Why Hospital-Based Rehab Is Best For Patients

by Dr. Steve Andersen

How do you choose where to send your patient after their acute inpatient care, especially when there are several available options? You may already have ordered PT, OT or speech therapy in the hospital. Your patient’s therapists might have recommended high-intensity care, an inpatient rehabilitation facility, or hospital-based inpatient rehabilitation. Among those options, it’s not always clear which is best for your patient’s long-term recovery.

Rehabilitation options for stroke patients

Stroke survivors should be treated in an inpatient rehabilitation facility (IRF) if they qualify for it, according to the 2016 American Heart Association/American Stroke Association Guidelines (Level of evidence: class I, level B). 

If your patient has some level of family support at home, then a hospital-based rehabilitation facility – such as the Providence Acute Rehabilitation Center at Providence Portland Medical Center – often can be the best option.

Stroke patients undergoing hospital-based IRF rehabilitation have a higher level of function, lower level of re-hospitalization, higher level of return to community and better survival than those treated in a skilled nursing facility (SNF). “The studies that have compared outcomes in hospitalized stroke patients first discharged to an IRF, a SNF or a nursing home have generally shown that IRF patients have higher rates of return to community living, and greater functional recovery …” (Weinstein, Stroke, 2016). 

Where do most stroke patients actually go after their stay in the hospital? According to recent Centers for Medicare and Medicaid (CMS) data, only 22% are admitted for hospital-based IRF rehabilitation. Meanwhile, 32% are discharged to a SNF, 15% go home with home health care, and a surprising 31% receive no rehabilitation care at all. 

The advantages of inpatient rehabilitation

IRF patients receive substantially more physical, occupational and speech therapy than SNF patients – about three hours of therapy daily at least five days a week. At the IRF, a physiatrist rounds daily; the rehab nurse tends to bowel, bladder, and skin disorders; and the rehab team creates and updates the treatment plan at least weekly. IRFs offer onsite medical services and consults, which are not available in SNFs, to support medically complex patients.

Hospitalized patients with stroke or any other disabling illness or injury should undergo pre-admission screening for hospital-based rehabilitation. Primary care and hospital-based providers can direct the hospital care manager or social worker to refer for inpatient rehab, even if they aren’t sure whether the patient will qualify. Inpatient rehab referrals also can be ordered through Epic at most Providence hospitals. Providers can help reduce patient anxiety by using phrases such as, “We’re figuring out the next step to help you recover from the stroke,” rather than, “I’ll see if you qualify for the rehab unit or the SNF.”

Providence-based resources for your rehabilitation patients

For patients whom you believe would benefit best from hospital-based rehabilitation, Providence’s IRF provides team-based care from its rehabilitation team and Providence Brain and Spine Institute.

Providence Acute Rehabilitation Center (PARC) is an inpatient rehabilitation unit, with all private patient rooms, located on the campus of Providence Portland Medical Center and is part of Providence Brain and Spine Institute. Our physiatrist-led team includes physical therapists, occupational therapists, speech language pathologists, clinical psychologist, 24/7 rehabilitation nurses, and in-house medical consultants and services.  

The most common reason for PARC admission is stroke. Average length of stay is 12-13 days, although patients with spinal cord injury or tracheostomy often stay longer. Patients who qualify for admission can continue hemodialysis or radiation therapy. PARC currently is not able to support most patients requiring ventilator support, hyperbaric oxygen treatments, chemotherapy, or surgical procedures during the actual inpatient rehabilitation stay.

PARC admission process at a glance

• Clinician refers the patient via the inpatient care manager or phoning PARC admissions staff. Epic order for PPMC or PSVMC is: Inpatient consult to rehab unit (CON 337).

• Admission staff and physiatrist will verify patient’s necessity, medical stability and ability to participate in three hours of daily therapy. They also will assess family’s ability to support discharge home.

• PARC admissions staff will work to get authorization from patient’s health plan.

• Referring clinicians are encouraged to set up follow up for outpatient medical care at least two weeks after the inpatient rehab admission date.

• Physiatrist will arrange home health, outpatient rehabilitation therapy referrals, and any needed medication prescriptions for the first month after inpatient rehabilitation.

How to determine what type of rehab is best for your patient

Below are some clinical indicators to help you decide what type of rehab is best for each of your patients:

• IRF: Patient is stable enough to discharge from acute care; has the potential to improve; and can tolerate three hours a day of an interdisciplinary rehab approach (not just PT alone). A physiatrist visits several times weekly to manage risk factors, comorbidities and functional problems. There must be a realistic plan for return to the community after the patient completes inpatient rehab admission (rather than transfer to a SNF).
• SNF: Physical therapy is the only requirement for recovering enough function to go home, patient has low tolerance or motivation for rehab, and it may not be feasible to return home or to another community-based setting. 
• Home health: Patient has no or very minimal post-stroke functional impairment on PT/OT/speech therapy evaluations. Family is able to supervise and support at home, including home health or outpatient rehab services.

Only you know what’s best for your individual patients, but we hope this overview and guidelines are helpful in better understanding your rehabilitation options.