Where should rehabilitation take place?
By Dr. Richard Senelick
With no scientific evidence of their efficacy in rehabilitation care, nursing homes were rebranded in the '80s. These "skilled nursing facilities" were simply marketed to meet the economics of managed care and insurance.
Since then, patients with strokes, joint replacements, and a host of disabilities have been shunted to skilled nursing facilities (SNF) to save money. One might believe that the care provided in an SNF is comparable to that of an inpatient rehabilitation hospital; however, you have to ask the questions:
- Does a stroke patient do as well in an SNF as in an Inpatient Rehabilitation Hospital?
- Is that patient as likely to be discharged home and back to the care of loved ones?
The answer to both questions is: "Definitely not!" I don't just say this because I work in an inpatient rehabilitation hospital, but because the medical literature supports this position.
Pam Duncan PhD, a noted researcher, looked at poorer outcomes in patients who went to nursing homes for rehabilitation and determined that the practice of utilizing nursing homes "is now shown to be potentially cost ineffective and detrimental to patient recovery." [PDF] Not just less effective, but detrimental.
The referral decision from the acute care hospital usually represents the first – and last – chance for patients to get the rehabilitation that will lead to maximum recovery. Withholding access to the aggressive level of therapy offered in a rehabilitation hospital creates a self-fulfilling prophecy:
- You didn't think they would get better.
- So you did not give them the intensive therapy needed.
- They confirmed your theory by showing little improvement.
Therapists working at an SNF are doing terrific work and helping many people, but they are constrained by fewer resources and hours. They frequently do not have access to the latest technology. Continued improvement and success in rehabilitation is dependent on the dose (hours) of therapy, performance of functional tasks, and motivating the patient. Skilled nursing facilities typically provide less than half the therapy hours provided at an inpatient rehabilitation hospital.
The evidence clearly favors rehabs hospitals over nursing homes:
- More intense therapy is required and provided in a Rehabilitation Hospital.
- Research demonstrates that it takes functional tasks to "rewire" the brain and restore function.
- Too often healthcare providers assume that severely affected patients are not candidates for an inpatient rehabilitation hospital. Most, even those with modest functional improvement, return to their homes and families.
- The data speaks for itself. Patients who go to an inpatient rehabilitation hospital achieve higher functional gains and are more likely to go home than those who go to a skilled nursing facility.
Therapists and case managers must be patient advocates. Too often, society and insurance companies look at a disabled or older person and assume that it is too late to do something to help. Patients surprise us all the time with progress we never could have predicted. But if you do not give them a chance, you will never know. Remember, it is not too late for them to be what they can be if they get the proper care.
We must make the best decisions for our patients and serve as their advocates with their physicians and payers so that they can achieve their highest functional level. If you have ever been in the hospital, you know that glorious feeling when you walk through the door of your own home and curl up in the familiar warmth of your own bed. Remember, this is what your patients want and deserve – not a nursing home.
Medical director of the Rehabilitation Institute of San Antonio, Editor in Chief of HealthSouth Press, and the author of more than 15 nonfiction books, Dr. Senelick is one of the leading experts on neurorehabilitation. Dr. Senelick also contributes to the Huffington Post and WebMD's stroke community.