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Chapter 66. Rehabilitation of the Orthopedic Surgical Patient

Doris J. Armour, MD, MBA; John L. Lin, MD

Acute rehabilitation tries to restore the premorbid physical and mental functioning of patients as much as possible by increasing muscle strength and patient endurance, improving muscular coordination and control, and providing adaptive equipment when necessary. Choosing the appropriate setting for provision of the needed services requires a working knowledge of the different levels of care available for rehabilitation services—acute inpatient rehabilitation, subacute rehabilitation, outpatient rehabilitation, and home health services. Determinants of the appropriate level of care include the functional limitations of the patient, the need for medical monitoring, social support, cognitive functioning, nursing needs, therapeutic disciplines required, and ability to tolerate three hours of therapy a day.

The Centers for Medicaid and Medicare Services recently instituted a prospective payment system for acute inpatient rehabilitation facilities. For Medicare approved facilities, a certain percentage of all admitted patients must have 1 of 13 diagnoses: stroke, brain injury, burns, SCI, neurological disorders, major multiple trauma, congenital abnormalities, inflammatory polyarthritis with impairments of ambulation and ADLs that have not responded to less intensive therapies, amputations, hip fractures, bilateral joint replacements, and unilateral joint replacements in individuals > 80 years old or the morbidly obese. Rehabilitation centers must provide, and patients admitted to the acute rehabilitation center must require, interdisciplinary, team-based care, 24-hour rehabilitation nursing, daily physician assessment, and three hours of therapy daily. The interdisciplinary team in acute rehabilitation facilities consists of a physician leader, registered nurse (RN) with rehabilitation certification or expertise, physical therapy, occupational therapy, speech therapy, therapeutic recreation, social work, nutrition, neuropsychology, and often psychology, an orthotist, prosthetist, and a chaplain. Patients receive therapy five to seven days a week (Table 66-1).

Table 66-1 Criteria for Admission to Acute Rehabilitation
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Table 66-1 Criteria for Admission to Acute Rehabilitation
  • Preadmission assessment must include:
    • Prior level of function
    • Expected level of improvement
    • Expected length of time to accomplish improvement
    • Risk for clinical complications (ie, decubitus ulcer, UTI, etc.)
    • Condition that caused need for rehabilitation (etiologic diagnosis, ie, stroke)
    • The impairments necessitating rehabilitation (diagnosis, ie, hemiparesis, dysphagia)
    • Combination of treatments needed (wound care, bowel/bladder training, antibiotics, therapies)
    • Expected duration of rehabilitation
    • Anticipated discharge destination (must be to community, SNF is not an acceptable discharge destination)
    • Any anticipated post acute rehabilitation therapies needed (ie, HH, outpatient therapy)
  • Acute inpatient rehabilitation is deemed reasonable and necessary if:
    • Multiple therapy disciplines are needed (PT, OT, and or ST) and PT/OT referral from the index hospital
    • Intensive level of rehabilitation provided (three hours per day and at least five days a week)
    • Ability to participate in intensive therapy and make reasonable improvement demonstrated
    • MD supervision provided on a daily basis
    • Interdisciplinary team approach utilized
    • Insurance approval required prior to transfer

HH, home health aid; OT, occupational therapy; PT, physical therapy; SNF, skilled nursing facility; ST, speech therapy; UTI, urinary tract infection.

Long-term acute care (LTAC) facilities may also provide daily therapies using speech (ST), physical (PT), and ...

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