As a physiatrist who works on an inpatient rehabilitation unit, I strive to admit patients as soon as they are medically stable and ready to benefit from our intensive therapy program. Early initiation of rehabilitation is beneficial for a wide range of disabling illnesses and injuries, and I recognize that there is tremendous pressure on physicians to discharge their hospitalized patients in a timely fashion.
Here are some of the most common reasons I have observed for delays in admission and some tips on how to avoid them.
1. No documentation of functional status
For most patients in need of inpatient rehabilitation following a hospitalization, we will need to document a change in functional status, generally a decline, in order to justify such an intensive rehab program. This entails obtaining history regarding the patient’s premorbid functional status with regards to their mobility and ability to perform their activities of daily living (ADLs), as well as an assessment of their current status. Physical, occupational, and speech therapy evaluations are very helpful in determining a patient’s current functional status, activity tolerance, and rehabilitation potential. When possible, they should be obtained prior to referral to an inpatient rehabilitation facility (IRF).
Few IRFs will accept a patient without a physical therapy (PT) evaluation. Therefore, it is essential to consult PT as soon as you identify a patient as possibly requiring inpatient rehab.
If there is a delay in your ability to obtain an occupational therapy evaluation for your patient, any member of the healthcare team can assess some basic self-care skills. For example, you can observe a patient attempt to put on a pair of slipper socks or feed themselves. If they are unable to do the task independently, document that assistance was required. Additionally, the nursing staff can document how much assistance, if any, the patient requires with toileting and if he/she is incontinent.
Speech and language pathology (SLP) evaluations are very helpful in assessing patients with impairments in cognition, speech, communication, and/or swallowing. If dysphagia is suspected, it is important that the SLP evaluation occur prior to admission to rehabilitation to ensure the patient receives the most appropriate diet in order to minimize the risk of aspiration. Other impairments commonly treated by SLP can be documented by other members of the health care team in order to help justify an inpatient rehab stay.
2. Missing documentation of the conditions that may necessitate or complicate rehabilitation
Patients admitted to an inpatient rehabilitation facility must require ongoing management by a rehabilitation physician. In order to justify this level of care, it should be clear for which conditions a patient requires ongoing care. A patient who has had a stroke, for example, may require management of hypertension, diabetes, spasticity, and/or afib. It can help expedite approval by insurance reviewers and rehabilitation admissions liaisons when these medical conditions are clearly spelled out.
It is also helpful when other conditions that may complicate someone’s rehabilitation are elucidated in the medical record. I frequently see no mention of conditions like prior stroke with residual deficits nor history of neuropathy in the charts I review, though such issues may make such intensive therapies more necessary after a new illness or injury. It is often easier to get insurance authorization for cases that seem more complex from a rehabilitation standpoint.
3. Patient is on medications that cannot be provided on rehab
Most rehabilitation units are unable to provide IV medications with the exception of antibiotics. They are unable to accept patients who continue to require IV pain medications or antihypertensives. By promptly transitioning patients to oral medications once medically appropriate, you may help prevent delays in their acceptance to IRFs.
4. Progress note cut and paste errors
Inpatient rehabilitation facilities must ensure that a patient is medically stable prior to admission. As such, admissions liaisons and rehabilitation physicians must review records prior to accepting a patient.
I’ll often start with the latest progress note. If anything on it suggests that the patient is not medically appropriate for admission, I stop there and inform my colleagues in the admissions office that the patient is not yet ready. On occasion, I have delayed admission because information in the chart was not updated appropriately by the referring team. For example, I’ve read notes that have incorrectly indicated a patient was still on pressors or mechanical ventilation when those interventions were discontinued several days prior.
If you are making a referral to a rehabilitation facility, it behooves you to make sure your most recent progress note is up to date. If you work with a resident or another practitioner, it’s a good idea to ensure they are not blindly cutting and pasting old information into their notes.
5. Referral was made just prior to a weekend or holiday
Patients with private insurance will need prior authorization for inpatient rehabilitation before they can be admitted, and it may not be possible to get authorization after 5 p.m. on a Friday or on a federal holiday. If you suspect a patient may be ready for admission on a weekend or holiday, making the referral early and letting the admissions team know when you believe the patient will be ready enables them to initiate the authorization process. In doing so, this may help prevent delays in admission to rehab.
Lauren T. Shapiro, MD, MPH is an Assistant Professor of Clinical Physical Medicine and Rehabilitation at the University of Miami. She is board-certified in PM&R and Brain Injury Medicine. She is also a 2017–2018 Doximity Fellow.