The Confusing World Of Rehab: How It Works

One of the learning curves for me as an advocate was the world of rehabilitation.  It is a system that appears to be easy to navigate but is not.  I had to develop a special radar for understanding the dynamics and innuendos of the system.  Mostly, I had to accept that information was not easy to obtain.  It was important to be vigilant about an every changing landscape and maintaining up to date information.

It all starts at the hospital.  Some people get placed to an acute rehab facility after the hospital has medically stabilized but the patient still needs medical supervision.  The time at an acute rehab is completely based on medical stability.  Actual rehab physical, occupational and speech therapy are included depending on the persons ability.  These services are generally stepped up from the hospital.

When the patient is stable in the acute care, the next step is skilled nurse facility also called subacute care.  The majority of short term subacute care facilities a part of nursing homes.  The quality of subacute care facilities vary dramatically.  Because the majority of facilities are Medicare approved, inspection reports are available on and state websites.

The  two issues that cause chaos with patients and families are discharge and insurance.  These are the areas I speak to families about immediately when I become involved.

Discharge can appear on the radar suddenly without any pre warning.  What often happens, is the discharge planner will speak with the patient or family and say, the doctor is going to discharge tomorrow and placement to a subacute will occur as soon as we have a bed or are you ready to take him/her home. Am I exaggerating? Actually, I wish I was.  I have experienced this too many times to count it has become normal for me.

How does this happen?  Poor communication. It is endemic in rehabs.  If information is needed, the patient/family has to push and be vigilant in tracking down the right person.  You have to ask everyday.  I actually don’t think people are trying to hide information, they are just not aware you need  or want it.

I always ask for a case conference with the players: family,medical, nursing, case management and therapies.  It isn’t unusual to get some grumbling about the problem of organizing it but it does get done.  The facilities know it is more of a problem to refuse.  A case conference is the first opportunity to pin down the facilities thoughts on discharge.  In some case, a date is already being tossed around.  It is SO important to be able to look at skilled nursing facilities and give the discharge planner a prioritized list.  Otherwise, the patient will be sent to the first facility that offers a bed with no concern for the needs or concerns of the family.

I recently had a client request a case conference in an acute rehab setting.  The case manager dragged her feet and then she called with a time.  She said everyone would be there.  On the day, the Fellow (medical),and two case managers were there.  The conversation essentially started with we have a tentative date of discharge of  four days to go home.  My client (caregiver) just about came out of her chair.  Not once had the discharge planner asked if the house was safe or ready for someone who had no balance, poor memory and needed supervision and assistance with all activities of daily living.  My client had no idea why discharge was being planned. As an advocate, I was able to shift the date of discharge (was actually not medically ready) and discharge when ready to a skilled nursing facility not home.  Why families are left out of planning is a complete mystery to me.

It is my mantra to tell client’s that the facility is already looking at discharge form the minute you arrive.  It is based on insurance criteria for care.  Medicare and all other insurance follow their lead, is very strict about criteria and discharge.  When you “plateau” in progress, insurances want you gone.

My sage advise is ask for case conferences, ask for daily information updates, asked to be called if there are any changes,and don’t take no for an answer.  All medical information is your right.

I will follow up tomorrow with just the insurance side.  It can be complicated.