Admitting a patient into an inpatient rehabilitation (IPR) facility is a multifaceted decision, weaving together medical conditions, functional capabilities, and various interconnected criteria. [1] This process necessitates careful consideration from a range of stakeholders, including the patient, the medical teams involved in admission and discharge, multidisciplinary therapists, and those responsible for financial coverage. A consensus among all parties is crucial, affirming the suitability of IPR for the patient prior to admission. The core of the IPR admission evaluation hinges on two primary elements: determining the patient’s appropriateness for this specific care model and addressing the facility’s reimbursement. The latter is especially critical in healthcare systems involving insurance, although financial aspects are not detailed here due to variations across systems.
Globally, the demand for rehabilitation services is on the rise, driven by an aging population and a growing incidence of disabilities. [2] A study from Australia, conducted roughly two decades ago, revealed that only 21% of patients deemed eligible for rehabilitation actually received it. [3] However, IPR acceptance rates have improved in recent years. In the United States, between 1986 and 1994, IPR referrals and admissions nearly doubled. [4] Current data from the US indicates that acceptance rates for IPR evaluations now range from 64% to 81%. [5, 6]
An effective acute IPR program is characterized by a multidisciplinary team of healthcare experts specialized in rehabilitation. This team collaborates across disciplines to meet the complex medical and rehabilitative needs of patients facing activity limitations. Therapy services typically encompass a combination of physical, occupational, speech, swallowing, cognitive, and respiratory therapies, along with mental health, dietary, assistive technology, social work, prosthetic/orthotic, and rehabilitation nursing services. Physiatrists often lead these inpatient teams, overseeing the medical and rehabilitative care. Acute IPR is often necessary when health conditions lead to significant functional impairments due to illnesses, trauma, or developmental issues. IPR facilities admit a diverse patient population, including those with spinal cord injuries, acquired brain injuries, multiple sclerosis, amputations, joint replacements, major trauma, debility, developmental disorders, and cancer. A key requirement for acute rehabilitation admission is the patient’s ability to actively participate in the program. The primary goals of acute rehabilitation are to promote neurological recovery, minimize disability, and maximize functional potential for mobility, self-care, and independent living. While complete independence may not always be attainable, demonstrable progress in functional ability is essential.
Key terms in IPR admission are “medical appropriateness” and “medical necessity.” Medical appropriateness, from a physician’s perspective, means the patient requires care, is likely to benefit, and the rehabilitation unit is the optimal setting. [1] Medical necessity, often defined by insurers, dictates whether healthcare services meet payment criteria under their policies. [1] The rehabilitation physician ultimately decides if a patient meets both criteria. Referrals often originate outside of physiatry, leading to consultations for patients who may not meet these standards. Misconceptions among referring providers about these criteria are common, causing confusion, frustration, and wasted resources. While many hospitals and insurance entities have developed formal admission criteria, significant discrepancies exist between these guidelines and real-world clinical practice. [1] These inconsistencies lead to disagreements that impact patient access to care and IPR reimbursement. Ultimately, all providers aim for the best patient care, making it crucial to address these misunderstandings. This report aims to clarify common misconceptions encountered during the IPR referral process.
MISCONCEPTION 1: INPATIENT REHABILITATION AS A SOLUTION FOR DISPOSITION ISSUES
A frequent point of contention in IPR referrals is the reason for transfer. Often, referrals are made for chronic, inactive patients in acute care who cannot participate in therapy and face discharge challenges. However, acute care rehabilitation is an active medical service, and these patients may not meet IPR criteria. Suitability for an intensive rehabilitation program and medical necessity are essential. Unfortunately, some patients, though ready for hospital discharge, are referred to IPR due to social or disposition issues. System-related factors like bed availability and acute care pressures also influence patient selection. [7] While physiatrists can offer expert advice to aid functional recovery and minimize disability, their consultations are usually for IPR suitability assessment. The expertise of social workers and care coordinators is vital in these situations. IPR referral might be mistakenly pursued due to a lack of understanding of IPR or to avoid potential legal or administrative concerns. Despite this, physiatrists continue to receive such referrals, highlighting a persistent misunderstanding. Furthermore, the need for nursing care alone does not justify IPR admission.
MISCONCEPTION 2: TRANSFER BEFORE ESTABLISHING AN ACUTE CARE REHAB DIAGNOSIS
Transferring a patient to IPR without a complete diagnostic evaluation is often inappropriate and potentially risky. Physiatrists must carefully evaluate such referrals. Incomplete investigations, from blood tests to imaging, can significantly alter disease understanding and patient management. The absence of a definitive diagnosis can impede therapy planning and necessitate further investigations, possibly requiring services not optimally available in a rehabilitation setting. This could lead to the patient needing transfer back to acute care. However, referring teams may resist readmission to acute care, insisting on continued management in IPR, a common dilemma even in tertiary care centers.
It’s crucial to recognize that a rehabilitation unit differs significantly from a surgical or medical inpatient ward. If a patient’s medical or surgical condition prevents participation in the rehabilitation program for a period, they may no longer require the rehabilitation unit and should be transferred to acute care. In some hospital settings, consulting physicians may be reluctant to transfer patients back to acute care, believing treatment can continue on the rehabilitation floor. They may not realize that rehabilitation units are not designed for exclusive medical care when patients are unable to engage in rehabilitation. Most IPR facilities lack resources for cardiac monitoring, inotropic support, and specialized drug infusions. Furthermore, specialized expertise for patients with left ventricular assist devices, tracheostomies, mechanical ventilation, or central lines may be unavailable.
MISCONCEPTION 3: MISUNDERSTANDING “MEDICALLY STABLE, MEDICAL APPROPRIATENESS, AND MEDICAL NECESSITY”
Confusion, particularly across specialties, arises from misunderstandings of medical appropriateness, partly due to the ambiguous concept of medical stability. Stability is context-dependent. A “stable” post-operative neuro-ICU patient differs greatly from a “stable” general ward patient, and both differ from an “outpatient clinic stable” patient. Stability depends on vital signs, mental status, and disease activity. Adding complexity, “stability” literally means unchanging status. Thus, a patient with 110/70 mmHg blood pressure requiring inotropes might be termed “stable.” Interpreting “stable” is challenging due to context and provider variations. Therefore, medical stability alone is insufficient for IPR transfer. Patients must be medically appropriate, meaning they will benefit from therapy and can actively participate for at least 3 hours daily. To address these ambiguities, an American Academy of Physical Medicine and Rehabilitation expert panel developed consensus standards for decision tools assessing physician judgment in IPR admissions. [1] A study by Poulos and Eagar found disagreement between acute care and rehabilitation teams on medical stability for IPR transfer, suggesting a review tool to improve this process. [8]
MISCONCEPTION 4: IPR TRANSFER BASED SOLELY ON THERAPISTS’ RECOMMENDATIONS AND PATIENT WISHES
Patient preferences are important in rehabilitation planning, and their motivation to participate in IPR is a positive prognostic factor. However, IPR admission decisions cannot be solely patient-driven. Referring teams sometimes argue for IPR based on recommendations from therapists in acute care, even when the patient is not deemed appropriate by the rehabilitation team. A rehabilitation physician must assess the patient to determine medical necessity. Even if physical therapy is needed, IPR might not be indicated if other therapies are not required. Generally, patients should need at least two of three therapies (physical, occupational, and speech therapy) for IPR eligibility. If IPR is unsuitable, post-discharge rehabilitation can occur through outpatient programs, skilled nursing facilities, assisted living, or home health therapy. The optimal setting is individualized. A study of cancer patients in IPR showed short-term outcome improvements, but gains were hard to sustain, [9] highlighting the importance of appropriate patient selection for IPR and multidisciplinary intervention and communication to improve referral appropriateness.
MISCONCEPTION 5: TRANSFER BASED ON PRECEDENT OF SIMILAR DIAGNOSES
Referring providers sometimes hold misconceptions based on past IPR referral experiences, recalling patients with similar diagnoses who were accepted. This confusion can be unintentionally reinforced by consulting physiatrists. Private rehabilitation facilities may sometimes relax admission criteria when census is low. A patient not medically ideal for IPR might be admitted due to bed availability. Later, when similar patients are denied, referring providers become confused, recalling past acceptances and questioning referral guidelines. Establishing IPR admission criteria should be straightforward, but standardization, consistency, and uniform application are challenging. Acute care physicians must understand that two patients with similar diagnoses may have different medical and rehabilitation needs, and thus different IPR eligibility.
PINNACLE OF ALL MISCONCEPTIONS: UNDERSTANDING INPATIENT REHABILITATION AND PHYSIATRY
A physiatrist specializes in physical medicine and rehabilitation (PMR), also called physiatry or rehabilitation medicine. Despite the US being a PMR pioneer, only 77 Accreditation Council for Graduate Medical Education-accredited programs exist across 28 states. [10] This reflects varied PMR familiarity among medical residents. [11] Clinicians’ understanding of IPR varies with their experiences, impacting patient access to rehabilitation. An Australian multicenter study found that 37% of stroke patients were not assessed for rehabilitation. [12] Lack of rehabilitation assessment significantly reduces post-stroke rehabilitation access. Many clinicians equate “physical therapy” and “rehabilitation medicine,” unaware of their differences. Some view PMR as geriatrics, others see IPR as addiction rehabilitation. Rehabilitation is broad and lacks clear boundaries. Because rehabilitation fields are not well-integrated into medical education, the role of each specialist is often misunderstood. Rehabilitation clinicians, especially physiatrists as field leaders, must proactively promote their specialties and roles. Addressing referring providers’ lack of awareness is an educational opportunity, best addressed administratively and academically.
CONCLUSION
We share the common goal of patient care within the healthcare system. IPR admission decisions are often finely balanced and have significant life consequences. Inappropriate admissions can cause clinical and administrative issues and waste resources. IPR admission criteria need to be simple, standardized, and well-known to referring providers, with consistent and firm application. Low census or financial factors should not sway physiatrists’ clinical judgment in IPR evaluations. IPR admission and discharge are complex, precluding rigid, quantified criteria. Physiatrists are crucial in applying their skills and knowledge to select appropriate IPR patients. Inappropriate admissions can harm rehabilitation programs, bed utilization, and efficiency, create financial burdens, and potentially risk patients. Effective interdisciplinary communication is vital to build beneficial relationships for patient care and minimize misunderstandings.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
The authors gratefully acknowledge the assistance of Elizabeth T. Mumford, MA for reviewing and editing the manuscript.
