Basic principals.

Cost-effectiveness is an increasingly important element of quality of care for patients needing rehabilitation treatment. By following principles of cost-effective rehabilitation, we can continue to provide the medical care necessary for patients with physical or mental impairments to achieve a basic level of dignity and quality of life. Resources invested on rehabilitation patients often yield lasting economic benefits as well, including increased individual productivity and reduced expenditures for later care.

Roemer describes four methods of medical cost containment: influencing the patient's behavior, using limited resources effectively, providing reasonable payments to providers, and influencing provider performance. Roemer also observes, "When physicians and others are organized as a team, in which there is a reasonable division of labor, both economy and quality can be protected."[1]

Rehabilitation teams include the physician, the patient, and other rehabilitation professionals whose skills are needed to achieve favorable patient outcomes. Teams are important in many areas of medicine, but particularly in rehabilitation, where several different disciplines may be treating a patient simultaneously.

Many successful health care models view the primary care physician as the overall manager of the patient's care. The primary care physician provides direct treatment for the great majority of medical conditions. When a patient's condition requires the intervention of other medical professionals, the physician becomes the leader of an integrated treatment team, overseeing all aspects of patient management.

The principles that are described in this article provide a structure for creating efficient and effective rehabilitation treatment plans. They can also focus the utilization and peer review processes and assist in determining medical necessity of rehabilitation services.

Functional Goals

The first principle is that patients undergoing rehabilitation treatment should be working toward the achievement of functional goals. Medicare Part B requires progress toward measurable functional goals as a requirement for coverage of rehabilitation services.[2] A functional goal relates to the performance of a real-world activity. As illustrated in figure 1, page 33, a goal of lifting boxes is functional; a goal related to a patient's subjective report of pain relief is not functional. The pain relief goal does not relate to any real-world activity. This does not mean that pain relief is not a worthy goal. As physicians, we are always pleased when our patients achieve pain relief. But pain relief is often not a realistic or reachable goal.

In fact, pursuing goals of complete pain relief and completely normal range-of-motion (ROM) can be damaging to a patient with chronic pain, for at least three reasons:

* Such a goal focuses the patient on pain rather than function. Significant gains can be made by reorienting the patient's body awareness away from pain and toward perception of functional abilities. Rainville et al.[3] demonstrated that physical performance in chronic low back pain patients could be improved without increasing pain levels, dissociating physical performance from pain perception in these patients. Likewise, awareness of achieving functional range of motion is preferable to perceiving disability because of limited range of motion after injury. Burton et al.[4] found that patients could achieve satisfactory pain control without complete return of previous spinal mobility.

* Goals of complete pain relief or full pre-injury ROM are often not realistic. Expectation of these goals sets the patient up for failure, which is antitherapeutic. It is far more therapeutic for the patient to achieve a real-world functional goal that makes a noticeable difference in his or her life. This experience empowers and gives the patient an area of control in his or her life.

* Many patients with chronic pain have difficulty with addictions in their lives - cigarettes, alcohol, or other maladaptive behaviors. It is certainly possible for these patients to develop addictive behavior toward their therapy, which increases their overall feelings of dependence and helplessness.

So, while the therapist may provide hands-on treatment that reduces pain, the goal of the chronic pain patient's rehabilitation program is to make the patient independent in pain management techniques. For patients with more severe impairments. functional goals may relate to reducing the intensity of services required to provide custodial care.

Realistic, Reachable Goals

The next principle is that the patient's goals should be realistic, and reachable within a reasonable amount of time. Because terms such as "realistic" and "reasonable" are subject to interpretation, it is important to structure the patient's goals so that progress toward them is measurable in some objective way.

The most therapeutic way of measuring progress is by quantifiable improvement in a functional task that is important to the patient. Objective measures include an increase in the number of hours that the patient is able to work, an increased number of pounds that can be lifted repetitively, or an increased ability to perform basic self-care and other higher level activities.

If the patient chooses functional goals, a contract of sorts is created. The patient agrees to work hard to accomplish chosen functional goals. The rehabilitation team agrees to help the patient achieve those goals. In this way, the patient acknowledges a share of the responsibility for the outcome of treatment.

Active involvement by the patient in the rehabilitation program is crucial to the success of the program. It follows that the patient deserves credit for success in reaching goals. It is therapeutic to recognize the patient and give credit for abilities gained. The favorable outcome is maximal patient independence.

Appropriate Level of Care

The next principle is that rehabilitation services should be provided at the lowest safe and effective level of care (LOC).

* Home, no therapies. Patients who can be rehabilitated at this lowest level of care have a self-limited problem, or one that can be managed at home with medical advice and appropriate treatment. Examples include an uncomplicated minor ankle sprain or lumbosacral strain.

* One to three instructional visits, out-patient therapy. Patients appropriate for this level of care require some instruction, typically in body mechanics or in performance of a home exercise program. It is reasonable to allocate one to three instructional visits so that a health aide chosen by the patient can learn to assist the patient in a home exercise program.

If a patient can learn to do an effective home exercise program, with or without the help of an assistant who has had up to three instructional visits, further skilled therapy services are not likely to be medically necessary. Some patients require sophisticated exercise machines to reach their goals, but most can learn to use this exercise equipment independently in a health club or similar exercise setting. Ownership of an exercise machine does not justify charging for skilled therapy beyond training the patient in the use of the machines. A small reimbursement to a therapy practice for giving patients access to exercise machines may be appropriate, but any such charges should be competitive with other organizations that provide exercise equipment at a fee (e.g., health clubs, YMCA, YWCA).

* Outpatient therapy program. The initial referral for outpatient therapy can specify 8 to 12 visits, depending on the complexity of the problem. The referring physician can expect the patient to have an evaluation and active, "hands-on" treatment during those visits. Passive modalities (ultrasound, electrical stimulation, others) may be a part of the program, but in most cases the therapist should involve the patient in some type of active treatment and exercise regimen. It is important to specify on the referral the expectation that the patient be independent in the performance of a home exercise program at the conclusion of the initial referral. Chronic musculoskeletal pain is an example of a condition appropriately treated at this level of care.

* Outpatient therapy program with extension to meet specific functional goals. This is the level of care most requiring physician attention. If additional therapy is requested by the patient or the therapist, it is reasonable to expect a clear reason why the patient is not ready for discharge. It is also reasonable to expect an efficient treatment plan for achieving clearly defined functional goals within a limited number of additional visits.

A telephone call to the therapist is often appropriate in this setting. Figure 2, above, provides a suggested structure for this brief phone call. This conference also gives physician and therapist the opportunity to discuss possible barriers to the patient's progress and to seek ways to reduce or eliminate those barriers. Perhaps the patient has well-established dysfunctional pain behaviors that would be best addressed by a psychologist or a formal pain management program. If so, continuing the patient's conventional outpatient therapy program may not be the most efficient or effective plan of treatment.

An example for this level of care is a patient with chronic low back pain who has done well and has valid new goals related to return to work or further upgrade in functional status. A second example is a patient whose rehabilitation potential has improved after removal of a barrier to progress, such as a recently treated medical or psychiatric illness.

* Extended outpatient therapy program. Patients with severe deficits or changing clinical status may be candidates for many weeks or months of therapy. The principles of realistic functional goals still apply, but the patient's progress is expected to be slow and steady over several weeks or months. In this case, goals and treatment plan are continually revised and updated as the patient's condition changes. The presence of a deficit, no matter how severe, is not an indication for rehabilitation unless that deficit has functional implications and has a realistic potential for improvement. In clinical practice, patients fairly often do require extended therapy programs to reach their maximum potential. Diagnoses of such patients include traumatic brain injury; spinal cord injury; stroke; peripheral neuropathies, including Guillain-Barre polyneuropathy; multiple sclerosis; certain postsurgical patients; and some peripheral nerve injuries.

* Home health care. In the past, patients needed to be "homebound" in order to receive rehabilitation services in their homes. The indications for home health care have broadened and now include patients with a wide spectrum of acuity and severity of deficits. Home health care may be an appropriate transitional stage between acute hospital care and outpatient rehabilitation. Decentralized rehabilitation programs, the "rehab without walls" concept, have appeared in many parts of the country. Examples of patients who may be appropriate for rehabilitation at home include those with severe strokes or degenerative central nervous system disorders.

* Subacute rehabilitation facility. Some patients have medical conditions, severe deficits, or equipment needs that make outpatient care unsafe or impractical. They are best managed at skilled nursing facilities (SNFs). These patients may have limited or focused rehabilitation needs or are anticipated to make slower progress than those who need care at a rehabilitation hospital (see below). Medicare has required a "qualifying" three-day acute hospital stay before a covered SNF admission will be authorized. Other insurers are not operating under those regulations and may authorize admission directly from home or after a shorter acute hospital stay.

Patients in many localities have the option of choosing medical insurance coverage by their health plan in lieu of their Medicare benefits ("risk" contracts). Many of these patients would meet Medicare criteria for inpatient rehabilitation but, in the judgment of their health plan physicians, could receive safe and effective treatment at the subacute level of care. Examples of patients who have customarily received treatment at the subacute level of care are those with disabling medical conditions, limited weight-bearing restrictions, and uncomplicated hip fractures. A hip fracture may become "complicated" from a level of care perspective when concurrent medical conditions (severe arthritis, cardiopulmonary insufficiency, other fractures) make close medical supervision of the patient at the rehabilitation hospital LOC advisable.

* Rehabilitation hospital. Patients eligible for the rehabilitation hospital LOC are generally able to tolerate and benefit from at least three hours of therapy daily from at least two services (occupational therapy, speech-language pathology, or physical therapy). These patients have medical conditions that require the 24-hour availability of a rehabilitation nurse and a physician with training and experience in rehabilitation. Patients with acute spinal cord injuries or severe traumatic brain injuries are usually best managed in an inpatient rehabilitation setting by professionals who specialize in the treatment of patients with these catastrophic illnesses. Patients with other diagnoses may also qualify.

Some patients who qualify for the rehabilitation hospital level of care under Medicare regulations can be managed well at the subacute level of care. The expertise of the treatment team and the focus of the institution are factors that need to be considered in making the decision between subacute and rehabilitation hospital level of care.

Seventy-five percent of the patients admitted to a rehabilitation hospital or dedicated rehabilitation unit must have one of 10 "rehabilitation diagnoses" for the hospital to keep its Medicare DRG-exempt status: stroke, spinal cord injury, congenital deformity, amputation, major multiple trauma, femur fracture, brain injury, polyarthritis (including rheumatoid arthritis), neurologic disorders (including multiple sclerosis, motor neuron disease, polyneuropathy, muscular dystrophy, and Parkinsonism), and burns. In spite of the severity of these disorders, all patients admitted to rehabilitation hospitals show the potential for significant functional gains.

* Custodial. Patients at the custodial level of care have reached a plateau or an endpoint in their potential for making further functional gains. However, they demonstrate a long-term need for supervision, assistance, or other services for health and safety. Patients requiring long-term custodial care may still require a high intensity of services: ventilator management, enteric feedings, and a maintenance therapy program to prevent the sequelae of immobility and chronic disease. Examples of patients receiving a custodial level of care include those who have end-stage neuromuscular disease or severe dementia or who are in a persistent vegetative state.

Active Program vs. Maintenance

Program

At all of the above levels except the custodial level of care, the patient is expected to be on an active therapy program. An active program is intended to upgrade the patient's functional status; a maintenance program is intended to prevent a decline in the patient's functional status. While a maintenance therapy program is often a medically necessary activity, it is not considered medically necessary for a skilled therapist to perform a maintenance therapy program. The appropriate level of care for maintenance therapy is in the patient's home or other community exercise setting, with or without the assistance of a nonprofessional as needed.

Discharge Planning Begins on Day of

Admission

Regardless of whether the patient is receiving inpatient or outpatient services, planning for a safe discharge begins on the day of admission. As soon after admission as possible, the treatment team should establish the anticipated level of care to which the patient will be discharged after rehabilitation. Goal-setting, length-of-stay projections, and projected postrehabilitation level of care are inseparable and essential pieces of information in creating the patient's treatment plan. Patients may become more focused on achieving their goals if they know the anticipated time frame for their rehabilitation. Barriers to successful discharge need to be identified early and corrected in advance of the discharge date.

Medically Necessary Rehabilitation

Services

Medically necessary rehabilitation services are a synthesis of the principles above. The patient should be participating fully in an active program working toward real-world functional goals. The therapy program should be carried out at the most efficient and effective level of care and should be concluded in a reasonable number of treatment sessions over a reasonable period. Patients who require the use of specialized equipment and may be charged a small fee for access to the equipment and may need one to three instructional sessions to use the equipment properly. However, patients should not be charged for continuing skilled therapy services related to that equipment except under unusual circumstances (e.g. unstable medical condition or surgical site).

Referring physicians have an opportunity to increase the efficiency of health care each time they are presented with a therapy recertification form. Under Medicare Part B and other insurers, physicians are requested to make a decision concerning medical necessity of continued therapy services every 30 days. This request places physicians with little training or experience in rehabilitation in an awkward position. It is certainly understandable that many physicians have given more thought to ordering a $30 lab test than to recertification of additional therapy services that may cost $2,000 or more, given the limited exposure most physicians have had to rehabilitation.

The information needed to manage a patient's rehabilitation may be only a phone call away. The referring physician can call the therapist, using the structure in figure 2 to determine medical necessity of further services. A phone call to the patient's surgeon may yield good information about the stability of any recent surgical repair and about the surgeon's expectations of therapy services. Physiatrists (specialists in physical medicine and rehabilitation) have had formal training and experience in leading rehabilitation teams and can be contacted for information on all aspects of the care of persons with disabilities.

In the December 1995 issue of Physician Executive, the second article in this two-part series will discuss approaches to remedy patient management problems that may lead to excessive or ineffective utilization of rehabilitation services.

Patients may be referred for rehabilitation services with a variety of diagnoses, including stroke, spinal cord injury, brain injury, multiple trauma, orthopedic disorders, arthritis, multiple medical problems, and chronic pain. The goals and endpoints for treatment of these conditions are often unclear. The principles that are described in this article provide a structure for creating efficient and effective rehabilitation treatment plans. These principles can also focus the utilization and peer review processes and can assist in determining medical necessity of rehabilitation services. Part one of this two-part article discusses general principles of cost-effective rehabilitation. Part two, in the December 1995 issue, will focus on individual patient management issues.

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

References

[1.] Roemer, M. National Health System of the World, Vol. 2. New York, N.Y.: Oxford University Press, 1993, pp. 150-2. [2.] Department of Health and Human Services, HCFA. Medicare Outpatient Physical Therapy and Comprehensive Outpatient Rehabilitation Facility Manual, Sections 502, 503, and 515, Washington, D.C.: HHS, May 1989. [3.] Rainville, J., and others. "The Association of Pain with Physical Activities in Chronic Low Back Pain." Spine 17(9):1060-4, Sept. 1992. [4.] Burton, A., and others. "Variations in Lumbar Sagittal Mobility with Low back Pain Trouble." Spine 14(6):584-90, June 1989.