Hospital Medicine

Physical Therapy and Occupational Therapy

I. Problem/Challenge

Physical Therapy and Occupational Therapy

The goal of physical and occupational rehabilitation is to restore health, physical function and improve activity limitations caused by illness or injury to achieve maximal functional independence.

Rehabilitation programs and strategies use a multidisciplinary approach that is provided by various health care professionals and specialists.

Physical therapy (PT) involves the evaluation and treatment of neuromuscular disorders through structured activity and exercises that focus on mobility, transfers, balance, posture, gait, leg flexibility, muscle strengthening and pain reduction.

Occupational therapy (OT) involves the evaluation and treatment of neuromuscular disorders through structured activity and training focused on activities of daily living (such as feeding, grooming, cooking, dressing, bathing), increase arm strength and hand dexterity, and improve cognition, decision-making, abstract-reasoning, problem-solving, and perceptual skills, as well as memory, sequencing, and coordination.

II. Identify the Goal Behavior.

Rehabilitation in the Hospital Setting

A. Orthopedic and Surgical patients - All orthopedic patients and most surgical patients need rehabilitation post operatively.

  • Physical therapists are consulted to assess degree or range of motion and function of surgically repaired site.

  • Pain assessment and management is addressed by orthopedic team to maximize physical rehabilitation.

  • Occupational therapists are consulted to help with achieving activities of daily living and maximum movement and comfort at home and workplace environment.

  • Therapists assist the patient to build strength to complete tasks independently.

  • Patients continue therapy in the hospital, subacute care facilities, at home or out-patient basis.

B. Intensive Care Unit (ICU) patients

  • Critical care weakness is a recognized complication that affects the recovery and return to former functional status of patients surviving multi-organ failure in the ICU.

  • Studies have demonstrated that early physical and occupational therapy, including during the period of intubation and ventilator support, can be safely performed and will likely improve patient outcomes with regard to functional status.

  • Early physical therapy among ICU patients was feasible and safe, without any increase in costs, and was associated with decreased ICU and hospital length of stay compared to usual care.

C. Stroke Rehabilitation

  • Acute stroke rehabilitaion is associated with a reduction in the odds of death or dependency and the need for institutionalization. It is not associated with reductions in mortality, functional disability and hospital length of stay.

  • Subacute Stroke rehabiltation is associated with reduction in mortality (especially in the subset of patients with severe stroke) and odds of death or dependency but no improvement in functional outcomes or need for institutionalization.

  • Early and aggressive stroke rehabilitation are associated with better functional outcomes.

D. Cardiac Rehabilitation

  • Cardiac rehabilitation is a secondary prevention and a cardiovascular risk reduction strategy that improves survival. It is a multifaceted and multidisciplinary approach consisting of the following core components: baseline patient assessment; nutritional counseling; risk factor management (lipids, hypertension, weight, diabetes, and smoking); psychosocial management; physical activity counseling; and exercise training.

  • The American Heart Association and the American College of Cardiology Foundation recommend all eligible patients with Acute Coronary Syndrome or those who were post- coronary artery bypass surgery or post- percutaneous coronary intervention, be referred to outpatient cardiac rehabilitation either prior to discharge or on the first follow up visit. Home-based cardiac rehabilitation can be an alternative for a supervised center-based program for low risk patients. Home and hospital-based interventions are similar in their benefits on risk factors, health-related quality of life, death, clinical events and costs.

  • Among Medicare beneficiaries, attending all 36 cardiac rehabilitation sessions was associated with lower risks of death and MI at 4 years compared with attending fewer sessions.

E. Pulmonary Rehabilitation

  • The program aims to improve respiratory function and decrease symptoms through exercise regimens, breathing training, relaxation techniques, nutrition counseling, medication management and emotional support.

  • It has been used primarily for patients with Chronic Obstructive Pulmonary Disease (COPD) and applied successfully to other chronic pulmonary conditions such as Interstital Lung Disease, Cystic Fibrosis, Bronchiectasis and thoracic cage abnormalities.

  • It is highly effective and safe intervention that reduces hospital admissions, improves quality of life and decreases mortality among COPD patients with recent exacerbations.

  • Home based pulmonary rehabilitation among COPD patients is useful and non-inferior to outpatient rehabilitation.

  • There is insufficient evidence to determine whether pulmonary rehabilitation improves long term survival among patients with COPD. Longer programs (beyond 12 weeks) produce greater sustained benefits than shorter programs.

III. Describe a Step-by-Step approach/method to this problem.

Acute Care Rehabilitation

Key points of inpatient rehabilitation coverage policy by the Center for Medicare and Medicaid Services (CMS) in the Medicare Benefit Policy Manual Chapter 1 (Rev-119) (https://www.cms.gov/manuals/Downloads/bp102c01.pdf) are as follows:

  • Pre-admssion screening is required within 48 hours prior to admission to the inpatient rehabilitation facility (IRF) by a certified licensed rehabilitation physician. It must comprehensively document the specific reasons why the IRF admission is reasonable and necessary; the condition that caused the need for rehabilitation, the patient's prior level of function, the expected level of improvement, and the expected length of time to achieve the improvement. It also must include an evaluation of possible risk for complications, the treatment plan, and the expected discharge destination and post-discharge treatment. "Trial admissions" are no longer acceptable. Physician extenders may do the screening but the rehab physician must concur.

  • Post- admission physician evaluation is required within 24 hours of admission to compare it with the pre-admission screening. It must identify any relevant changes that may have occurred since the pre-admission screening in order to ensure continuity of rehabilitation care. CMS has specific guidelines if the patient can continue IRF or discharged to another level of care if discrepancies are found.

  • Individualized overall plan of care must be completed within 4 days of admission, outlining the patient's medical progress, anticipated interventions, functional outcomes and expected discharge destination.

  • Admissions orders must be documented by the physician upon admission.

  • IRF Patient Assessment Instrument is required in the patient's medical record.

  • The following IRF medical necessity criteria must be met: (1) the patient must be scheduled to receive multiple rehabilitation services, of which one must be PT or OT; (2) the patient must be able to participate in 3 hours of therapy per day at least 5 days per week or 15 hours of intensive services over a 7-consecutive day period; (3) the patient must be able to actively participate in and benefit from the plan of care; (4) the patient must have a documented face to face encounter with the rehab physician at least 3 days per week in order to modify and maximize patient's course of treatment.

  • The following health health professionals must actively participate in patient care and have a weekly team meeting: (1) rehab physician; (2) specialized rehab registered nurse; (3) a social worker or case manager; (4) a licensed or certified therapist from each rehab discipline.

  • The intensity level and services provided must be documented in the patient's chart.

  • Discharge planning and patient's functional improvement must be documented. Achieving independence and total self- care is not necessary for continued IRF services.

Examples of conditions that require acute inpatient rehabilitation include, but are not limited to, are stroke, brain and spinal cord injuries, amputations, major multiple trauma, burns, major joint replacement and severe polyarthritis.

Sub-acute Care Rehabilitation

Sub-acute care rehabilitation entails a short-term, goal oriented treatment and transition plan with more hours of skilled care than normally provided for long term care patients in Skilled Nursing Facilities. Patients have serious illness or injury but are recovering and they no longer require acute inpatient care, after a 3-day qualifying hospitalization. Sub-acute rehabilitation care guidelines are found in the Medicare Benefit Policy Manual Chapter 8 (Rev 89) (https://www.cms.gov/manuals/Downloads/bp102c08.pdf):

  • The services must be reasonable and necessary or the treatment of the patient's illness or injury.

  • Patients require more intensive therapy interventions requiring > 2 hours of rehabilitation services per day (OT/PT/Speech Pathology etc) at least 6 days per week. Patient must be physically and cognitively willing and able to participate in and benefit from the rehab program.

  • Patient requires complex medical and nursing care as outlined below:

    • Central Lines - administration of total or peripheral parenteral nutrition, PPN, fluids, or medication via central access.

    • Pain Management - complex monitoring and frequent titration of pain medications of patients with uncontrolled pain.

    • Parenteral Fluids/Medications - administration of 2 or more different intramuscular or intravenous meds on a daily basis and monitoring of lab values or medication levels.

    • Respiratory care - Chest PT and or nebulizer therapy more than 3 times per day; monitoring of oxygen saturation and titration of oxygen requirements, or ventilator management (in special SNF).

    • Wound care - including decubitus ulcers, complex cases requiring aseptic technique, packing, debridement, irrigation, wound vacuum management, frequent evaluations for infectious or vascular compromise.

  • Medical assessment, evaluation and weekly progress by a rehab physician or physician extender must be documented in the medical record.

  • Custodial care is not covered. Examples include administration of routine oral medications, general care of ostomies, urinary catheters, dressing changes for chronic skin conditions, assistance with activities of daily living, personal hygiene, turning and positioning and incontinence care.

IV. Common Pitfalls.

N/A

V. National Standards, Core Indicators and Quality Measures.

N/A

VI. What's the evidence?

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