Neurotrauma day program appeals to payers

Duration, intensity depend on needs, benefits

A neurotrauma day treatment program that’s custom-tailored to patients’ needs and insurance benefits has gained the support of payers who like the flexibility in duration and intensity the program offers.

"We are successful in getting treatment approved and have gained the respect of the payers because we aren’t trying to soak the system," explains Barb Wasilk, MA, CCC/SLP-L, program supervisor of Centegra Health System’s neurotrauma day treatment program in Crystal Lake, IL.

Flexibility is key to the program. Patients may come to the center anywhere from two days a week to five days a week, depending on their needs. Treatment lasts from three hours to six hours a day. The staff negotiate with payers for a per diem rate or an hourly rate, depending on which will be the most cost-effective for the patient.

Lengths of stay have ranged from two weeks to nine months. Most patients stay in the program from three to six months, depending on their goals, severity, and progress.

The case managers work closely with insurance companies and have accomplished "amazing things" in getting patients with limited benefits the treatment they need, she adds.

Patients are referred to the center as soon as a week after injury. At most, they start treatment several months post-injury. Referrals come from physicians, individuals, social service agencies, inpatient rehab providers, home health, families, and friends.

When patients are referred to the program, a case manager determines if they meet admission criteria and investigates funding sources.

Patients are evaluated by all members of the team who will provide care. The team tallies the number of hours of treatment, and from that determines how many days a week and how many hours a patient will come to the center. (For more on how the team functions, see story, above.)

The staff work to minimize the cost to insurers and provide only the treatment deemed necessary, even when a payer approves more.

For instance, one patient was referred by a workers’ compensation insurer willing to pay for five days a week of therapy, but the staff didn’t think it was necessary and created a less-intensive program. In a short time, the patient was able to go back to the same job in the same company for 20 hours a week and begin transitioning back to full time, Wasilk says.

The idea of the program began several years ago when Wasilk was a speech therapist in a hospital outpatient program.

"We were getting outpatients who needed more than we had to offer. We started talking about it internally and brought in agencies and family members to discuss the feasibility of setting up a day program," she says.

A feasibility study showed that a significant number of patients were being discharged from inpatient rehab to nursing homes. Most patients could have gone home but had family members who worked and couldn’t afford day care in the home, Wasilk says.

Since the neurotrauma day treatment program opened in November 1995, the number of patients discharged to nursing homes has dropped significantly, she says.

"We are not a day care center. The families still have to take the responsibility of doing things, but we help get them more independent so it gets easier at home," Wasilk says.

The neurotrauma day program provides a transdisciplinary treatment approach to patients with brain injury, stroke, or other neurological impairments. Treatment is based on each patient’s individual goals. For instance, if the patient wants to get back to work, the staff collaborate with the employers to make that happen as soon as possible. The center has succeeded in returning patients to executive positions, a teaching position, a grocery store clerk’s position, a job as a car wash worker, and back to school.

The program typically takes patients ages 18 and older, but the staff will make an exception for young patients if they think the patients can be helped by the program’s services, Wasilk says.

Wearing many hats

Many program staff fill dual roles. For instance, Wasilk, who directs the program, also functions as a speech pathologist. One case manager is the rehab nurse; the other is the vocational counselor for the program.

The comprehensive treatment team also includes a physiatrist, physical therapists, occupational therapists, a social worker, a recreation therapist, a rehab tech, a rehabilitation psychologist, other speech pathologists, a secretary, and van drivers.

The program is located in the community with easy access to shopping, dining, and parks. The treatment plan concentrates on taking patients on outings to help them learn to function in the community.

For instance, one woman’s goal was to be able to walk in her favorite department store. Much of her therapy took place in the aisles of that store.

"This worked out better than having her ambulate in another setting. Just because a patient with a brain injury can walk 1,000 feet in a hospital setting, they aren’t necessarily safe in the community. When you bring them into the community setting, you can work on attention problems, maneuvering around obstacles, and safety issues," Wasilk says.

By the same token, writing a check in the therapy room isn’t the same as writing it in the grocery store line when there are people waiting, she adds.