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Toni Talks about PT Today

The Changing Role of Rehab

Published January 4, 2011 6:22 PM by Toni Patt

The definition of rehab today is very different from the definition of many years ago. In the simplest sense, rehab refers to the process of receiving the various therapies with the goal of improving function. Back in the day, going to rehab implied a long hospital stay. Patients didn't leave rehab until they were either better or as better as possible.

I can remember when we didn't have to fight with insurance companies to approve a rehab stay. Years ago, a diagnosis of stroke was justification for admission. Now it takes a diagnosis, therapy notes indicating a need as well as potential to improve, the ability to tolerate 3 hours of therapy and medical justification of why the diagnosis requires rehabilitation. Once admitted, additional documentation is required for just a two-week length of stay. With a few exceptions, gone are the days of staying on rehab until you were ready to go home.

Today, we discharge home patients who would have been considered ideal candidates for admission 10 years ago. Our patients have more medical complications, greater levels of impairment and more severe mechanisms of injury. Today, stroke patients can't be very ambulatory if they want to come to rehab. Anyone able to walk around the nursing floor is deemed ready to go home by today's standards. I can document numerous gait deviations and safety issues. The best I can hope for is outpatient or home-health therapies.

Many rehab patients today would have gone to skilled nursing a few years ago. One of my responsibilities is making discharge recommendations for stroke patients, so I'm familiar with the guidelines. Somewhere along the way, the line has blurred between "will benefit," "might benefit" and "has no other option." Everyone deserves therapy. Not everyone is appropriate for rehab. The only result of admitting someone too soon is wasting his rehab days.

Skilled nursing facilities have become the new rehab. Many of my stroke patients who will benefit from rehab go to SNFs because the length of stay is longer. Many of them get close to 90 minutes of therapy but at a much slower pace. As with everything else, there are good SNFs and bad SNFs. The trick is figuring out which is which. I've worked at SNFs. Patients wear their own clothes. They aren't allowed to lie in bed. Help is available for ADLs if needed. Some have better equipment than I have.

In some ways, my unit has become the unit of last resort. We accept patients with and without funding. As a result, we admit many patients who have no other option. If they don't come to this unit, they will get no therapy at all. That policy leads to an increase in inappropriate admissions. That sort of defeats the purpose of the unit. It would be one thing if this was an infrequent occurrence. At any given time, we usually have at least one of those on the unit. I wouldn't be surprised to learn we're not the only ones with this problem.

I love my stroke patients so I'm not going anywhere. My boss would probably be very relieved to read that. That doesn't mean I like what is happening to my unit.


As a student I remember the check off list of services provided. We checked off what we did and turned it in w/o written justification and letters of reference from everyone involved. Problem was not every therapist was honest.  

You are right the SNF's are the new rehab unit and not every SNF is prepared for this.  We often lack appropriate equipment to deliver services and are pressed for time with the MDS and capturing appropriate minutes for the patient. Group therapy is often the norm for efficiency sake due to a decrease in reimbursements from insurances.

Jason Marketti January 5, 2011 11:35 PM

I remember when the shift from medical facility to business could no longer be denied.  And as you point out so well, the patients are the biggest losers.  Pretty sad when the people who fund the business are the ones consistently getting the short end of the stick.

Jane Goude January 4, 2011 10:29 PM

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