The physiatrist's role in post-acute rehabilitation
Steve M. Gnatz, M.D.
There simply aren't enough physiatrists to go around. Physiatrists have been traditionally linked with medical rehabilitation units in hospitals and freestanding inpatient rehabilitation facilities. In that setting, physiatrists provide important input on admission eligibility under current regulations, attend rehabilitation patients, provide direction to the inpatient rehab team, and help assure quality outcomes with the most efficient use of resources. In rehabilitation settings other than the IRF, the role of physiatry is less well defined.
Rehabilitation in the skilled nursing facility environment is rapidly emerging as the predominant level of inpatient rehabilitation care in the United States. The effects of the so-called 60% rule, level of care determinations by payers, and other restrictions on IRF rehabilitation, have led to a 25% decline in IRF cases between 2004 and 2013. More patients receive will their inpatient rehabilitation in a SNF today than in an IRF – and the trend is likely to continue.
Skilled nursing facilities vary greatly in their ability to provide a consistent, cost effective rehabilitation “product.” The cause is multi-factorial. Most importantly, Medicare reimbursement based on a resource utilization group daily rate rather than a case rate (such as the IRF prospective payment system) incentivizes SNFs to maximize length of state for traditional fee-for-service Medicare patients up to the maximum allowable.
The recent shift to managed Medicare and accountable care organizations may be a counterbalancing force in this dynamic. However, only a small minority of SNFs are currently geared up for these shorter dictated lengths of stay with the a higher intensity of therapy that will assure a good outcome in such a short time. Secondly, medical direction of the rehabilitation case in a SNF is often lacking. SNF medical directors and “SNFists” (attending physicians in the SNF environment) are often general internists or geriatricians and do not generally have the training or experience in leading the rehabilitation team matching that of physiatrists. Unfortunately, the result is that leadership of the SNF rehabilitation team may be absent or deferred to either the therapists or to a non-physician therapy director.
Therapists in the SNF environment are given incentives to maximize the not only the provided therapy minutes (RUG level) but also the number of days in therapy, which may result in longer lengths of stay than necessary when there is no physiatrist directing the team. Many therapy directors themselves might not realize that they will be more successful by offering the shortest inpatient rehab stay safely possible. Lastly, most SNFists see their patients on admission and monthly unless there is a problem. Parenthetically, while there is a Medicare requirement that patients in a SNF be seen at least monthly by their attending physician – this requirement seems to have somehow led to a widespread interpretation by doctors that the patient may only be seen once a month while in a SNF. Therefore, most are not available in the facility to attend team meetings or follow their patients closely while in short-term active rehabilitation. This role may be delegated to a mid-level provider (physician assistant or nurse practitioner) who is likely equally untrained in coordinating rehabilitation care.
Physiatrists tend to follow our patients closely through their rehabilitation. Because of this close relationship with the patient, the physiatrist may recognize a change in patient condition before the nursing staff or primary physician does. In some cases, the physiatrist may suggest changes (elimination of a medication leading to an adverse side effect, for example). In other cases (e.g. early identification and treatment of a UTI) may lead to the patient being able to continue rehab uninterrupted. Both of these examples demonstrate physiatrist interactions that tend to reduce the likelihood of hospital readmission, a goal of most organized systems of healthcare. Regular communication with the primary physician (or mid-level provider) helps assure good patient care.
In the IRF environment, it is mandated by federal regulation that the rehabilitation physician performs several key functions. It is not specified that this doctor necessarily be a physiatrist, but only a physician with training and experience in rehabilitation. In the SNF environment, there is no such requirement. The closest evidence there is to a mandate for physiatry in the SNF environment is the Centers for Medicare & Medicaid Services requires provider organizations to differentiate between physical therapists and physiatrists when identifying rehabilitation professionals for Medicare Advantage plans. We rely on vague language in Medicare regulations that specifies that patients may be seen “as medically necessary” in the SNF environment. It is medically necessary for patients undergoing active rehabilitation to have medical direction of their program. The frequency of physiatry interaction has generally been interpreted to be 2-3x/week for patients in active rehabilitation while in a SNF, but this has never been clarified by CMS or fully substantiated by audit or case law.
Due to the historical dearth of physiatrists working in the SNF environment, misconceptions and misinformation abound. Medical directors or SNFists may feel threatened that their patients may be “stolen” or that they will not be able to bill for their services at the same time as the physiatrist - neither of which is true, of course. Therapists may feel their autonomy threatened - when in fact they should welcome appropriate professional oversight and strengthened documentation of the need for therapy services. Administrators may balk at reducing patient length of stay and not recognize that by turning over patients more quickly their facility will instead be seen by the acute hospital referrers as being a more viable post-acute placement, with the effect of increasing patient volume to balance out shorter lengths of stay.
Physiatrists assess patients for functional deficits, and work with the rehab team to both minimize disability and maximize independence. We set goals appropriate to the patient and family needs and work to eliminate any barriers impeding transition to home or a more home-like environment.
In order to do so, we use long-standing and time-honored physiatry principles including medical knowledge of the pathology and pathophysiology of diseases and trauma that may lead to physical and cognitive impairments and assessment of physical, cognitive, and behavioral aspects of people with acquired and congenital disabilities with an eye toward preservation and/or restoration of function. We use an evidence–based model of the use of physical agents, activity, repetition, and neuromuscular re-education that can restore function; prescription of pharmacological agents, technology (such as prosthetics), and physical agents, to minimize pain and disability. We focus on maximizing independence by encouraging incremental improvement toward self-efficacy, and have the ability to counsel patients and families at a time when they are in crisis due to a loss of independence.
In recent years, physiatrists have begun to follow our rehabilitation patients out of the IRF and into other post-acute environments, at present mostly into the SNF. Comparing the number of inpatient rehabilitation patient days between the years of 2004 and 2013, there was a decline in the IRF setting of about 1.4 million. Many of these patients received their rehabilitation in a SNF environment, yet only roughly an additional 236,000 physiatry visits occurred in the SNF setting in 2013 compared to 2004. Some of this difference may be explained by the decreased frequency of physiatry visits in the SNF, but certainly not all. It has been estimated that if every active rehabilitation patient in a SNF environment had a physiatrist seeing them 2-3 times per week, that there would be a need for over 3000 full-time equivalent physiatrists engaged in this work. Clearly there has been some migration of physiatrists from the IRF environment to the SNF, but the estimated workforce needs exceed by far the supply of physiatrists interested and trained in this type of work.
If the physiatry presence in the SNF environment is spotty at best, it is nearly non-existent in most other post-acute levels of rehabilitative care.
Day rehabilitation programs provide similar therapy intensity to IRF rehabilitation while patients sleep at home and are usually associated with IRF's. As such, they often have physiatry direction of the rehab program. In addition to the traditional “step-down” mode for complex neurological patients transitioning from IRF programs, day rehabilitation programs have demonstrated cost-effectiveness for certain orthopedic patients (e.g. total joint replacement).
Other than the increasingly rare comprehensive outpatient rehabilitation facilities (CORF), physiatrists are not often involved in coordinating the care of other outpatient rehabilitation levels of care. These outpatient rehabilitation programs, including CORF's, have been severely limited by the therapy caps imposed by Medicare.
Home health rehabilitation programs may suffer from lack of coordination as well. Inefficiencies of logistics for therapist visits with the patient, lack of specialized equipment in the home, and lack of a structured team communication forum may hamper the interdisciplinary process and lead to nothing more than a disconnected group of therapy services. Most of the best evidence of cost-effectiveness of home-based rehabilitation comes from outside the US. In a 2008 Cochrane review, there was “insufficient evidence to compare the effects of care home environments versus hospital environments or own home environments on older persons rehabilitation outcomes.” It seems most likely that home-based rehabilitation may be found to be cost-effective for some types of post-acute diagnoses (such as total hip or knee arthroplasty) that are relatively uncomplicated, but not for others (such as stroke or brain injury) where cognitive/behavioral or other factors weigh more heavily.
New and innovative approaches will undoubtedly develop. For example, the use of underutilized hotel space for organization of a coordinated rehabilitation program as an alternative to SNF placement has been proposed. One might even imagine an UberHealth rehab team delivered to your home in the future.
Hybrid programs (such as a combined short inpatient rehab stay with a subsequent coordinated home program using the same team) may show some promise to control costs and provide good quality outcomes.
In the emerging future of post-acute rehabilitation, the physiatrist's role will remain the same – to help assure the highest quality of rehabilitative care in the most cost-effective manner so that our patients may resume their lives minimally encumbered by disability and with the maximum quality of life.
Steve M. Gnatz, M.D., M.H.A., is the Chief Medical Officer for Integrated Rehab Consultants, a nationwide group of physiatrists practicing sub-acute rehabilitation.