Day rehab fills gap between inpatient, outpatient care

Patients receive 16-24 hours of therapy per week

Rehab facilities can fill a much-needed and reimbursable niche by providing a special rehab day treatment program for patients discharged from an inpatient setting but not ready for outpatient treatment.

HealthSouth of Birmingham, AL, decided to start this kind of program after noting a trend in which patients were being discharged from rehab hospitals with nowhere to go. Home health agencies and skilled nursing facilities once might have provided therapy services to those patients, but now they no longer have financial incentives to admit them, says Lisa Combs, RN, case manager of outpatient services and program manager of day rehab for HealthSouth Northern Kentucky Rehabilitation Hospital in Edgewood. The 40-bed hospital is a full-service outpatient provider.

"Our corporate offices saw a need for a program like this, given all of the federal Medicare cutbacks," Combs explains.

HealthSouth piloted its day treatment program at the Edgewood hospital, where the average daily census is 15 to 22 patients. The program provides a gentler regimen of therapy than a typical outpatient program provides, and it offers constant supervision. However, it cannot be mistaken for an adult day care center, where the emphasis is on supervision rather than therapy. Patients admitted to a rehab day treatment center might not stay the entire day, and they receive some level of therapy or education throughout their time in the center, even during the rest periods. "We felt we could offer a more consistent and better quality of care with our inpatients if they were discharged and followed through a day rehab center," Combs says.

CARF…The Rehabilitation Accreditation Commission, based in Tucson, AZ, began accrediting adult day programs in July 1999. The day treatment center offers patients a level of care that fits neatly between inpatient and outpatient services, she says. "In an acute rehab facility, patients will undergo therapy anywhere from 40 to 60 hours per week; in home care or an outpatient setting, they may get three to 10 hours per week. But by coming into a day treatment center, they are here for one-half to a full day, and they receive 16 to 24 hours a week of therapy."

Those patients need care and supervision that are more intensive than that offered by traditional outpatient programs, Combs says. Also, while it used to be an option to refer such patients to home health care or a skilled nursing facility, the Balanced Budget Act of 1997 greatly limited that option by cutting reimbursement for patients who had long-term therapy needs.

"Home health agencies and skilled nursing facilities can’t afford to take these patients," Combs says. "We were being turned down with referrals, or the patients were discharged before they were ready for outpatient rehab care."

Another HealthSouth facility, HealthSouth Rehab Hospital of Central Kentucky in Elizabethtown, also has formed a day treatment program that is designed to suit the needs of patients who no longer require inpatient hospitalization and 24-hour nursing care but still have definable therapy needs, says Angela Portman, RN, day treatment coordinator of the 40-bed hospital.

"We look at this as a step down, a gradual process to community re-entry," Portman says. "A lot of patients have had strokes, and we have several traumatic brain injury [TBI] patients who are not safe to be home alone and have need for therapy."

TBI patients are a good example of patients who benefit from a day treatment program, Portman adds. "We’ve had several occasions where a TBI patient reaches the inpatient goal and is ready to be discharged, but to bring the person back as an outpatient would not work."

A TBI patient might come in for an hour of therapy and have to stay at the clinic, unsupervised, waiting for the next therapy session. "Under the day treatment program, they would not be unsupervised," Portman says. "So this is for patients who have safety issues."

Patients typically attend the center three times a week for an average of four weeks, although some have stayed as long as 18 weeks. Once they are discharged, they can be referred to the outpatient setting for a continuation of therapies.

"But most of the time, they’ve gotten all the services they require and they’re discharged completely," Combs says. "We have some patients who graduate from the day treatment center and come back here as volunteers."