverage for Skilled Nursing Facility (SNF) Stays

  
  

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  SNF Days	Medicare Pays for Covered Services	Patient Responsibility for SNF Services
  1–20	Full Cost	Nothing
  21–100	All except a daily coinsurance	Up to $176 per day in 2020
  >100	Nothing	Full cost

   
  
  
  
  
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  Patients with a brain injury are usually admitted to this level of care from acute hospital care or after acute inpatient rehabilitation.

Home health rehabilitation

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  Rehabilitation therapy and nursing services can be provided in a patient’s home by a home care agency.

  
  
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  A doctor sends orders for therapy to the agency, which then visits the patient at home to assess their need for skilled services and provides those services.

  
  
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  Home care agencies provide standard PT, OT, SLP, registered nurse (RN), home health aide, medical social services, and necessary medical supplies, excluding durable medical equipment such as wheelchairs.

  
  
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  The intensity of therapy services is usually one to three times per week for each therapy.

  
  
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  RN visits may be one to seven times per week for wound care, medication management, bladder catheterization, or other services.

  
  
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  Home care services are short term. Medicare defines a maximum 60 days for home care services per episode of care. Patients typically receive these services for a few weeks after hospitalization.

  
  
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  To be covered by Medicare, the patient must be certified as homebound by the referring physician, meaning that the patient must be unable to leave the home, an activity that would require a “considerable and taxing effort.”

Outpatient rehabilitation

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  Outpatient therapy services are provided in the outpatient departments of acute care and rehabilitation hospitals, in rehabilitation clinics, and in doctors’ offices.

  
  
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  Besides standard PT, OT, and SLP services, they may offer pool therapy, driving evaluation, orthotic and adaptive technology services, wheelchair clinic, vocational rehabilitation consultation, electrical stimulation, robotic, and virtual reality therapy interventions.

  
  
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  Therapy frequency is usually one to three times per week.

  
  
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  In 2018, Congress eliminated the limits on Medicare payments for therapy services in one calendar year.

  
  
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  For Medicare to pay for services, the law requires the therapist or therapy provider to confirm that therapy services are medically reasonable and necessary when they reach these amounts each calendar year:

  
  
  
  
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    $2080 for PT and SLP services combined in 2018

    
    
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    $2080 for OT services in 2018

  
  

Disorders of consciousness program

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  Persons with disorders of consciousness (DoC) who are in a coma, vegetative state (VS), or a minimally conscious state (MCS) remain at a high level of medical acuity after intensive care.

  
  
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  Individuals with DoC recover over a longer period and many regain the ability to function independently. In those who survive severe brain injury, there is a marked variability in long-term medical, cognitive, and physical needs.

  
  
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  DoC programs determine the patient’s level of consciousness and responsiveness, identify barriers preventing effective communication and environmental control, advise on medical stability for continued care, establish prognosis, monitor for recovery, optimize the medication regimen, identify long-term care needs, prevent secondary complications, and ensure proper medical equipment is available.

  
  
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  Families who are provided comprehensive education and hands-on training with follow-up support are likely willing and able to provide care for medically stable persons with DoC at home.

  
  
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  Patients may be transitioned to mainstream inpatient rehabilitation programs once they emerge.

Day program rehabilitation

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  Coordinated form of outpatient rehabilitation may take place in a day program, with PT, OT, and SLP therapies, group treatments and group activities, case management, and team meetings to set goals and review progress.

  
  
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  The length and intensity of treatment are determined by the patient’s needs but are largely constrained by health insurance payer contracts and public funding policies limiting the duration of care and range of covered services.

Supported living programs

Team models

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  Rehabilitation usually denotes that multiple disciplines engage with patients and their families to determine and work toward attainable goals.

  
  
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  A team comprises different professional disciplines that are needed to provide comprehensive rehabilitation care.

  
  
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  Almost all rehabilitation programs involve a team of treating providers. However, the team may be configured in different ways, each of which addresses a particular set of treatment goals.

  
  
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  There are multiple team models:

  
  
  
  
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    Multidisciplinary teams involve multiple professions working in parallel to treat patients who have reasonable awareness of a small set of circumscribed problems. This model is commonly used in the outpatient setting.

    
    
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    Interdisciplinary teams are a coordinated group of experts from several different fields, working together toward common goals. It is the preferred team delivery system in IRFs, requiring routine communication to achieve these goals.

    
    
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    Transdisciplinary teams require providers from various disciplines to offer treatment in a coordinated fashion and temporarily adopt each other’s roles in treating the patient. Transdisciplinary teams are most common in residential or day treatment programs.

  
  

Management principles

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  Team leadership typically is the responsibility of the physiatrist, but there may be shared leadership related to a specific patient issue or program focus.

  
  
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  It is important to set expectations and know how to delegate.

  
  
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  Interdisciplinary teams with strong physiatrist leadership and involvement have been associated with high team cohesiveness, showing behaviors that focus on patient services.

  
  
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  External factors that influence team processes and functions are healthcare facility cultures, hospital-level administration and hierarchy, and supervisory expectations.

Team interprofessional relationships

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  Five central components of inpatient rehabilitation team functioning are:

  
  
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  Physician support

  
  
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  Shared leadership

  
  
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  Supervisor team support

  
  
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  Team cohesiveness

  
  
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  Team effectiveness

  
  
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  A team culture is developed through collaborative leadership, care philosophy, relationships, environmental contexts, and communication.

  
  
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  Team members often develop alliances within the team, usually among those engaged in the physical needs of patients or those supporting psychosocial needs.

  
  
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  Communication within teams is a required interpersonal skill for all team members, especially the team leader.

  
  
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  Communication is usually complex and often nonlinear, requiring both formal and informal communication among team members.

Development of therapeutic alliance

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  Therapeutic alliance refers to the positive relationship, mutual trust, and shared goals between provider and patient in a treatment program.

  
  
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  Therapeutic alliance has been identified as a significant variable in enhancing outcomes in posthospital brain injury rehabilitation.

  
  
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  Rehabilitation programs seek to develop a positive working relationship with their patients with varying degrees of success, with some programs monitoring therapeutic alliance and providing interventions as needed.

The rehabilitation team conference

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  The purpose of the IRF interdisciplinary team is to foster frequent, structured, and documented communication among disciplines to establish, prioritize, and achieve treatment goals.

  
  
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  Team conferences must be held once a week, starting within seven consecutive calendar days that begin on the day of admission.

  
  
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  Document participation by professionals from these disciplines (who must have current knowledge of the patient as documented in the IRF medical record):

  
  
  
  
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    A rehabilitation physician with specialized training and experience

    
    
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    An RN with specialized training or experience in rehabilitation

    
    
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    A social worker or a case manager (or both)

    
    
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    A licensed or certified therapist from each discipline involved in treating the patient

  
  
  
  
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  A weekly interdisciplinary team meeting must be led by a rehabilitation physician who is responsible for making the final decisions regarding the patient’s treatment in the IRF.