Caring for a stroke patient on the acute care side has been a focus at many hospitals, both large and small. In fact, in response to the demand for quality care, hospitals across the country have successfully established stroke centers of excellence within their hospital walls, achieving the designation of a primary stroke center.
However, a patient’s recovery post-stroke isn’t as clear cut when it comes to where (which rehab setting or facility) the stroke patient should be cared for in order to return to the highest level of independent living.
Considering the latest increase in stroke incidence, especially among younger adult COVID-19 positive patients, we felt additional details and steps around improving outcomes in stroke recovery should be further reviewed.
It’s Hard When the Access to Timely and Factual Information is Delayed
The reality is, post-acute stroke treatment and care options are often overwhelming for the patient and family, and frustratingly difficult for the physician and medical team to access.
Surprised? I’m not.
As a healthcare leader with 35 years’ experience including ER/ICU nursing as my primary clinical background, I find myself (at least once a week) in a conversation with a physician who tells me there’s still a great deal of confusion across medical disciplines regarding the different types of post-acute rehab programs and parallel levels of care. Therefore, it is often difficult for physicians to make confident, “best” recommendations to families regarding stroke rehab programs.
Added Frustration: Fighting Denials
Adding more aggravation to the situation for physicians is the high incidence of fighting Medicare Advantage denials on pre-authorization. One of the additional downsides to physicians and the clinical team when it comes to choosing and recommending “appropriate” post-acute patient rehabilitation placement is the time burden.
Seema Verma, Administrator of the Centers for Medicare & Medicaid Services has stated that “patients are frustrated, and doctors are sick of the pointlessly wrangling with insurance companies.” Verma confirmed that the agency (CMS) would be making prior authorization changes this year and noted automation as a possible solution.
While these changes may provide some good news, those same physicians who I spoke with also acknowledge that they often face yet another dilemma when it comes to making the “best” recommendation for rehabilitation placement. On the surface, choosing a path of least resistance and selecting the facilities ‘known’ to the physician remove obstacles to rehab care and also reduce time burden for all.
However, hundreds, if not thousands of recovering stroke patients a year end up in a less than optimal rehab program and do not receive the care they need, deserve, or could have otherwise received. These choices sadly can result in less than favorable outcomes and loss of opportunity to regain function.
Navigating Post -Acute Care for Stoke Patients
Is post-acute care really that complex? And if so, what is causing the confusion?
It is my hope that this post can serve as a helpful guide to physicians in selecting the best rehabilitation program option for your stroke patients. Let’s begin with a clarification of the various post-acute options. For a comprehensive overview, take a look at our previous blog post, Access to Care: Steps for Senior Citizens where we detail post-acute options and their levels of care.
For the purpose of this discussion we will comparing and contrasting two post-acute care rehab program and facility options:
1. Skilled Nursing Facilities (SNFs), which are licensed as a long-term care facilities and
2. Inpatient Rehabilitation Facilities (IRFs) which are licensed as acute care hospitals
Improved Outcomes, Including Physical Mobility and Potentially Less Readmissions in IRFs
Recent JAMA studies showed that there was substantial improvement of physical mobility and self-care and well as the potential for less occurrence of readmissions in an IRF versus a SNF (reminder that SNF may be part of a larger facility which include other levels of sub-acute care commonly called nursing homes, swing beds, etc.).
The improved outcome at an IRF could mean the difference between the patient returning to a greater level of independence or potential risk of hospital readmission or move to a situation requiring longer term assistance or possibly even readmission to the hospital. The pre-admission screening, process, its intensity and quality of therapy, and the specialized physician access add to the complexity and differences in an IRF.
In addition, it should be noted that Patient Driven Performance Measurement (PDPM) which started Oct. 2019, provided changes to the reimbursement at a SNF that would be based on functional outcomes rather than therapy minutes in consideration of all co-morbidities and the complexity of co-morbidity. These changes will further solidify the differences and potential placement between a SNF and an IRF and facilitate a greater trend of focus on value of the services, i.e. outcome of the patient versus volume of services given.
Stroke Recovery is very Complex
A number of factors must be considered for a stroke patient placement since stroke is one of the most complex neurological conditions affecting multiple body systems and requiring coordinated intensive therapy from several disciplines of physical therapy (PT), occupational therapy (OT) and speech therapy.
The following chart highlights the most significant differences that can help in choosing the best site of care for your stroke patient:
What accounts for this documented advantage of an IRF over an SNF for rehabilitative care?
The significance for stroke patients would be the:
frequent assessment by a physician and care team to evaluate the progress and goal towards outcomes with modification to make medical and functional plans.
Specialized rehab nurse availability is a focus in an IRF in addition to a higher nurse per patient ratio resulting in higher intensity of specialized care per patient.
The more advanced technology available typically in an IRF can have significant impact on the ability to modify therapy and achieve desired outcomes. For stroke patients, technologies with computerized touch screen technologies both challenge and motivate patients through visual motor activities but these technologies also facilitate greater collaboration across the therapists and physicians allowing them to with the ability to document assessments, progress, and outcomes.
Important Note: Patients who aren’t able to communicate and undergo this level of intense therapy would not meet the admission criteria for an IRF and would be better suited for a SNF.
The Facts Make it Clear: Inpatient Rehabilitation is the rehabilitation of choice.
The significance of these therapy requirements, the multi-disciplinary therapy team model led by a Physiatrist and greater access to technologies all result in a higher incidence of the stroke patient returning to home and functioning at a higher level of daily living and reduced readmissions.
The Take Away An Inpatient Rehabilitation Facility (IRF) provides the necessary intensive rehabilitation to complex stroke patients who require specialized care.