Introduction:
This guide was designed to assist medical staff, patients and families to better understand the rehabilitation process. The increased understanding will allow for better overall care and more efficient access to services. The guide provides a framework for understanding the basic terminology of rehabilitation, distinguishing the levels and types of services available, and knowing the techniques necessary to access different services.
Glossary:
Impairment: Any physical deficit or dysfunction
Disability: Any limitation in a person's functional abilities
Handicap: A limitation in vocational or community activities brought about by an environmental barrier
Durable Medical Equipment (DME): Any piece of equipment prescribed to increase one's independence in mobility and self care activities.
Physical Therapy (PT): Structured activity focused on mobility skills, leg flexibility and strengthening, trunk control and balance, endurance training and using adaptive equipment to facilitate mobility.
Occupational Therapy (OT): Structured activity focused on activities of daily living skills( feeding, dressing, bathing, grooming), arm flexibility and strengthening, neck control and posture, perceptual and cognitive skills and using adaptive equipment to facilitate activities of daily living.
Speech and Language Pathology (SLP): Structured activity focused on communication skills, perceptual and cognitive skills and swallowing.
Social Work (SW): Supportive service for psychosocial adjustment and intervention, financial resources, and discharge planning.
Therapeutic Recreation (TR): Structured activity focused on increasing strength and endurance, leisure awareness, and community barriers through the use of leisure and recreational skills.
Personal Care Services: Non-skilled assistance provided to individuals in their homes.
Medicare: A federally funded insurance program that offers standard services nationwide, that may vary if a managed care product is present. Individuals are eligible and can receive for free Part A (pays for inpatient care, all rehabilitation care, equipment) if they have been employed for 10 or more years and are either 65 and older, disabled for 2 years or more, or have end-stage renal disease. Individuals are eligible for Part B (pays for physician services) if they have Part A, but must pay a monthly fee. Medicare does not pay for medications, personal care services at home, or custodial nursing home care, but does provide for skilled nursing facility (rehabilitation or medical) in a nursing home for 100 days ( per each medical or rehabilitation incident separated by 60 days).
Medicaid: A state-funded insurance program that varies by state, and may vary within the state if a managed care product is present. Individuals are eligible and can receive the insurance for free if they meet maximal income limits, are pregnant, are <21 years of age, or have sufficient enough medical bills. Pays for all rehabilitation services, and medications (a co-pay is usually needed for medications). All Medicaid in Virginia is managed care (as of 4/99).
Rehabilitation Continuum of Care Options:
Acute Care Rehabilitation:
Definition: Moderate intensity( 0.5-1.5 hours a day, 5-7 days a week of 1 or more therapy types), Multidisciplinary services performed in a acute care hospital.
Criteria: Any acutely hospitalized individual who has a new disability (or an exacerbation of an existing one) is appropriate for acute therapy services. This can vary from something as straight-forward as weakness-related inability to walk or perform ADL's, to new swallowing difficulties, to higher-level thinking deficits.
Funding: Most insurers will pay for acute care therapy-based rehabilitation. Certification for the acute hospital stay typically covers these services.
Inpatient Rehabilitation Services:
Definition: Intensive ( at least 3 hours a day, 5-7 days a week of at least 2 different types of therapy), interdisciplinary services performed on a discrete, licensed unit either within a hospital (e.g., The Rehabilitation and Research Center at VCUHS) or a free-standing hospital (e.g., Sheltering Arms Rehabilitation Hospital).
Criteria: Individuals who meet all the following criteria are appropriate for inpatient rehabilitation:
- have an acute disability that prevents them from returning home with family care
- medical or surgical conditions are sufficiently stable to allow participation in therapies
- demonstrate the ability to participate in at least 1 hour of therapy two times a day
- demonstrate the ability to make progress in the acute care therapies
- have a social support system that will allow them to return home after reasonable improvement of function
- receive financial clearance from their insurer.
Funding: Almost all insurers have inpatient rehabilitation benefits, however there are different procedures needed to receive clearance. Pre-certification is almost always required, except for Medicare (non-managed care).
Day Rehabilitation Services:
Definition: Intensive (at least 3 hours a day, 5 days a week of at least 2 different types of therapy), interdisciplinary services performed in a discrete location, often adjacent to an inpatient rehabilitation unit. Transportation to and from the services may be provided.
Criteria: Individuals who meet all the following criteria are appropriate for day rehabilitation:
- have an acute disability that does not prevent them from returning home with family care
- medical or surgical conditions sufficiently stable to allow participation in therapies and return home
- the ability to participate in at least 1 hour of therapy two times a day
- the ability to make progress in acute care therapies
- a social support system that allows them to remain at home
- financial clearance from their insurer.
Funding: Almost all insurers have day rehabilitation benefits, however there are different procedures needed to receive clearance. Pre-certification is almost always required, except for Medicare (non-managed care).
Skilled Nursing Facility (SNF):
Definition: Low to moderate intensity (0.5-2.0 hours a day, 5-7 days a week of 1 or more therapy types), interdisciplinary services provided on a discrete unit or within a nursing home (also called a "Skilled Nursing Facility" or SNF).
Criteria: Individuals who meet all the following criteria are appropriate for subacute rehabilitation:
- have an acute disability
- have medical or surgical conditions that may not be sufficiently stable to allow full participation in therapies, but do not require inpatient hospitalization
- demonstrate the ability to participate in at least 1 hour of therapy a day
- acceptance of fiscal responsibility by insurer and/or patient
Funding: Most insurers have subacute rehabilitation benefits within a nursing home ( skilled nursing facility or "SNF"), including non-managed care Medicaid, non-managed care Medicare Part A, and most private insurers. Subacute rehabilitation in an acute rehabilitation unit or acute hospital is only occasionally covered by insurers. Medicaid reimbursement for SNF level care specifically directed at rehabilitation (as opposed to medical) needs is rare.
Outpatient Therapy:
Definition: Moderate intensity (0.5-2 hours a day, 3 days a week of 1 or more therapy types), multidisciplinary services performed in a specific therapy gym, often attached to an acute care or rehabilitation hospital. Occasionally found adjacent to a physician's office. It is felt to be more efficient at improving disability than home health services.
Criteria: Individuals must meet these criteria:
- have an acute disability or physical complaint
- medical or surgical conditions which allow them to return home and be transported to/from therapy
- the ability to participate and make progress in therapies
- acceptance of fiscal responsibility by the insurer and/or patient
Funding: Most insurers provide for outpatient therapy services, however pre-certification is usually required and there are specific limits on the duration of services.
Home Health Rehabilitation:
Definition: Low intensity (0.5-1 hours a day, 3 days a week or 1or more therapy types). Multidisciplinary services performed at the patient's home.
Criteria: Individuals who are considered "home bound" (do not leave the home, except for medical visits) and meet the following criteria are eligible:
- have an acute disability
- medical or surgical stability that allows them to return home safely
- the ability to participate and progress with therapy
- acceptance of fiscal responsibility by insurer and patient
Funding: Most insurers have home health benefits, however pre-certification is usually needed and some plans have a limit on total visits.
Access to Rehabilitation within the VCU Health System
Acute Care Therapy:
Ask Resident Physician to place an order for the appropriate therapy type ( OT, PT, SLP)
Inpatient Rehabilitation:
- Patient must meet rehabilitation criteria, therefore they must be receiving acute care therapy ( to document participation and progress)
- Consult Rehabilitation Medicine Service ( Resident pager 7566 or Dr. Pat McGowan, Rehabilitaton Medicine Consult Attending, pager 256-0027) to evaluate patient and make referral
- Insurance pre-certification is required by most insurers. Inpatient Rehab admissions coordinator, Brenda Kitchen will contact acute care Social Worker for required documentation.
Day Rehabilitation:
- Patient must meet rehabilitation criteria; therefore they must be receiving acute care therapy to document participation and progress
- Patient must meet funding criteria and obtain pre-certification
- Consult Rehabilitation Medicine Service to evaluate the patient and make referral
- Social Worker provides patient/family with location choices / phone numbers for therapy.
Skilled Nursing Facility (SNF):
- Patient meets rehabilitation criteria, therefore they must be receiving acute care therapy (to document participation and progress).
- Resident physician speaks with patient/family about the need for SNF services and possible limitations to bed availability. Resident should also educate patient/family on the difference between SNF and custodial nursing homes.
- Consult Rehabilitation Medicine Service to evaluate patient and make a referral.
Outpatient Therapy:
- Patient must meet rehabilitation criteria, therefore they must be receiving acute care therapy to document participation and progress
- Patient must meet funding criteria and obtain pre-certification
- Resident physician writes outpatient prescription for appropriate therapy (e.g., Outpatient PT 3xweek for 4 weeks for transfer and gait training)
- Social Worker provides patient/family with location and choices/ phone numbers for therapy.
Home Health Rehabilitation:
- Patient must meet rehabilitation criteria therefore they must be receiving acute care therapy to document participation and progress
- Patient must be "home bound"
- Patient must meet funding criteria and obtain pre-certification
- Contact the RN Care Coordination to arrange for Home Health Services.
For More Information about Inpatient Rehabilitation Contact:
Pat McGowan, MD
Rehabilitation Medicine Consult Attending
Pager 256-0027
Rehabilitation Medicine Consult Resident
Pager 7566
Brenda Kitchen, MA, CRC, CCM
Admissions Coordinator
Phone (804)828-2156
Fax (804)628-5022