It was a chilly but jam-packed four days in San Antonio last week, where many of my fellow physiatrists and I attended the Annual Assembly of the American Academy of Physical Medicine and Rehabilitation (AAPMR). As always, it was great to learn from experts in our field and to reunite with friends and colleagues. I also thoroughly enjoyed checking out the latest equipment hitting the market that may aid in our patients’ rehabilitation.
Among the highlights of the conference for me was the opportunity to meet with other inpatient rehabilitation doctors from across the country who attended the inaugural meeting of the newly formed inpatient rehabilitation member community. It was a small but diverse group of physiatrists from across the country who primarily practice in inpatient rehabilitation facilities (IRFs). Although our practices differ in size, organization, and location, we shared a number of the same concerns and issues, which centered around the following themes.
How Do We Balance Rehabilitation and Increasing Medical Acuity?
There was consensus that the patients admitted to IRFs seem to have ever-increasing medical acuity. We noted that there is often considerable pressure from referring acute care facilities to accept patients before they are able to optimally benefit from the intensive therapies. Many of us, unfortunately, feel like we spend far more time on medical stabilization of our patients than we do otherwise fostering their functional recovery.
Another related concern is the potential trade-off in skills expected of our rehabilitation nurses and therapy staff. As we prepare them to care for higher medical acuity patients, does the education we now have to provide regarding medical-surgical care take away from the time spent on essential rehabilitation training? We also shared strategies we are using to provide such training to the IRF staff. I was thoroughly impressed by one physiatrist in attendance who reported doing in-services at 2 a.m. for the night staff on his rehab unit.
How Can We Ensure We Can Serve Those Patients That Most Need Us?
A major challenge for many in the group lies in complying with the 60% rule, especially in light of the many extremely medically-complex patients that cannot be properly cared for in less intensive rehabilitation settings, but who often do not have one of the 13 qualifying conditions. Patients with cancer, transplants, and advanced heart failure requiring ventricular assist devices pose particular challenges.
Some also voiced difficulty admitting patients to IRF who remained under observation status in acute care. They reported increasing usage of this status for complex patients at their referring hospitals that one would expect may require intensive rehabilitation before going home.
What Are the Optimal Ways to Staff Our Rehab Units?
I was fascinated to hear from colleagues running inpatient rehabilitation units as the sole rehabilitation doctor in rural areas, and so impressed with their commitment to providing access to care in the less populated parts of our country. They discussed some of the challenges in such settings, including the need to complete regulatory documentation on their patients every weekend and holiday, when other colleagues who are not “rehabilitation physicians” help provide medical coverage.
We discussed some pros and cons of IRF staffing models in which the rehabilitation physician serves as a consultant, with an internist/hospitalist acting as the primary service. This can be particularly attractive for solo rehabilitation physicians, but comes with the aforementioned challenge.
How Do We Measure Functional Improvement?
Some at the meeting expressed concerns with how functional improvement in our patients would be assessed and reported following the recent removal of the FIMTM instrument from the IRF-Patient Assessment Instrument. While data continues to be submitted on mobility and self-care domains, there is no reported measure regarding cognitive status on discharge. This is a particular concern of mine as well, as my inpatient service is mostly comprised of patients recovering from traumatic brain injuries and strokes. I hope we can continue to show the substantial benefit of inpatient rehabilitation when it comes to improving cognitive and communication outcomes.
I am looking forward to meeting with this group again at next year’s Assembly in San Diego!
Lauren T. Shapiro, MD, MPH is an Assistant Professor in the Department of Physical Medicine and Rehabilitation at the University of Miami Miller School of Medicine. She is board-certified in PM&R and Brain Injury Medicine. She previously served as a Doximity Fellow (2017-2018).
Illustration by Jennifer Bogartz