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Invited Perspective

Physical Medicine and Rehabilitation and AcuteInpatient Rehabilitation

Murray E. Brandstater, MBBS, PhD

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Postacute medical rehabilitation provides care to people with a disability after a recenthospitalization due to trauma or illness, and has as its main goal functional improvement forthese individuals to help them prepare to live as independently as possible. Postacute care(PAC) encompasses a wide range of services offered in different settings, including inpatientrehabilitation facilities (IRFs), outpatient therapy, services provided in the home by homehealth agencies, long-term care hospitals, and skilled nursing facilities. PAC involvesrehabilitation, but the intensity and nature of the rehabilitation provided in these differentlevels of care vary. The amount and intensity of therapy are determined by the needs of thepatient, statutory requirements, and payment policies.

A number of factors have led to an increasing demand for postacute rehabilitationservices. The value of postacute rehabilitation has been recognized for many years by thepublic, health care professionals, and insurers, and the health care industry has respondedby expanding the volume of services that provide postacute rehabilitation. Althoughrehabilitation services are provided to patients of all ages, from young children to theelderly, older adults in particular have fueled this increased demand due to the growth intheir numbers and because they have a higher incidence of disabling conditions, such asstroke, arthritis, hip fracture, and amputation. Furthermore, the patterns of care in acutehospitals are becoming more complex, and higher acuity patients, with more comorbidities,are increasingly being referred for PAC. Many of these medically complex patients are beingadmitted into IRFs, and many more who need less intense care are being managed in theirhomes or skilled nursing facilities.

PHYSICAL MEDICINE AND REHABILITATION AND IRFs

Physiatrists have a tradition of holding a major interest in care delivered in IRFs because,through their training, they have acquired the knowledge and skills required to providecomprehensive care to patients who participate in medical rehabilitation. IRFs are certifiedas acute care hospitals or units within a hospital, where they provide skilled nursing care 24hours a day. Patients must require the daily medical oversight of a physician trained inrehabilitation, and they must receive at least 3 hours of active therapy at least 5 days a weekfrom a coordinated multidisciplinary team of allied health professionals. The need fortrained physicians to direct clinical programs in inpatient rehabilitation was one of the keyelements that led to the development of physical medicine and rehabilitation (PM&R) as arecognized medical specialty in 1947.

Right from its beginning, PM&R was founded on some basic tenets that included theprovision of care that focused on individual patients to ensure restoration of physical,psychological, and social functions to the most optimal level possible. The early pioneers ofthe specialty, especially Drs Frank Krusen and Howard Rusk, wrote eloquently about thephilosophy of patient-centered care and the role of the physiatrist in providing care throughdirection of a multidisciplinary team of health care professionals [1,2]. The conceptsexpressed in their teaching and writing are still regarded by physiatrists as central to the waythey view their professional role in the care of patients. The beliefs and attitudes aboutrehabilitation embraced and promoted by Krusen, Rusk, and other pioneers are incorpo-rated into what defines the specialty of PM&R. It is in the setting of inpatient rehabilitationwhere this philosophy of comprehensive rehabilitation is best observed, learned, and

practiced. Every physician undergoing training to be a physiatrist must receive in-depth

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M&R © 2011 by the American Academy of Physical Me1934-1482/11/$36.00 Vol.

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M.E.B. Physical Medicine and Rehabilitation,Loma Linda University, 11406 Loma Linda Dr,Loma Linda, CA 92373. Address correspon-dence to: M.B.; e-mail: mbrandstater@pol.net

isclosure: nothing to disclose

isclosure Key can be found on the Table ofontents and at www.pmrjournal.org

dicine and Rehabilitation3, 1079-1082, December 2011

OI: 10.1016/j.pmrj.2011.11.0061079

1080 Brandstater PM&R AND ACUTE INPATIENT REHABILITATION

experience, lasting at least 12 months, caring for patientsundergoing acute inpatient rehabilitation. It is in the IRFwhere residents have the opportunity to gain this experiencein comprehensive rehabilitation. Therefore, the IRF contin-ues to be a vital resource for physiatrists in current practiceand an essential setting for the education of the future gen-eration of physicians committed to medical rehabilitation.

There was a major expansion in the number and sizes ofIRFs in the 1980s and 1990s after the U.S. Congress enacteda prospective payment system for patients in acute carehospitals, which gave hospitals a strong financial incentive todischarge patients more quickly from acute care beds intoPAC settings that continued to be reimbursed on a cost basis.The numbers of IRFs increased from 357 in 1984 to 1087 in1998. Rehabilitation emerged from a state of relative obscu-rity and became widely recognized as an essential componentof the postacute continuum of care for patients. In recentyears, about a third, or more than 10 million, of Medicarebeneficiaries who leave acute care hospitals each year enterthis postacute phase of care [3]. This expansion of rehabili-tation care fueled a parallel expansion in the number ofresidents in PM&R training programs to ensure an adequatesupply of physicians to care for the patients in these IRFs.Utilization of rehabilitation services in the future is expectedto rise substantially with aging of the population and survivalof more individuals with physical disabilities.

CURRENT TRENDS

Although physiatrists are still guided by the underlying phi-losophy proclaimed by those pioneers, major changes haveoccurred in the 60 or more years since the formal model forinpatient rehabilitation programs was created. The quality ofrehabilitation care has improved over the years, mainlythough expert consensus rather than evidence-based re-search. This consensus, however, has helped to improve carethrough the general adoption of clinical protocols that haveprovided some standardization in the way patients aretreated. Evidence from research for better therapies has con-tributed only in a relatively minor way to the advancement ofthe field. In recognition of the need for a research agenda toestablish a scientific base for clinical practice and for thedevelopment of public policy a Rehabilitation Symposiumwas convened in February 2007 [4]. A series of articles fromthat symposium was published in the Archives of PhysicalMedicine and Rehabilitation in November 2007 [5].

Subspecialization within the field of rehabilitation hasoccurred in the care of patients with spinal cord injury andtraumatic brain injury, bringing with it a greater focus onquality medical and nursing care and on the comprehensiverehabilitation process. This subspecialty trend has occurredespecially in larger more specialized centers, which havetended to care for patients with more complex impairments,

for example, high tetraplegia. Although this has had some

impact on smaller and less specialized centers, there are stillmany other patients with disorders such as stroke and gen-eral debility who require medical rehabilitation. One seriousconstraint that has limited access of some patients to IRFs isthe 75% rule that was established by the Centers for Medicareand Medicaid Services. This rule requires that 75% of pa-tients admitted to an IRF must have a diagnosis that is one ofthose on a list of 13 diagnoses established by Centers forMedicare and Medicaid Services. Due to the constraints im-posed on patient admission to IRFs by the 75% rule, it isanticipated that, in the future, more and more patients whoneed and would benefit from comprehensive medical reha-bilitation will have limited access to IRFs because their diag-nosis is not one of those on the Centers for Medicare andMedicaid Services list.

A major and important advance in rehabilitation was theintroduction of systems to measure disability, notably theFunctional Independence Measure, which has providedthe tools to record patient progress and measure functionaloutcome. The quality of rehabilitation care also has improvedas nursing and allied health professionals brought a higherlevel of knowledge and skill to the rehabilitation processthrough enhanced education.

There is great regional variation in access to PAC, and,among those patients who do enter the PAC continuum,there is variability in how patients are triaged into the differ-ent levels of care. Increasing attention is now being given tothe study of the effectiveness of PAC and optimal utilizationof the different levels of PAC. Because of the cost of PAC,there is major interest in the development of a policy thatbuilds in some cost control while ensuring that patientsreceive quality care.

Over the past few years, the role of the physiatrist as aconsultant, decision maker, and medical director for IRFs hasbecome more important and more demanding as the role ofthe physician has been refined by policy makers and payers.There is increased scrutiny of medical decision making onadmission of patients to ensure that the admission criteria aremet. These criteria include the need for 24-hour nursing andmedical conditions that require daily physician visits formedical care. For a physician treating patients in an IRF,there are requirements for more detailed documentation ofthe medical care and the progress of the patient in therehabilitation program. The admitting physician often faces adilemma in making the admit decision because the patientshould be medically stable to participate in an intensiverehabilitation program but still have sufficient medical needsto require hospitalization and daily physician visits.

Because of the expansion in numbers of IRFs and theaccompanying escalation in the cost of rehabilitation in thepast few years, greater attention has been given to postacutemedical rehabilitation by those responsible for establishinghealth care policy, particularly regarding cost containment.

Care providers and IRFs have responded to this increased

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1081PM&R Vol. 3, Iss. 12, 2011

scrutiny by screening patients more carefully before admis-sion and managing to shorten the overall lengths of stay. Weare uncertain how government policies may force change inthe future with regard to IRFs, but it can be expected thatpressure on the utilization of IRFs will continue. However,there are trends that would suggest that the utilization of IRFswill continue to increase. The population is aging, and, withincreasing age, more individuals will develop diseases thatconfer impairments and disability that will require rehabili-tation. Further, it is becoming clear that more intensive levelsof rehabilitation improve patient outcome. For example, ithas been shown that for stroke patients, greater intensityof therapy does positively influence the outcome [6], evi-

ence that justifies admission of stroke patients for acuteehabilitation of a higher rather than a lower intensity. It isoped that future policies will be based on the results of theesearch agenda for PAC that has as one of its aims theevelopment of sound evidence to support the claims thatedical rehabilitation is beneficial.

THE CHALLENGE FOR PM&R

There has been a gradual increase in the complexity andintensity of medical care required to manage patients in acuterehabilitation facilities. Because PM&R is the only specialtythat requires extensive training in comprehensive rehabilita-tion during postgraduate education, it is expected thatphysiatrists will continue to be the main physician careproviders for these patients. The challenges that face themedical director of the rehabilitation unit and the physicianswho provide patient care in the IRF include the following:

● Before a patient is admitted to an IRF, a physician mustperform a careful review of the case to ensure that theadmission criteria are met.

● Attending physicians are spending more time addressingmedical issues at the bedside as higher acuity patients withmore comorbidities are admitted.

● Some patients with very complex diagnoses are beingadmitted; for example, patients with organ transplant andwith severe deconditioning, severely debilitated cancersurvivors, and patients who are debilitated after survivinglong stays in the intensive care unit with multiorgan fail-ure.

● The care of patients with comorbidities and complex diag-noses often requires collaboration with physician col-leagues in many other specialties.

● The rehabilitation physician must collaborate with alliedhealth professionals in refining treatment protocols anddeveloping new protocols for the rehabilitation of lessstable patients with multiple comorbidities and complexdiagnoses.

● There is more rapid turnover of these patients in the IRF,shortening the overall length of stay and increasing the

burden on the physician to ensure coordination of ongoing m

care in addition to the customary tasks involved in carefuldischarge planning, family counseling, and rehabilitationfollow-up.

● The medical record must include detailed documentationof the patient’s daily medical care and progress in rehabil-itation to justify continued stay in the IRF.

● Physician compensation will become an issue. As the med-ical acuity of their patients increases, attending physicianswill have difficulty maintaining a high census of inpatientsand that could reduce the measures of physician produc-tivity. Furthermore, the amount of time that the physicianhas to spend in administrative activities will increase, es-pecially those related to utilization management.

ll of these developments are contributing to an increasedorkload for the physiatrist as medical director and attend-

ng physician of the IRF, but physiatrists are responding tohese challenges. Already physiatrists have begun to adapt tohe increased demands on their practice time. In some busyommunity rehabilitation units, physiatrists have amelio-ated this additional workload by using physician extendersuch as nurse practitioners or physician assistants. By dele-ating routine tasks and some time-consuming documenta-ion, the attending physician can direct the care of manyore patients. In another common approach, the physiatrist

elinquishes the role of the attending physician to a hospital-st or the patient’s primary care physician and retains theesponsibility for directing the patient’s rehabilitation pro-ram in a joint service model of care. However, this model ofare may not be generally adopted because some insurancearriers are not or will not be willing to accept the additionalost involved when 2 physicians are jointly managing theatient.

At a hospital-wide level, the medical director of the IRFas always had an important role in advocating for theehabilitation program. Now, in a larger institutional sense,he medical director of the IRF should be positioned torovide institutional leadership as new arrangements areeing made for PAC in the future and, in particular, as newayment methods are proposed, for example, bundling.hen, as it seems likely, payment to hospitals and providers

or PAC becomes bundled with payment for acute care, thereill be a potential threat to rehabilitation. Institutions willant to provide the least costly care. In the short term thatight favor skilled nursing facilities over IRFs for medical

ehabilitation. Although there is a dearth of good outcomeata, there is much evidence to support the value of short-erm intensive rehabilitation in providing better ultimateutcomes, better patient survival, fewer late complications,nd less hospital readmission. The role of the physiatrist nownd in the future should continue to include strong advocacyor disabled patients and for optimal arrangements for PAChat include inpatient acute rehabilitation for patients who

eet admission criteria.

1082 Brandstater PM&R AND ACUTE INPATIENT REHABILITATION

As we consider the changes that face the practicing physi-atrist, attention must be paid to the implications for residencytraining. The current residency program requirements in-clude a provision for each resident to spend a minimum of 12months providing direct, complete, and comprehensive carefor patients on inpatient rehabilitation services. The prepon-derance of this inpatient experience should include the careof patients in the acute rehabilitation setting. Residents mustalso gain an understanding of the range of services availablefor patients receiving PAC and be able to appropriately assesspatients and refer them to different levels of care within thepost-acute continuum. All of these requirements should bereinforced because the principles involved will continue to beimportant in the larger picture of quality patient care. There alsois a current provision in the residency training requirement forinstruction of residents in medical administration on the IRF.Given the increasing importance of the role of medical direc-tor of the rehabilitation service, there should be more explicitlanguage regarding what residents should understand aboutthat role. Such language would include, for example, patient

admission criteria, patient safety, teamwork, quality im-

provement, and a knowledge of government policies govern-ing rehabilitation, including how hospitals are reimbursed.With these measures, we should be able to ensure that therewill be an adequate future workforce to provide medicaldirection and patient care in IRFs.

REFERENCES1. Krusen F. Concepts in Rehabilitation of the Handicapped. Philadelphia,

PA: Saunders; 1964.2. Rusk HA. Rehabilitation Medicine. 2nd ed. Saint Louis, MO: C.V.

Mosby, 1964.3. Buntin MB. Access to postacute rehabilitation. Arch Phys Med Rehabil

2007;88:1488-1493.4. Heinemann AW. State-of-the-science on postacute rehabilitation: Setting

a research agenda and developing and evidence base or practice andpublic policy. An introduction. Arch Phys Med Rehabil 2007;88:1478-1481.

5. Special communication. Arch Phys Med Rehabil 2007;88:1478-1541.6. Horn SD, DeJong G, Smout RJ, Garraway J, James R, Conroy B. Stroke

rehabilitation patients, practice and outcomes: Is earlier and more ag-gressive therapy better? Arch Phys Med Rehabil 2005;86(Suppl 2):S101–

114.