Recently at my practice area (acute hospital), management made the decision to deny us the ability to make recomendations for SNF vs. Inpatient, stating that instead we must defer to the physiatry consult. Only when a patient is deemed by physiatry then we are allowed to make 'clarifications' as to their needs for inpatient rehab. It has been suspected that this recent change by administration is geared towards pressuring physiatry to fill beds at our acute rehab setting here in the hospital. In the past, we have had many disagreements (OT + PT together) about the appropriateness of patients refered to our own inpatient rehab, and the worry is that this move is to deny us the documentation we feel is needed to refer patients to SNFs who are not appropriate for an acute rehab intensity or disposition.
In short, is this legal? It certainly does not seem ethical.
One thing we have done at the request of the IPR is to recommend a skilled therapy setting ,and that could be SNF or IPR and then let all the players decide. There are too many variables. Insurance, proper discharge plan after rehab, family and patient preference and yes, The IPR is a business and does need to fill the beds and will accept more marginal patients when there are empty beds in IPR and be more selective when beds are few in the IPR> Don't try to "figure it out" because it changes and that will drive you nuts.
It is less stressful for us to just let them decide.
The 4 questions 1) Is this a NEW diagnosis that fits the criteria needed for an iPR admit and is their CURRENT function less than baseline and expected to improve? 2) do they need INTENSIVE, 3+ hours per day multi-disciplined care with medical oversight? 3) Are they MOTIVATED to participate in the intense schedule ? 4) at the end of a typical 2 week stay will they be at the level needed to discharge ? for instance if they are now max A and usually can be expected to advance one FIM level in a short rehab stay- will there be the support in place to provide MOD A for them? If not - they might need SNF first THEN IPR> If yes, maybe they can do IPR. they are always a bit more cautious if the patient lives alone. And rightly so.
I document PLOF-current function-tolerance-motiviation- support system in place after rehab and let them make the decision, it actually works out better that way, less stressful, and the doctors trust my judgement and ask me personally if they want a nay or yay vote from me.
If they accept a patient that I feel would have done better at the slower paced SNF, and they struggle through working with a weak or unmotivated patient I try not to say "I told you so". ah well. Nobodys perfect -- right? ;-)
If the patient or family asks me my two cents worth I always preface it with "I'm only a therapist, but I'll give you my two cents. Neither one is "good" or "bad" they both have good points, it just depends what you want. If you want to work really hard and bust your buns to get home quicker, consider IPR or "boot camp". If you want a slower, more relaxed pace, or want the option to stay longer if you need to before going home, consider the SNF (which we call the "rehab center" these days not the "nursing home' of your grandmothers era. Plenty of younger people with elective surgeries do their rehab at SNF- so we do not call them nursing homes any more. that usually is a good enough explanation for most folks.
I work in an acute care hospital with an inpatient rehab unit. Our therapists have been coached to indicate need for continued OT or rehab at d/c, though to not specify setting until that is certain. This is done in part as a safeguard for the inpatient rehab unit. In the event of an audit, we want therapy notes to support the need for an inpatient rehab stay. An auditor could potentially raise a red flag if we admitted a patient to rehab when therapy notes recommend d/c to SNF.
There is also benefit for the patient, family members and other staff. You may be aware of the numerous and ever-growing criteria for inpatient rehab. Patients who are clinically appropriate may not meet regulatory criteria. We want to ensure that everyone involved in the patient's care, including the patient and family, receive a consistent message. The general message would be that the patient will need rehab after d/c from the acute hospital, though the setting has not been confirmed. Those who know of the intricacies of admission to inpatient rehab educate the patient and family of the process.
I understand the need and desire for wanting to keep a rehab unit full. Because of the shared-payment system, our facility is not likely to admit a patient to rehab who will not d/c to a community based setting.