Approaches to patient management problems.

The principles outlined in part one of this series (October 1995) are best used as guidelines for the care of populations of patients. As in all of medicine, physicians weigh many factors in reaching a decision concerning treatment of individual patients. The following are clinical situations in which clinical judgment is particularly important for achievement of the most favorable rehabilitation outcome.

* Postsurgical patients. The patient's surgeon directs the rehabilitation program during active tissue healing after surgery (8-12 weeks, possibly longer). If recovery is proceeding well, the patient can be expected to transition to an independent home exercise program quickly. If the surgical repair is delicate or unstable, continued skilled therapy may be required to protect the surgically treated area until it becomes more stable.

* College/professional athletes. A longer period of skilled therapy may be indicated for these patients because of requirements of exceptional strength or conditioning.

* A worker with objective evidence of injury. Patients who have suffered fractures diagnosed by radiographs or nerve injuries documented by electrodiagnostic studies (electromyography and nerve conduction studies) may present management problems out of proportion to their injuries. Motivated and responsible patients may be able to return to work on modified or light-duty status long before their injuries reach medical end-points. However, other patients with documented injuries will be able to find physicians who will excuse them from any type of work, even if a work capacity evaluation indicates that available jobs are well within their demonstrated abilities to work. If these patients are pressured to return to work against their will prior to complete healing, either the patients or their physicians can sabotage the return-to-work plans. The best way to manage these patients is to coach them to set realistic return to work dates, in cooperation with their employers and surgeons or other consultant physicians. Two interventions may encourage early appropriate return to work.

First, modified or light duty must be available at the patient's workplace. Even if the patient accomplishes little at light duty, he or she develops the expectation of going to work every day. Second, the patient should not feel entitled to stay at home. Initial orientation at the workplace should include the message that the patient will be expected to report to work at a duty status appropriate to his or her medical condition at the earliest possible date after injury.

* Work hardening programs, work capacity evaluations. Work hardening programs are most successful if the patient is motivated to return to work and has an identified job that will begin during or immediately after work hardening. Work hardening followed by unemployment is rarely cost-effective. Work capacity evaluations are useful to document the performance level that can be expected of a worker. Unfortunately, these evaluations are often used to force reluctant workers back to work or to stop their benefits if they refuse to return to work.

Vocational rehabilitation can be very helpful in achieving a return to productive employment that is favorable to all concerned. Effective vocational rehabilitation directs patients to occupations in which jobs are available, so that the patient moves directly from vocational rehabilitation to an available job. Vocational rehabilitation, like work hardening, is rarely cost-effective if followed by unemployment.

Early recognition of the psychosocial aspects of a worker's injury can lead to more effective use of resources. Pati who hate their jobs, their co-workers, or their bosses may return to the work force sooner if an alternative placement can be identified. Patients who would be laid off if returned to active duty (as fairly commonly occurs) would also graduate from the worker's compensation system sooner if a more secure job could be identified.

Patients with a very low probability of returning to work of any type should be identified as soon as possible by physicians experienced in the treatment of injured workers, with or without consultation from psychological professionals. If these patients have no further functional goals, they should be discharged from medical rehabilitation treatment at the earliest possible date.

* Brain injury postacute programs. Shopping for a residential postacute program can be similar to shopping for a car. The car dealer may try to put as many options on the car as possible before ever showing it to you and will try to sell you a package of additional options that you may not really need. The brain injury postacute program may present a package of therapies including physical therapy, occupational therapy, speech therapy, recreational therapy, and psychological treatment, as well as the per diem cost of the residential setting. Each type of therapy in these programs needs to be individually justified on the basis of reasonable functional goals, just as for any other type of patient. Brain injury postacute programs may attempt to justify therapy services for a patient by stating that the patient needs individual skilled therapy services to fill his or her day with structured activity. Clearly, this is not a valid functional goal for skilled therapy services.

Social and behavioral problems are usually the limiting factors in brain-injured patients admitted for postacute rehabilitation. These patients can benefit from a coordinated program that includes psychological intervention and rehabilitation therapies as needed.[1] It is important to expect that these patients will be undergoing medication trials for the management of their problem behavior. Several classes of medications may be helpful[2-5]; each medication may need to be tried over a three-week period before adding or substituting another class of medication. Look for a documented decrease in problem behaviors as a necessary condition for continuing the program.

Brain injury postacute programs are very costly. In 1988, the "typical" brain injury postacute program lasted 15 months, with an average cost of 195,000.[6] Efforts to improve the efficiency of programs treating brain-injured patients are ongoing.[7]

* Chronic pain management programs. Both inpatient and outpatient pain management programs are available. Medicare guidelines specify patient qualifications for inpatient pain management, including pain of at least six months duration, resulting in significant life disturbance and limited functioning, attributable to a physical cause, and intractable to usual methods of treatment.[8] Other insurers may have different guidelines.

Inpatient pain management programs have customarily been approximately four weeks in duration, although efforts to improve efficiency are also ongoing in this area. Medicare specifies that programs not exceed six weeks in duration. Patients must show progress in order for Medicare to continue coverage. Documentation of progress might include a reduction in pain behaviors, reduced use of medication, or effective use of pain management techniques to reach a higher functional status.

It is important that patients not enter the program with the expectation that their pain will disappear. The focus of chronic pain programs is to help the patient become independent in effective pain management techniques, resulting in less medication use, a higher functional status, and reduced dysfunctional pain behaviors.

Medical Necessity

It is difficult to convince some patients to attend needed therapy sessions. Other patients would gladly continue having therapy for the rest of their lives. Achieving a successful discharge for patients who want more therapy than is considered medically necessary can be a challenge. Some of the more common dysfunctional reasons for requesting further therapy and suggested approaches for their management are:

* Unrealistic expectations. ("If I get more therapy, I'll be back to normal.") Most of the neurologic recovery after stroke occurs in the first six months, with some further recovery in the second six months after stroke. If a patient presents with a nonfunctional arm one year after stroke, it is extremely unlikely that further therapy will restore function to the affected limb.

Patients can make functional gains even several months or years after stroke, however. If a patient was unable to undergo rehabilitation at an earlier date, for whatever reason, it is quite reasonable to bring him or her back into therapy long after stroke if the patient demonstrates potential to make meaningful functional gains.

Unrealistic expectations can be managed by helping the patient choose reachable functional goals. Reasonable functional goals for a severely impaired arm include using the arm as a stabilizer to cut vegetables or to read a newspaper.

* Convenient maintenance program. ("It feels good when I go to therapy, but the pain always comes back.") As discussed in the first part of this article, the professional attention of a skilled therapist is not considered medically necessary for the performance of a maintenance therapy program. Patients are expected to be independent in the performance of their home therapy programs or to arrange for a health aide of their choice (commonly a friend or family member) to assist them if necessary. It is understandable that patients would seek a therapist to help their home exercise program if their insurance policy provides coverage. However, few if any insurers will provide coverage for maintenance therapy.

It is recommended that, whenever appropriate, therapy referral prescriptions specify that the patient be made independent in his or her home exercise program prior to discharge. Patients who need help with their home programs will usually recruit a friend or family member to help them or will become independent with guidance from their therapists and physicians. The friend, family member, or health aide can attend one to several therapy sessions in order to learn the proper performance of the home exercise program.

* Proof of Illness or Disability. ("I must be sick; I'm still going to therapy.") Patients who use their attendance at therapy to document the severity of their illnesses may be persisting in a passive dependent role. They often are not sharing responsibility for their own recovery. This passivity can be a serious barrier to patients' rehabilitation progress.

This is an opportunity to search for factors or persons that may be perpetuating the patient's dependency. The patient's lack of progress can be presented in a nonthreatening format, as follows. "On your first visit, you expressed an interest in being able to manage your pain well enough to do your housework and care for your elderly mother. You haven't made much progress in your past few visits. What do you think is holding you back?"

Patients need to know early in their rehabilitation programs that, if they do not make progress, they will not be able to continue going to therapy. It is important to emphasize the message that the patient must work hard to achieve his or her goals, with the assistance of physician and therapist.

* Avoidance of work/responsibilities. ("I'm not ready to go back to work yet; I still need more therapy.") It is important for the physician to involve the worker's compensation patient in setting goals and setting a return-to-work date. This treatment planning process gives the physician an opportunity to address all of the patient's concerns about returning to work, including interpersonal friction in the workplace, being fired or laid off, and risk of future injury.

Each of these concerns is valid and real. Often a psychologist will be able to help a patient work through problems of interpersonal friction at work. Vocational rehabilitation may benefit some who would be laid off if they left worker's compensation roles. The concern of risk of future injury deserves some further consideration.

The patient's employer has the responsibility to make the workplace as safe a place as possible. The patient's physician may feel a responsibility to intervene if the patient feels that his or her work site is not ergonomically well-designed or if some of the patient's duties predictably cause pain. The Americans with Disabilities Act requires employers to make appropriate modifications to the workplace in order for a person with a disability to work safely. However, there is an irreducable risk to working. Each time we go to work, we risk injury. We cannot tell our patients that their pain will not recur if they return to work. In fact, it is reasonable to train patients in pain management techniques in the likely event that pain will recur.

Nachemson makes several observations that are useful in discussing return-to-work issues with patients. "[In patients who have subjective symptoms with no objective signs of disease or injury], a gradual, biomechanically sound return to activity and work in all probability is the treatment that will make them symptom-free most rapidly. Patients must be told repeatedly that a gradual return to work will not worsen their condition in the future. However, at the same time patients must be warned of the possibility of recurrence, the incidence of which is well known. It has been demonstrated that symptoms recur in about 50 percent of patients during the first two to three years after an acute episode of back pain, but no evidence can be found in the literature that such recurrences are related to an early or late return to work."[9]

* Entitlement. ("I've paid my insurance premiums for 20 years and never been sick. Now I have a right to as much therapy as I want.") Patients will understand the concept of medical necessity if it is explained to them clearly. It is especially helpful if all members of the rehabilitation team provide consistent explanations regarding functional goals and discharge planning.

Physicians can encourage this consistent communication by prescribing a specific number of therapy visits in the initial outpatient referral and in all subsequent recertifications. Length-of-stay decisions on inpatient rehabilitation units are made at team conferences led by the physician or by a person designated by the physician. Therapists and other members of the rehabilitation team then have the responsibility to contact the physician or designated team leader for a team decision on any change in length of stay. After consensus on length of stay has been reached, the patient can be notified.

The patient is a member in good standing of the rehabilitation team and participates in goal-setting and other team functions. However, patient-led decisions on length of stay are rarely cost-effective. It is more appropriate for the team to determine an appropriate length of stay to achieve goals that are important to the patient.

* Financial. ("If I use the exercise machine at the therapist's office, I don't have to pay for a health club membership.") Once again, explanation concerning medically necessary therapy services is usually well-received by patients. Patients will appreciate any effort by physicians to recommend health club memberships. Many companies include free or reduced-cost health club memberships as part of their employee benefit packages. When such memberships are a benefit, designing and implementing a patient's independent maintenance therapy program is often much easier.

* Social/Motivational. ("My husband is retired and had a stroke. If he doesn't go to therapy, he just sits at home and doesn't exercise.") This is a common scenario, and one for which there is not always an easy answer. The patient in many cases is content to be inactive; however, the spouse is unhappy with the patient's inactivity. It may not be possible to motivate some inactive elderly stroke patients, but several interventions are worth a try. For the more healthy and mobile patient, community centers (YMCA, YWCA, Jewish Community Centers, and other religious and secular organizations) offer exercise programs and companionship. Patients who are more limited in their abilities can often be transported to adult day care centers in the centers' vans. Helpers to assist in the home exercise program (friends, family members, home health aides) may be more appropriate for the truly home-bound.

Outcomes

All physicians do informal outcome analysis as part of medical practice. We evaluate the performance of our consultants and others who participate in the care of our patients. We seek ways to improve outcomes that appear unfavorable or not up to the patient's potential.

Many outcome studies have appeared in the rehabilitation literature over the past 30 years.[10-13] The science of outcome measurement is rapidly becoming more refined. It seems likely that today's larger groups of physicians will develop more formal outcome measurement systems that can be used at the level of the medical group practice and that can be subjected to statistical analysis. Third-party payers may provide the impetus for the creation of these formal outcome measures and may reward practices that can produce data based on statistical analysis of outcomes.

Conclusion

The referring physician has the opportunity to increase the efficiency and effectiveness of rehabilitation treatment for his or her patients. The following interventions are suggested to favorably influence rehabilitation outcomes.

* Write informative therapy referrals. These referrals should include diagnosis, number of visits (e.g. twice weekly for four weeks), functional goals, and specific services requested (if any). "Cookbook" therapy prescriptions (e.g., "hot packs and ultrasound") should be avoided.

* Develop cohesive rehabilitation teams to care for patients. Treatment teams benefit from clear communication and mutual support among professionals who are "team players."

* Use the telephone. The "world's most underused piece of medical equipment" can be a rapid source of information on patient management issues. The referring physician can often get the information needed to make difficult patient management decisions by calling the treating therapist or a consulting physician (e.g., surgeon, physiatrist).

* Expect each therapy visit or patient contact to meet standards of medical necessity for rehabilitation care. The patient should be on an active therapy program designed to achieve functional goals, carried out over a reasonable time at the most efficient and effective safe level of care possible.

* Identify patients who have reached the point of maximum medical improvement; limit further resources spent on these patients. Discharge patients promptly when they have reached their functional goals or demonstrate the potential to reach those goals by independent performance of a home or community exercise program. Manage emotional, social, or vocational issues through appropriate community resources.

* Refer to consultants when they improve efficiency of care and treatment outcomes. Surgeons, physiatrists, and other medical specialists are often helpful resources in solving difficult patient management problems. A telephone call can clarify whether or not a formal consultation will be needed.

* Expect favorable outcomes. Ask for outcome data; if they are not yet available, ask what steps are being taken to document and improve outcomes; ask about efforts to improve efficiency of care; ask for literature references to support treatments being provided.

* Table 1. When the Usual Rules of
Cost-Effective Rehabilitation May
Need to be Modified
* Postsurgical patients.
* College/professional athletes.
* Objective evidence of work injury.
* Work Hardening programs/work
  capacity evaluations.
* Brain injury postacute programs.
* Chronic pain management programs.
* Table 2. Patient Reasons for Wanting
More therapy than Is Considered
Medically Necessary
* Unrealistic expectations.
* Convenient maintenance program.
* Proof of illness or disability.
* Avoidance of work/responsibilities.
* Entitlement.
* Financial.
* Social/motivational.

References

[1.] Cope, D., and others. "Brain Injury: Analysis of Outcome in a Post-Acute Rehabilitation System. Part 1: General Analysis." Brain Injury 5(2):111-25, April-June 1991 [2.] Glenn, M. "A Pharmocologic Approach to Aggressive and Disruptive Behaviors after Traumatic Brain Injury. Part I." Journal of Head Trauma Rehabilitation 2(i):71-3, Spring 1987. [3.] Glenn, M. "A Pharmocologic Approach to Aggressive and Disruptive Behaviors after Traumatic Brain Injury. Part 2." Journal of Head Trauma Rehabilitation 2(2):80-1, Summer 1987. [4.] Glenn, M. "A Pharmocologic Approach to Aggressive and Disruptive Behaviors after Traumatic Brain Injury. Part 3." Journal of Head Trauma Rehabilitation 2(3):85-7, Fall 1987. [5.] Glenn, M. "CNS Stimulants: Applications for Traumatic Brain Injury." Journal of Head Trauma Rehabilitation 1(4):75-6, Winter 1987. [6.] Cope, D., and others. "Brain Injury: Analysis of Outcome in a Post-Acute Rehabilitation System. Part 2: Subanalyses." Brain Injury 5(2):127-39, April-june 1991. [7.] McLaughlin, A., and Peters, S. "Evaluation of an Innovative Cost-Effective Programme for Brain Injury Patients: Response to a Need for Flexible Treatment Planning." Brain Injury 7(1):71-5, Jan.-Feb. 1993. [8.] Department of Health and Human Services, HCFA. Medicare Bulletin Number 282. "Chronic Pain Program Guidelines, Jan. 22, 1990. [9.] Nachemson, A. "Work for All; for Those with Low Back Pain as Well. Clinical Orthopedics 179:77-85, Oct. 1983. [10.] Boyle, R., and Scalzitti, P. "Study of480 Consecutive Cases of Cerebral Vascular Accident." Archives of Physical Medicine and Rehabilitation 44(1):19-28, Jan. 1963. [11.] Lehmann, J., and others. "Stroke; Does Rehabilitation Affect Outcome?" Archives of Physical Medicine and Rehabilitation 56(9):375-82, Sept. 1975. [12.] Greenough, C., and Fraser, R. "Assessment of Outcome in Patients with Low Back Pain." Spine 17(l):36-41, Jan. 1992. [13.] Wilkerson, D., and others. "Use of Functional Status Measures for Payment of Medical Rehabilitation Services." Archives of Physical Medicine and Rehabilitation 73(2):111-20, Feb. 1992.

Joel F. Moorhead, MD, is affiliated with Phoenix Rehabilitation Center, Phoenix, Ariz.