Guest Columns

Addressing rehab 'outcome killers'

Dr. Richard Juman
Dr. Richard Juman

When a resident leaves a skilled nursing facility after a successful rehabilitation, it's a clear signal to the community the facility is doing its job. In fact, satisfied residents often become the facility's best salespeople by sharing positive reviews with family and friends. On the other hand, when a resident fails in rehab, they may spread a very different message in the community — that the facility failed and is not a good choice for others who need rehab services.

Hospital systems and insurance companies are continually making the same evaluation, asking which facilities they should trust with their patients who need rehab. In contrast to long-term care units, where a constellation of factors collectively known as “quality of life” are the most critical elements, rehab outcomes are cold, hard facts referral sources can see: What percentage of the patients return home? How long does it take? How many need to go back to the hospital?

The bottom line is that facilities that want to survive the changes in the structure and financing of health care need to deliver top-notch rehab outcomes.

In my experience, it's not the size of the gym or the brand of equipment that distinguish the best rehab units. These factors, while important, are external to the patient. What really matters is what happens when patients are confronted by the enormous emotional challenges of rehab. How the facility helps its patients respond to common psychological demands and distress is what separates a successful discharge from an unsuccessful rehabilitation outcome.

All subacute patients experience psychological distress. By definition, they have recently endured some traumatic event — a stroke, a broken hip, a car accident, etc. They spent a few disorienting days in a hospital where their diet, routine, medication regimen and other anchoring elements of their life were disrupted. They often had significant pain and fatigue. And after all that, when they get to the subacute facility, they're told, “Let's get to the gym!” So it's not surprising that many subacute rehab patients, at exactly the moment they need to put forth a Herculean effort, fail to do so because of significant levels of anxiety, depression, poor motivation and other psychological factors.

In fact, the vast majority of subacute rehab patients who receive a solid biopsychosocial evaluation will present with several of these “rehab outcome killers":

  • Depressed, withdrawn, tearful, passive, pessimistic

  • Combative, irritable, frustrated, non-compliant, angry

  • Unrealistic expectations or recognition of disability

  • Cognitive impairments

  • Maladaptive personality issues

  • Chaotic or intrusive family dynamics

  • Low frustration tolerance

  • Poor tolerance of pain

  • Hopelessness, low motivation


It is unrealistic to expect residents to overcome the physical challenges they are facing without aggressive attention to these behavioral health issues. Not addressing these factors produces predictable results, including:

  • Increased time demands on staff

  • Premature, unsuccessful discharge from rehab

  • Increased risk of re-hospitalization

  • Increased chance of permanent disability

  • Poor functional capabilities

  • Dissatisfaction on part of resident and family

  • Lost revenue for program and facility

  • Discharge from the facility is more problematic

  • Possible admission to long-term care facility


Facilities that respond quickly to these emotional “rehab outcome killers” by aggressively treating them with evidence-based behavioral health care can significantly improve their outcomes. Unfortunately, many facilities fail to do this.

Typically, patients struggling in rehab because of psychiatric factors are not referred for behavioral health services until it is already too late to treat the problems that are interfering with an optimal outcome. Frequently, the rehab team does not make a referral until concluding the resident will fail. At that point, the patient is often angry, frustrated, disengaged, confused, resistant and complaining — and so is their family. And the behavioral health clinician can do little more than prepare the patient for the disappointment of returning home with a loss of significant functional capacity, or possibly not being able to return home at all. Wouldn't it be better to intervene early so these patients can go home and resume their lives?

The most successful facilities get psychiatric and psychological services involved at the first indication of an emotional issue that might impede a successful rehabilitation outcome. When referrals occur early, behavioral health services can make the difference between a successful discharge back to the community and a failed rehab stay.

In addition to utilizing optimal medications and psychotherapy to address common mood disorders, behavioral health providers can be instrumental in developing a facility culture that gets patients and families invested in rehab goals, and in helping the entire rehab team provide consistent messages and feedback about the patient's progress towards successful discharge. Psychologists work with staff to respond to problematic behavior and negative attitudes that can derail a rehab stay, leading to improved motivation, improved readiness for change and an increased ability to manage the biopsychosocial factors necessary to return to the community. Physical and occupational therapists will see behavioral health providers as allies helping them address issues interfering with their therapies.

If you want your facility to become known as a top provider of subacute rehabilitation, have your rehab managers ask themselves a simple question: “Who am I worried about?”  Or, to put it another way: “Whose mood, motivation or attitude is likely to interfere with a good outcome?”

At any given point, on every rehab unit, there are multiple patients who fit this description and who may fail if their psychiatric issues are not addressed quickly. Make sure your facility identifies those patients and takes action. You'll improve the efficiency of the rehabilitation department, increase attendance in rehabilitation, and demonstrate improvements in success rates. Staff on rehab units will also find their work easier and more fulfilling when fewer patients are non-compliant and they can devote more time to their primary responsibilities of direct patient care.

Of course, helping a resident adjust to a long-term care facility is an important aspect of behavioral health in post-acute care, but it's tantamount to defeat when the resident might have been able to return to the community. It's time for SNF and behavioral health providers to work together to prevent as many of these poor outcomes as we can.

Richard Juman, Psy.D., is a psychologist and regional director with TeamHealth.

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