MDNews - Cleveland-Akron-Canton

+++++++++++++++++++++++++++++++ + + +++++++++++++++++++++++++++++++ CARING FOR THE ELDERLY +++ +++ Physician Is Key to Referring Patients to Appropriate Rehabilitation Services By Frederick S. Frost, MD C HOOSING HOW AND when to make a referral to a rehabilitation hospital after hospitalization for stroke, injury or a medical illness can be perplex- ing. Patients are faced with a confusing array of post-discharge offerings. They depend on their hospital physician to provide the best advice on post- discharge care. Unfortunately, some physicians are uninformed of the differences between levels of follow-up care. Others may maintain ongoing relationships with nursing homes and steer patients to those facilities based on longstanding referral patterns. Often times these referrals represent the "path of least resistance" instead of getting the patient to the right venue for their rehabilitation care. The priority is to recommend the set- ting that best meets their rehabilitation needs and potential. Then you do your best to accommodate geography, insur- ance restrictions and the preferences of the patient and the family. Successful discharge from a rehabilitation venue is an art; balancing medical and rehabilita- tion needs with the patient's desires and readiness to return home. A major difference between acute rehabilitation hospitals, skilled nursing facilities (SNFs) and nursing homes is the level of medical acuity of the patients. Acute rehabilitation hospitals care for patients whose primary need is comprehensive rehabilitation, provided in a setting where close medical supervi- sion is available. Although SNF patients are often remarkably complex from a medical standpoint, their problems are likely to be more chronic and stable in nature. SNFs typically admit patients with medical conditions that require rehabilitation provided at a more modest pace. The patients are less likely to require around- the-clock physician availability. It comes down to a balance between the need for convalescence and rehab. Our SNF patients are slightly older as a group, and move more slowly towards their goal of home discharge. "More" is not always "better" in this situation. The risk of musculoskeletal injury with exercise can be as high as 10 percent in elderly patients. Therapy services need to be engaged with great care. Another important criterion for a patient's referral to an acute rehabilita- tion hospital is his or her potential to tolerate three hours of daily therapy. Nationally, about 2 to 4 percent of all hospital discharges are admitted to an acute rehabilitation facility. In addition, the Centers for Medicaid & Medicare Services (CMS) mandate that 60 percent of patients admitted to an acute rehabilitation hospital fall within 13 diagnostic groups. (See chart.) Preference is always given to patients with these diagnoses. That still leaves a cushion of 40 percent of acute rehabilitation beds that can service those who don't fall into these diagnostic categories and might be over- looked. Younger patients recovering from critical illness, certain cancer patients, CMS '60 PERCENT' RULE CMS MANDATES THAT 60 percent of patients admitted to an acute rehabilita- tion hospital fall within the following diagnostic groups: + Stroke + Spinal Cord Injury + Amputation + Major multiple trauma + Hip fracture + Brain injury + Neurological disorders ( e.g., multiple sclerosis, Parkinson's) + Burns + Active rheumatoid arthritis, psoriatic arthritis and seronegative arthropathy + Joint replacement for both knees or hips when the surgery immediately precedes admission, or unilateral joint replacement when body mass index is 50+ or the patient is over age 85 and those with recent organ transplants, for example, are often best served by an intensive level of rehab. Dr. Frederick Frost is the interim chair- man of Cleveland Clinic's Department of Physical Medicine and Rehabilitation and executive director of Cleveland Clinic Rehabilitation and Sports Therapy. n 24 | Cleveland-Akron-Canton MD NEWS MDNEWS.COM NOVEMBER-DECEMBER 2011

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