What's on the Horizon: The Rehabilitation Hospitalist
Article Outline
The year was 1982, the second year of my residency training in physical medicine and rehabilitation (PM&R). I was evaluating the first patient with a spinal cord injury I had ever cared for in the emergency department of Thomas Jefferson University Hospital. Three residents arrived at the bedside after the trauma alert, one each from the departments of rehabilitation medicine, orthopedics, and neurosurgery, and one attending physician, John F. Ditunno Jr, MD, chair of the Department of Rehabilitation Medicine. The examination of the patient was carefully completed, and decisions were made about surgery and rehabilitation based on the evaluation. The PM&R resident and the attending physician communicated with the patient and the family. This was the beginning of lifetime care for this patient, in the intensive care unit, the medical-surgical unit, the inpatient rehabilitation hospital, and then ambulatory care, provided through the Delaware Valley Spinal Cord Injury Model Systems Program at Thomas Jefferson University and Magee Rehabilitation Hospitals, funded through the National Institute on Disability and Rehabilitation Research (NIDRR). No one was called a hospitalist back in that era, but I think the role we in PM&R played is consistent with that label.
An adult or pediatric physiatrist who works primarily in a hospital setting provides care to inpatients as an attending physician or a consultant, and the term “rehabilitation hospitalist” seems apt. I discovered recently that recruiters use the label, although a search yielded no articles in the medical literature. As we enter this new era in health care, I hope we will continue to see a major expansion of the role of the rehabilitation hospitalist beyond what has been the role of PM&R physicians in the NIDRR Model Systems Programs.
The term “hospitalist” was coined in 1996 to describe physicians who focus on the care of medical inpatients [1]. In a hospitalist system, other nonhospitalist physicians, usually primary care physicians or emergency department physicians, transfer the responsibility for hospital care to an inpatient specialist whose expertise is defined not by an organ system but by a site of practice. This was a change from the traditional practice of primary care physicians who cared for their own patients when they were hospitalized. Hospitalists function as attending physicians but also as consultants to other physicians in the emergency department or other units of the hospital. Most hospitalists spend all of their work hours in the hospital, although others have combined practices in ambulatory care or other postacute care (PAC) sites, such as skilled nursing facilities (SNF). Some hospitalists are paid a salary, and others receive salary and incentive payments for productivity and/or quality; the evolution of the field is, in part, a consequence of the identification of the need for quality-improvement and error-reduction initiatives in hospitals across the United States. It is true that physicians give up autonomy when working full- or part-time for hospitals and health systems, as is the case with hospitalists. However, with the very rapid growth of the hospitalist movement (from a few hundred in the late 1990s to approximately 30,000 hospitalists today), there is likely no going back to a traditional model of hospital medicine [2].
Hospitalist roles in other specialties have more recently been defined; these include the “neurohospitalist” [3] and the “pediatric hospitalist” [4]. The rehabilitation hospitalist fills similar roles; we serve as consultants in the hospital and admit to and care for patients in rehabilitation hospitals and units. As we look toward the future, we can take a few lessons from other hospitalists and also advocate for our involvement in patient care from the beginning days of hospitalization for many populations, not just trauma patients.
Inpatient rehabilitation hospital units within hospitals and free-standing rehabilitation facilities, designated by the Centers for Medicaid and Medicare Services as inpatient rehabilitation facilities, or IRFs, have provided hospital-level care in the United States over many decades. Approximately 200 IRFs are freestanding and about 1000 are units within hospitals. IRFs provide a high level of care for a diverse group of patients, including those with major multiple trauma, spinal cord and brain injuries, severe burns, multiple sclerosis and other neurologic disorders, and rheumatologic and other musculoskeletal conditions. Advances in the medical and surgical treatment of diverse patient populations have expanded the population of patients served in hospital-level rehabilitation. Now, patients with complications from cancer or after transplantation, those with disabling cardiac and pulmonary disorders, and other patients with complex and debilitating disorders also benefit from care in these inpatient settings. Pediatric patients with disabling conditions are also similarly cared for by pediatric physiatrists in children's hospitals or hospital units.
Many forces have been operative to expand and then to slow the expansion of IRFs. In 1980, there were approximately 18,000 IRF beds, and, by 1990, after the impact of various changes in acute care regulation and reimbursement, there were approximately 33,000 rehabilitation hospital beds [5]. By 2009, there were just 35,757 IRF beds because regulatory and reimbursement changes negatively affected inpatient rehabilitation [6].From 2004-2010, inpatient rehabilitation costs to the Medicare system have not increased and remain approximately $6.4 billion; however, SNF costs have increased by 52% during that time period and now total $26.4 billion [7]. This major increase in SNF care and costs is the result of shortened hospital lengths of stay and an aging population, changes in referral patterns due to incentives, and the lack of rehabilitation hospitals and rehabilitation hospitalists to triage patients to appropriate PAC sites.
What can we as rehabilitation hospitalists offer, not only for hospitalized patients in medical-surgical and rehabilitation units, but also for patients receiving care across a care continuum that may be funded, for example, through bundled payments or within accountable care organizations? In the new era of value rather than volume-based health care, and especially if the hospital becomes the primary unit of accountability in accountable care organizations, the rehabilitation hospitalist will provide essential consultations in hospital venues for adult and pediatric populations, from the emergency department, the trauma bay, the intensive care unit, and other units within adult and pediatric hospitals. We will collaborate with hospitalists and care teams to advise and triage patients with complex, disabling conditions to IRF and other levels of PAC. As Kane [8] points out, discharge planners may not be well suited to the role of determining discharge destinations due to mandates for rapid discharges. Rehabilitation hospitalists are ideally suited to collaborate to assure optimal PAC environments.
More than 1.6 million Americans reside in nursing homes, and, in 2006, nearly 24% of the people admitted to a SNF were rehospitalized within 30 days, and some estimates suggest these rehospitalizations cost more than $4 billion per year [9]. In the absence of clinical trials due to ethical considerations, observational studies have been the primary type of study of outcomes across the continuum of PAC. IRF readmission rates are substantially lower than those of SNFs (9.5% vs. 22%), and discharge-to-community rates are also favorable (81.1% for IRF and 45.5% for SNF) [7].
As pointed out by Kangovi and Grande [10], the readmission rate is a measure of health service use, which is influenced by quality of care and a patient's health status but is also a function of access to health services and socioeconomic resources such as income or social support. Results of other research suggests that patients cared for by hospitalists are less likely to be discharged home, more likely to have emergency department visits, readmissions, and fewer visits with primary care physicians, and more likely to have nursing home care [11]. The lower rates of hospital readmission and higher rates of discharge to the community from IRFs may be, in part, due to favorable aspects of care in regard to factors such as these. The identification and training of caregivers, assessment of health literacy among patients and families, and development of individualized training programs for patients and families are major focuses in IRFs. Rehabilitation hospitalists can assist other hospitalists to determine the best PAC placement to avoid rehospitalization and other complications due to inadequate discharge planning or the lack of patient and/or family education about medications and care plans at home.
We need to consider the oldest patients and those with the most complex and challenging conditions for IRF care due to physician and nursing staffing ratios in these settings. We need to take chances on the admission of patients without family or support systems who can be rehabilitated to a functional level that allows them to be discharged to a community setting, such as an assisted living or board-and-care facility. We will need to further clarify guidelines for determining whether a patient is a candidate for IRF or for admission to another PAC setting, and the field of PM&R needs to lead the way. The term “medical necessity” needs to be replaced by a more sophisticated set of criteria for admission that are based on measures of severity of disease and injury, functional measures, and classification of comorbid conditions that necessitate care in a hospital-based setting. In a more perfect world, the acute care Diagnosis-Related Groups system will be supplanted by a system that is based upon those elements as well, and this will lead to more appropriate discharge plans from acute care to various PAC settings, even when the patient is not a candidate for IRF admission. We also need to enhance programs in SNFs and other PAC settings through consultative work for those patients who do not qualify for IRFs. We need to argue for and build outpatient programs, such as day hospital or day treatment programs for patients who do not need 24 hours a day 7 days a week of nursing or physician care but who will have superior outcomes with an intensive 5 days per week therapeutic program.
We will be reliant on the electronic medical record in integrated health systems, and these systems will support our work as hospitalists, especially if information about the patient is provided across all levels of care. We will provide specialty care in all hospital units. As with other hospitalists, we will be involved in hospital administrative roles, providing leadership concerning quality metrics and utilization. As our systems become more integrated and the importance of care transitions and care coordination is fully understood, the rehabilitation hospitalist will play a key role in improving quality and decreasing costs of care. Our communication skills will be a key advantage to make certain that the level of PAC matches the patient's medical needs and preferences, and the needs of the family for reducing the burden of care. We will bring to this work our core values, including patient-centric care, team approaches, and practice philosophies that include comprehensive medical management, primary and secondary prevention, functional prognostication, and goal setting based upon the outcomes most important to patients and their families. We must insist on the same performance and quality metrics for SNF, IRF, and outpatient programs, with standardized measurement tools used across the care continuum.
The rehabilitation hospitalist role is essential, and we in PM&R must share a collective vision of the necessity of being involved at the beginning of episodes of care by working in collaboration with other physicians to provide comprehensive, coordinated care, and decision making. As physicians who understand both medical and rehabilitation care needs of the patient, functional and medical prognosis, family support and capacity to provide care, and the differences in levels of PAC, we can determine how best to match the patient's needs with the setting of care. As incentives change, the site of care will be less important than the expertise we can provide to the populations that we serve, and we will need to be able to provide expert care across many settings, beginning in the hospital or even in the emergency department. Providing our expertise to patients and families and to our colleagues in the early acute phases of care after injury or major illness and continuing to provide care across the care continuum will be our most important contributions. Through this work, we will provide optimal functional and medical outcomes for the most complex populations we serve.
During the past few decades, PM&R training programs have moved from a focus on inpatient to outpatient PM&R as incentives changed. The residency requirement for inpatient training, just 1 year of hospital-based training, may not leave the trainee with confidence in rehabilitation hospitalist practice. Residents who plan to focus on hospital medicine often seek fellowships in brain injury or spinal cord injury medicine for additional training, and this may be necessary for some residents. For this vision to become a reality across the country, we will need a work force trained to evaluate and care for complex adult and pediatric inpatient populations with both medical and rehabilitation needs. The American Board of Internal Medicine offers internal medicine certificate holders the opportunity to be recognized in a Focused Practice in Hospital Medicine maintenance of certification program [2]. Perhaps our field could provide a similar program for rehabilitation hospitalists. Incentives must change again for this important work to be done and for a sufficient work force to be trained to provide it. However, unless as a field we take the initiative to develop the capacity through training of the work force, we cannot establish the true value of the work.
We will need to assure that a work-life balance is in the equation and that appropriate staffing and systems of support for rehabilitation hospitalists are provided in ways that prevent the stress and burnout that have challenged hospitalists in other fields. For those of us who have spent our careers doing primarily hospital-based work, we know the rewards are great for us, for our patients, and their families, and we cannot imagine doing any work that is more gratifying. It is hoped that a new generation of rehabilitation hospitalists will catch the spirit and will be supported by hospitals, health systems, and health care policies to make major contributions to the care of patients with complex and disabling conditions.
References
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- Report to the Congress: Medicare Payment Policy . Medicare Payment Advisory Council . March 2011;209; http://www.medpac.gov/documents/mar11_entirereport.pdf Accessed: December 4, 2011
- Fact Sheet: AHA Briefing on Deficit Reduction Strategy for Inpatient Rehab . American Hospital Association . October 18, 2011; http://www.aha.org/content/11/11oct-irfdeficitreduccall.pdf Accessed: December 4, 2011
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- ⁎ Disclosure: 2A, PM&R senior editor; 8B, NIH Clinical Center, NINDS, and Kaiser Permanente
Disclosure Key can be found on the Table of Contents and at www.pmrjournal.org
PII: S1934-1482(11)01428-6
doi:10.1016/j.pmrj.2011.12.005
© 2012 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.
