VCU Physical Medicine and Rehabilitation

Guide to Rehabilitation Services

Introduction: This guide was designed to assist medical staff to better understand the rehabilitation process. This increased understanding will allow for better overall care and more efficient access to services for patients. 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.

The following individuals were responsible for developing this guide:

A – Glossary

• Impairment: Any physical deficit or dysfunction (e.g., arm or leg weakness, an amputation).
• Disability: Any limitation in a person’s functional abilities (e.g., inability to walk, incontinence). 
• Handicap: A limitation in vocational or community activity brought about by an environmental barrier (e.g., inability to work because job site isn’t accessible).
• Durable Medical Equipment (DME): Physical Therapy (PT): Structured activity focused on mobility skills (bed, transfers, wheelchair use, walking), 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 ADL’s.
• 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.
• Restorative Nursing (NRS): Replication of activities initiated by PT, OT, and SLP performed by nursing staff (range of motion, dressing, hygiene, walking, feeding, etc.).
• Personal Care Services: Non-skilled assistance (i.e., bathing, dressing, light housework) 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 two 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 (around $35). 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 a 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 care, equipment, custodial and skilled nursing home care, home personal care services, and medications (a co-pay is usually needed for medications). All Medicaid in Virginia is managed care (as of 4/99).

B – Determining rehabilitation needs

Acute care rehabilitation

• Definition: Moderate intensity (0.5-1.5 hours a day, five to seven days a week of one or more therapy types), multidisciplinary services performed in an acute care hospital.
• Criteria: Any acutely hospitalized individual who has a new disability (or an exacerbation of an exiting one) is appropriate for acute rehabilitation 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 allows for these services, and while their availability is required by JCAHO standards, they do not generate additional revenues for the hospital (they are included in the “package price”).

Outpatient rehabilitation

• Definition: Moderate intensity (0.5-2 hours a day, three days a week of one 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: 1) have an acute disability or physical complaint (e.g., back pain), 2) medical or surgical conditions allow them to return home and be transported to/from therapy, 3) demonstrate the ability to participate and make progress in therapies, 4) acceptance of fiscal responsibility by the insurer and/or patient. Individuals who are not “home bound” must receive this type of therapy after hospital discharge.
• Funding: Most insurers provide for outpatient therapy services, however pre-certication is usually required and there are specific limits on the duration of services. Medicare (Part B) has a $1,500/year cap on outpatient PT/OT services. Charges are typically $75-150/hr.

Day rehabilitation services

• Definition: Day Rehabilitation: Intensive (at least three hours a day, five days a week of at least two different types of therapy), interdisciplinary services performed in a discrete location, often adjacent to an inpatient rehabilitation unit (e.g., HealthSouth Rehabilitation Hospital of Virginia). Transportation to and from the services is provided. 
• Criteria: Individuals who meet all the following criteria are appropriate for inpatient rehabilitation: 1) have an acute disability that does not prevent them from returning home with family care, 2) medical or surgical conditions are sufficiently stable to allow participation in therapies and return home, 3) demonstrate the ability to participate in at least one hour of therapy two times a day, 4) demonstrate the ability to make progress in acute care therapies, 5) have a social support system that will allow them to remain at home despite their disability, and 6) receive 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 (unmanaged). Charges are $400-600/day.

Home health rehabilitation

• Definition: Low intensity (0.5-1 hours/day, three days a week of one or more therapy types). Multidisciplinary services performed at the patient’s home.
• Criteria: Individuals who are considered “home bound” (do not leave home, except for medical visits) and meet the following criteria are eligible: 1) have an acute disability, 2) medical or surgical stability that allows them to return home safely, 3) demonstrate the ability to participate and progress with therapy, 4) acceptance of fiscal responsibility by insurer and patient.
• Funding: Most insurers have home health benefits, however pre-certification is usually needed and there is a cap on total visits. Charges are $75-150/hour.
  
  Medicaid Home Health annual (July 1- June 30) visit limits:  
  RN = 32
  PT = 24
  OT = 24
  SLP = 24
  HHA= 32
  *If services beyond these limitations are ordered by the physician, the provider has to request authorization from DMAS before providing such services.

InPatient rehabilitation services

• Definition: Intensive (at least three hours a day, five to seven days a week of at least two different types of therapy), interdisciplinary services performed on a discrete, licensed unit either within a hospital (e.g., the Rehabilitation and Research Center at MCV Hospital) or free-standing (e.g., HealthSouth Rehabilitation Hospital of Virginia).
• Criteria: Individuals who meet all the following criteria are appropriate for inpatient rehabilitation: 1) have an acute disability that prevents them from returning home with family care, 2) medical or surgical conditions are sufficiently stable to allow participation in therapies, 3) demonstrate the ability to participate in at least one hour of therapy two times a day, 4) demonstrate the ability to make progress in acute care therapies, 5) have a social support system that will allow them to return home after reasonable improvement of function, and 6) 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 (unmanaged). Charges are $750-1500/day.

Skilled nursing facility (SNF or “Subacute Services”)

• Definition: Low to moderate intensity (.5-2.0 hours a day, five to seven days a week of one or more therapy types), interdisciplinary services performed on a discrete unit, either within a rehabilitation unit (e.g., the Rehabilitation and Research Center at MCV Hospital), an acute care hospital, 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: 1) have an acute disability, 2) have medical or surgical conditions that may not be sufficiently stable to allow full participation in therapies, but do not require inpatient hospitalization, 3) demonstrate the ability to participate in at least one hour of therapy a day, 4) acceptance of fiscal responsibility by insurer and/or patient insurer.
• Funding: Most insurers have subacute rehabilitation benefits within a nursing home (“skilled nursing facility” or “SNF”), including non-managed care Medicaid (no limit on length of stay as long as progress occurs every two to three weeks), non-managed care Medicare Part A (100 days coverage for each new disability as long as progress occurs every two to three weeks), 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 poor. Charges range from $120-400/day (NH-based SNF) to $450-750/day (hospital or rehabilitation unit-based services).

C – Access to Rehabilitation

Acute rehabilitation (target turn-around: 12 hours)

1. Ask Resident Physician to place an order for the appropriate therapy type (PT, OT, SLP)

Outpatient rehabilitation (target turn-around: 24 hours)

1. Patient must meet rehabilitation criteria, therefore they must be receiving acute care therapy (to document participation and progress).
2. Patient must meet funding criteria and obtain pre-certification (ask acute care social worker to perform).
   
3. Resident physician writes outpatient prescription for appropriate therapy (e.g., Outpatient Physical Therapy 3x/week for four weeks for transfer and gait training for diagnosis of stroke).
   
4. Social Worker provides patient/family with location choices/phone numbers for therapy.

Day rehabilitation (target turn-around: 12 hours)

1. Patient must meet rehabilitation criteria, therefore they must be receiving acute care therapy (to document participation and progress).
2. Patient must meet funding criteria and obtain pre-certification (ask acute care social worker to perform).
3. Consult Rehabilitation Medicine Service (Resident pager 828-7566 or Dr. Cifu 755-0326) to evaluate patient and make referral.
4. Social worker provides patient/family with location choices/phone numbers for therapy.

Home health rehabilitation (target turn-around: 48 hours)

1. Patient must meet rehabilitation criteria therefore they must be receiving acute care therapy (to document participation and progress).
2. Patient must be “home bound”.
3. Patient must meet funding criteria and obtain pre-certification (ask “referral certification nurse” to obtain – 828-2273 [VCU-CARE]).

Inpatient rehabilitation (target turn-around: 24 hours)

1. Patient meets rehabilitation criteria, therefore they must be receiving acute care therapy (to document participation and progress).
2. Consult Rehabilitation Medicine Service (Resident Pager 828-7566 or Dr. Cifu 755-0326) to evaluate patient and make referral.

Skilled nursing facility (target turn-around: 48 hours)

1. Patient meets rehabilitation criteria, therefore they must be receiving acute care therapy (to document participation and progress).
2. Resident Physician speaks with patient/family about the need for SNF services and the often limited bed availability.
3. Consult Rehabilitation Medicine Service (Resident pager 828-7566 or Dr. Cifu 755-0326) to evaluate patient and make referral.
4. Consult Beth Herndon-Schnitzer, R.N., for patient with complex issues/needs at pager #4568.