As the role of physiatrists continues to evolve, the practice of rehabilitation medicine may pose additional challenges to physicians who manage patients with acute and chronic conditions that affect overall function. Medical emergencies, although infrequent, are reported in the rehabilitation setting, and staff must be trained in appropriate responses. The physiatrist must also know when to request early consultation to prevent minor medical problems from developing into major medical catastrophes. Physiatrists are frequently the “gatekeepers” of medical and nonmedical services when patients are participating in rehabilitation. The idea of gatekeeping, as promoted in other specialties such as family medicine, internal medicine, and pediatrics, requires that physiatrists be involved in the general coordination and medical care of patients with disability.
Health insurers, particularly Medicare, have continued to promote financial incentives for inpatient rehabilitation for acutely ill patients and patients with several comorbidities. Patients are admitted to an acute inpatient rehabilitation unit with the expectation that they will be able to tolerate or participate in at least 3 hours of rehabilitation services per day. The broader interpretation of the 3-hour rule supports the treatment of medical problems that previously required transfer to an acute medical floor. Acute medical events, such as deep vein thrombosis, pneumonia, chest pain, or high blood pressure, are treated in the inpatient rehabilitation unit—unless these conditions suggest hemodynamic instability—with the expectation that the patient’s progress and functional recovery may be interrupted many times during the acute rehabilitation program In addition, many managed health care providers, as well as Medicare, will not pay for hospital-based inpatient rehabilitation programs unless medical justification is explicitly defined to keep the patient in a hospital setting. Patients are expected to have active comorbidities that require medical management by a physiatrist or a consultant during their progression through functionally oriented programs, and merit a hospital-based rehabilitation stay. Otherwise, less-expensive settings for participating in rehabilitation programs are sought.
Several factors have contributed to changes in the types of patients who utilize acute rehabilitation settings, among them:
Older patients are participating in rehabilitation. More people are living beyond the age of 65 years. Aging baby boomers are becoming more involved in their health care management.
Sicker patients are participating in rehabilitation (eg, those with traumatic brain injury, spinal cord injury, and multiple traumas).
More people with chronic diseases that are treated with highly technical surgical and medical interventions are participating in rehabilitation.
Thus, changes in the overall demographic distribution, advancing medical and surgical knowledge and methods, and social policies directing cost-containment are creating a rehabilitation population at greater risk for developing medical emergencies that may interfere with traditional rehabilitation programs. Rehabilitation professionals are expected to prevent emergencies by anticipating the anatomic and pathophysiologic impact of rehabilitation interventions in such high-risk patients.
Centers for Medicare and Medicaid Services: Coverage of inpatient rehabilitation services. Medicare Learning Network (MLN) Matters. January 18 , 2013; 1–11.