Sg2 Web Seminar 06012007 Emerging Trends In Irf[1]

Emerging Trends in Orthopedics and
Neurosciences Inpatient Rehabilitation
Holly Wisniewski, MBA
Consultant

Kelly Huseby
Consultant

Guest Expert Presenters:
Susan Gregg, VP
Darlene D’Altorio, PT, MBA, Director Of Rehab &
Support Services
Akron General Edwin Shaw Rehab

June 1, 2007

5250 Old Orchard Road Skokie, Illinois 60077 www.sg2.com

Agenda
Introduction
Changing World of Inpatient Rehabilitation
Strategies for Successful Management of Inpatient Rehab Facilities
Questions

Inpatient Rehabilitation: A Time of Flux

Demand for postacute care has increased over the past 20 years and will
continue to increase.
Baby boomers are entering the prime age for strokes and heart attacks.
Over the next 10 years, the most common procedures requiring rehabilitation will be:
Stroke: +21%
TJR: +51%
Fracture: +9%
Advanced technologies save larger proportions of babies with birth defects or
special needs.
Increasing evidence highlights the value of early rehab integration.
Rehabilitation needs of patients are changing with the evolvement of acute
care treatment, regulation and reimbursement.

Effective management and differentiation are key for financial and care delivery success.
TJR = total joint replacement.
Sources: Impact of Change® v6.0; NHDS; Sg2 Analysis, 2007; www.seniorjournal.com; www.bohse.com.

3
Confidential and Proprietary © June 2007 Sg2

Spending for Postacute Care Has Risen
in Each Setting
Medicare Spending in the Postacute Care Setting, 1992–2005
Dollars (Billions)
Postacute
45
Home Health
42.1
SNF
40
38.9
IRF
35.7 LTACH
35 34.1
32.9
32.6
31.3
30 29
27.7
25.3
25 25
24

20
18.5
18.2 17.9
17.4 17.2
15.7 15.2
15 13.1 14.7
14 13.2
12.9 12.9
12.8 12.3
11.3
10.9 10.8
10.6
10 9.9 9.9
9.7 8.9 8.8 6.6
8.4 8.4
7.2 7.1 6.4
6.2
5 5 4.9
3.6 4.6
4.2
4.1
4
3.9
3.8 3.8
3.6
3.5
3.4 3.4 3.1
2.8 2.5
1.9
1.7 1.7
1.4
1.2
1.1
0.8
0.6
0.3 0.4
0
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Note: These numbers are program spending only, and do not include beneficiary copayments.
SNF = skilled nursing facility; INF = inpatient rehab facility; LTACH = long-term acute care hospital.
Source: MedPAC, 2006.
4

About Akron General Edwin Shaw
Rehab (ESR)
4 Scopes of Service
Inpatient medical rehabilitation: 48 beds
Inpatient skilled nursing services: 49 beds
Outpatient medical & vocational services
4th location opening in July
Chemical dependency services
Most CARF-Accredited Rehab
Programs in Ohio
19 programs accredited 2007 to 2010
Inpatient medical rehab (child, adult)
Brain injury, inpatient, outpatient,
vocational services (child, adult)
Inpatient case management (child, adult)
Inpatient and outpatient stroke specialty
Outpatient single service, multiservice
(child, adult)
Vocational employment services
A 100-acre freestanding rehabilitation facility
~50 miles south of Cleveland, OH Governance standards applied
CARF = Commission on Accreditation of Rehabilitation Facilities

5

Edwin Shaw Rehab: Answering
Community Needs, 1915 to Present
Akron General Edwin Shaw Rehab History
Opened to serve 4-county area in the treatment of tuberculosis
1915
Transitioned to skilled nursing facility
1961
Added chemical dependency treatment
1974
Opened IRF beds while retaining skilled beds
1977
Added vocational rehab outpatient services
Early 1980s
Introduced multiservice outpatient medical rehab
Late 1980s
Added outpatient locations
1990s
Acquired by Akron General from Summit County to complete a full continuum of care
2005
Accredited by CARF in 19 programs
2006
Participated in numerous research studies (eg, electrical stimulation on the stroke
affected hand).
Showed financial improvement in first full year post transition that was 43% better
than 2005 and 66% better than 2004 (last year of full county ownership)
Demonstrated an average FIM (24.3 vs 22.3) gain that was 8% higher than national
average despite having patients with 11% higher acuity from 2002 to 2006
FIM = functional independence measure

6

Fragmentation of the Postacute Care
World Makes Management Difficult
Comparison Between Therapy Requirements, Payment, and Outcomes
Assessment Between IRF, SNF, LTACH, HHA and OP Rehab
Type IRF SNF LTACH HHA OP Rehab
Hours/Day 3 hrs/day 0.5–2 hrs/day — 0.5–1 0.5–2
hrs/day hrs/day
Days/Week 5–7 days/week 5–7 days/week
3 days/week 3 days/week
Payment Unit 100 CMGs + tiers 44 RUG-III LTACH DRGs 80 HHRGs Physician
groups Fee
Schedule
Type of Per discharge Per diem Per discharge, Per 60-day Per therapy
Payment per 60-day episode unit
episode
Assessment IRF PAI (Uses MDS None OASIS —
Tool/Basis rehab impairment (Diagnosis and
of Payment code [RIC] and clinical service
ICD-9 codes oriented)
Functional FIM MDS–Section — — —
Tool G/ADL scores
HHA = home health agency; CMG = case mix group; IRF DAI = Inpatient Rehab Facility Patient Assessment Intrument; MDS = minimum data set;
HHRG = Home Health Resource Group; OASIS = Outcomes and Assessment Information Set.
Sources: VCU Health System: Rehabilitation and Research Center, 2002.

8

Inpatient Rehabilitation Offers Unique
Benefits to Patients and Families

Benefits Challenges
Intense medical oversight that Continuous regulatory changes and
allows for the management of increasingly difficult claims process
multiple medical comorbidities and Stringent provision of care requirements
the reduction of potential
No common patient instrument used to
complications
assess patient care and guide placement
Rigorous therapies that enable decisions
patients to achieve maximum
Limited evidence-based standards and
independence upon departure
research
Unique interdisciplinary clinical
Resource-intense care provisions—
approach and environment that
medical supplies and equipment, staffing,
fosters patient and family education
etc
Social, emotional and physical
Little data transparency across the
support that assists a variety of
postacute settings—quality, outcomes,
medically complex patients
financial, patient diagnosis

9

Inpatient Rehabilitation Regulation Has
Impacted the Provision of Care

75% Rule
This is a component of the strict criteria that a facility must fulfill in order to qualify as an IRF. Under
the rule, facilities must prove that at least 75% of their patients have 1 of 13 designated medical
conditions for which CMS deems inpatient rehab medically necessary.

Phased Approach of the 75% Rule
Since 2003, there has been continuous debate over the fairness of the 75% Rule.
To ease implementation, CMS has created a 4-year transition period for compliance:
50% for cost reporting cycles beginning on or after July 1, 2004 and before July 1, 2005
75% for cost reporting cycles beginning on or after July 1, 2008

Legislation pending in Congress would freeze the threshold at the current 60%.

Source: MedPAC, 2007
10

Shifts in Case Mix Illustrate the Direct
Impact of Regulatory Change
Akron General Edwin Shaw Rehab,
Distribution of Most Common Types
Volume by Patient Diagnosis 1997–2006
of Cases in Inpatient Rehabilitation
Facilities, MedPAC
500
Types of Cases 2004 2005 2006 470
440
450
437 437
Stroke 16.6% 19.0% 20.3% 419
400 397
Major joint Ortho 372
24.6% 21.3% 18.4% 357
replacement 350
Hip fracture 13.1% 15.0% 16.0% 300
Burns 11.8% 10.4% 10.2%
250
Stroke
Neurological 5.1% 6.0% 6.7% 208 203 191
186 182
200 184
180 174
Brain injury 4.0% 5.1% 5.8% 201
Brain Injury 163
150 141
Other orthopedic 5.2% 5.1% 5.0% 140 140
123
119
126
100
Spinal cord injury 4.4% 4.4% 4.6% 97
64 93
79 77
Gen Med
65
60 58
Cardiac 5.2% 5.2% 4.0% SCI
54 53
50 50 49 43
36 36 34
32
31 28
26
23 17 17
Other 14
10% 9.5% 9.0% Neuro
0
1997 2000 2001 2002 2003 2004 2005 2006

IRF PPS
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Beware of Basing Future Success With
the 75% Rule on Past Performances

ESR 75% Rule—Conditional and Presumptive Compliance,
Newest Regulatory Rule Application
Percent
90 85
77
80 75
73
70
67 66
70 65
60 75% Conditional
58
60
50 75% Presumptive
40
30

20
10
0
2002 2003 2004 2005 2006

12

Government Effort to Control Cost Has
Shifted Acuity and Discharge Disposition

There has been a decrease in days in acute care facilities.*
This is due to a multitude of factors, such as reimbursement changes and technology
advancements.
ESR has seen a 15% increase in the average CMI from 2002 (CMI=1.17) to YTD
(CMI=1.37).
Regulation has dramatically impacted discharge disposition.
IRF percent discharge to the community has decreased from 84% in 1998 to 70% today.
Despite the acuity shift, Medicare continues to redefine CMG length of stay.

IRFs at a Glance, MedPAC 2002–2005
Annual ∆ ∆
2002 2003 2004 2005
2002–2004 2004–2005
Number of Cases 439,631 478,723 496,695 449,321 6.4% -9.5%

Medicare Spending (Billions) $4.9 $6.2 $6.6 $6.4 15.5% -3.0%
Payment per Case $11,152 $12,952 $13,275 $14,248 9.1% 7.3%
ALOS (days) 13.3 12.8 12.7 13.1 -2.4% 3.6%
*ESR has traditionally accepted patients from acute care sooner than regional and national averages, but this disparity has begun to level out.
CMI = case mix index.
13

Despite the Regulatory Challenges, Large
Margin Variability Suggests Opportunity
The aggregate Medicare margin for 2005 was Medicare Margins by Type of IRF
13%.
Type of IRF 2003 2004 2005
25th percentile: -4% margin
75th percentile: 22% margin
All IRFs 17.8% 16.2% 13.0%
For-profit has 2x margin of nonprofit
2007 margin estimates: 2.7% due to 75% rule Urban 18.6% 16.8% 13.5%
Payer mix will continue to shift.
Rural 10.0% 10.5% 8.4%
Medicare may no longer be the majority payer
due to Medicare Part D.
Freestanding 23.0% 24.3% 20.9%
Edwin Shaw payer mix example:
2003: 59% Medicare
Hospital-based 14.9% 12.0% 8.5%
2006: 47% Medicare
April 2007 YTD: 32% Medicare
Nonprofit 14.3% 12.4% 9.6%
Reimbursement will continue to fluctuate.
For-profit 24.5% 24.5% 20.0%
National Medicare reimbursement/day
2001 pre PPS : $1,414
Government 10.8% 9.0% 5.0%
2002 post PPS : $976
2006 post PPS : $1,114
PPS = prospective payment system.
Sources: MedPAC: Report to Congress: Medicare Payment Policy, March 2006.
14

Regulatory Changes Has Caused the Roles
of Postacute Care Settings to Blur

There is increasing debate over the best care setting as the government pushes for universal
outcome and reimbursement methodology.

Individual “silos” of postacute care don’t function as an integrated
system.
There is no common patient instrument used to assess patient care and guide
placement decisions.
Payment reflects the resource needs of the patient and not the setting.
Outcomes don’t gauge the value of the care furbished.
Almost nothing is known about:
Patterns of postacute care use across settings
The costs associated with particular patterns
How providers have altered patterns of postacute care use in response to changing
financial incentives
Several barriers inhibit integration.
Case mix measurement is inaccurate.
Data on quality and outcomes are not comparable.
Evidence-based standards are lacking.

15

Data Suggest Shift From IRFs to Other
Settings
Number of Rehabilitation Facilities, 1985, 1996, 2004–2006
% Change
1985 1996 2004 2005 2006
2004–2006
Rehab Hospitals and Units 454 1,050 1,359 1,233 1,227 -9.7%
Hospitals 68 195 218 218 218 0%
Units 386 841 1,141 1,015 1,009 -11.6%
CORFs 86 378 638 637 634 -0.6%
Long-Term Care Hospitals 86 185 317 363 385 21.5%
SNFs 6,725 15,338 14,935 14,129 15,028 +0.6%

Major Takeaways:
<13% of IRFs will qualify as such if they continue to serve populations excluded from
the 75% rule.
Facilities are either closing, merging or changing to LTACH or SNFs.
LTACH growth is expected to slow.
MedPAC, stating that there is excess capacity and few clinical studies, suggested a $460 million
cut from Medicare reimbursement over the next 3 years.
CORF = comprehensive outpatient rehabilitation facility.
Source: American Medical Rehabilitation Providers Association.

16

What Does the Future Hold For
Postacute Care?

?
1998 SNF: PPS

2000 HH: PPS

Increased postacute care utilization
1997 HH: Interim 2004 IRF: 75% Rule
Continued government reaction to increase
Payment System
utilization and cost
2002 IRF: PPS
Drive for additional rehabilitation research
2002 LTCH: PPS Push for consistent reimbursement and
patient functional measures
2000 OP: Pmt Cap

Past Future
1995 2000 2005 2010 2015 2020 2025 2030

1997: BBA
2003: MMA
1999: IHI Report

1996: HIPAA

BBA = Balanced Budget Act; MMA = Medical Modernization Act; IHI = Institute for Healthcare Improvement;
HIPAA = Health Insurance Portability and Accountability Act.

17

Utilize 4 Strategies for Success in the
Management of IRFs

1. Understand your current market and operations to determine
feasibility of IP rehab.
2. Monitor and collect data to improve outcomes and reimbursement.
3. Communicate, educate and coordinate.
4. Differentiate your services.

19

1. Assess Your Market
Location of IRFs in the US, 2004 Implications:
The number of IRFs vary
geographically making
competition differ greatly
by region.
The IRF setting may not
be appropriate for your
market.

Key questions to help assess your market:
Who provides IRF services in your market?
Are there subacute rehabilitation or long-term acute care services available?
Who provides home health and outpatient services?
How has Medicare Part D affected your payer mix?
Is there population growth in the 45+ age cohort?
How are your services differentiated?

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1. Understand Current Capabilities

Where does rehabilitation fit in
your system? Is rehabilitation a
core service?
Assess your internal
capabilities.
Consider all options for
Women’s
Health
providing rehab.
Cancer Orthopedics Internal development
Partnership
Acquisition
Joint venture
Cardiovascular Pediatrics

Neurosciences

21

1. Understand Current Capabilities

Current Capabilities Checklist
Clinical Expertise Do you have a physician champion (physiatrist) for rehabilitation?
(MD, PT, OT, SP) Does your staff have particular specialized expertise (RN, PT, OT)?
Current Patient Mix Do you have the volumes to support the 75% rule?
Resource What resources is your organization willing to dedicate to
Dedication rehabilitation (financial, facilities, equipment, training, etc)?
Care Coordination Do strong referral pathways exist?
(Internal and What relationships do you have with other postacute care providers?
External Referrals)
Equipment Do you have appropriate equipment to meet patient demand?
Dedicated Space Do you have enough dedicated space to meet patient volume?

22

1. Consider Various Structural Models
for Providing IP Rehabilitation

IP Rehab Models:
Partnership
Example: Rehabilitation Institute of Chicago and St Joseph Regional Medical Center,
South Bend, IN
Example: Telemedicine and St Luke’s Rehab Institute, Spokane, WA
Joint Venture
Example: Seton Family of Hospitals, Austin, TX, and RehabCare Group, Inc
Internal Development
For hospitals that don’t offer rehab or are considering limiting rehab, a specialized
hospital unit trained to care for specific patient population can be successful.
Example: comprehensive stroke units
Specialized interdisciplinary stroke teams
Patient remains in same bed throughout acute and rehab stages of care
Lower ALOS
Higher patient satisfaction
Better outcomes
Acquisition
Example: Akron General Edwin Shaw Rehab

23

1. Partnership Case Example

Partnership between St Joseph Regional Medical Center
(South Bend, IN) and the Rehabilitation Institute of Chicago

Evaluated growth rate in its regional market of north central Indiana and southwest
Michigan
Determined there was a 12% 5-year growth rate in the aged 65+ population, the
largest users of rehabilitation

Partnered with RIC to expand physical medicine and rehabilitation (PM&R)
services
Allows SJRMC to be only health care system in region to offer RIC’s full
spectrum of PM&R for acute and postacute care
Med/surg rehab
Inpatient rehab
Long-term acute care
OP rehab
24

1. Partnership Case Example

Technology can assist with staffing limitations.
St Luke’s Rehab Institute (Spokane, WA)
Telemedicine:
20 telemedicine sites across rural eastern Washington
link Inland Northwest Health hospitals to St Luke’s.
St Luke’s therapists can teleconference with PTs in
tertiary care hospitals.
Assist PT in setting up treatment regiments
Perform physical examinations of patients
Form support groups

Results:
Improves communication
Uses staff resources more efficiently
Helps with specialist shortages

Printed with permission of InTouch Health.

25

1. Joint Venture Case Example

Joint Venture Between Seton Family of Hospitals (Austin, TX) and
RehabCare Group, Inc

Freestanding Facility
Rehab Unit Within
Seton Medical Center
36 bed IRF
26 bed SNF
40 bed LTACH

Initial Steps: Joint venture:
Initially losing money in SNF despite high 80%/20% ownership (RehabCare/Seton)
occupancy rates meant minimal capital investment for
Moving rehab to a freestanding facility to Seton
allow SNF beds at Seton to be converted into 50%/50% representation on board
additional acute med/surg beds Can still capture rehab patients
In interim, re-licensed SNF beds as IRF beds unqualified for IRF
until the new facility is built Enhanced care provision and patient
experience

26

2. Monitor and Collect Data

Collect data.
erehab.com
Uniform Data Set for Medical Rehabilitation
Understand the regulatory impact for your system.
Understand Ruling: 85-2’s definition of “reasonable and necessary” in order
to defend a rehabilitation level of care using the 8 screening criteria
established by CMS. Make this part of the mind set for the preadmission
screening process.
Compare conditions in 75% rule and associated ICD-9 codes with your
patient population diagnoses and ability to meet “medical necessity”
requirements.
A predominantly neurologically impaired patient population will be able to
more easily comply with the 75% rule.
If you have an IRF, analyze acute care discharges to see if additional
patients could be captured.

27


Understand Ruling 85-2’s definition of “reasonable and necessary”
in order to defend a rehabilitation level of care using the 8 screening
criteria established by CMS. Make this part of the mind set for
preadmission screening process.
1. Close medical supervision by a physician with specialized training or experience in
rehabilitation
2. 24-hour rehabilitation nursing: Review fall risk, pain level, safety interventions, skin
interventions, bowel/bladder interventions and the need for rehabilitation nursing carry over in ADL
training 24hrs/day.
3. Relatively intense level of rehabilitation services: Amount of therapy provided; either here or
section 5; include specialty consults; orthotics, etc.
4. Multidisciplinary team approach to delivery of program, looking specifically at all persons that
must be involved; must have at least 2 therapies
5. Coordinated program of care is required.
6. Significant practical improvement is expected. This takes an experienced clinician to review all
the data and preadmission hints of recovery.
7. Realistic goals: Try to be certain the support systems are available to help meet those goals.
8. Length of rehabilitation program: Keep in mind that you are using the probable CMG LOS as
the target.

28


Evaluate staffing coverage.
Set guidelines to assist in staff coverage:
Number of patients with infections that result in isolation
Number of high level spinal cord injury
Number of brain injury patients
If applicable, cross train in order to float staff between care settings.
Outpatient staff can move to inpatient.
Nursing and therapy staff can float between skilled and rehab units.

29


Johns Hopkins Hospital Average Length of Stay (ALOS) Reduction Project
Background/ Longer stay doesn’t result in higher payments.
Goal LOS was measured against country’s most efficient hospitals and
adjusted for case mix and severity.
LOS was compared among similar cases with different physicians.
Actions Based on data, an action plan was created.
Delays in diagnostic tests and consultative work were reduced.
Social workers and case workers began postdischarge planning early on.
Clinicians focused on proven best practices.
Proper coding of the severity of cases was assured so that predicted LOS
was appropriate. For given diagnosis, appropriate LOS was determined
and adhered to.
Results Overall ALOS was reduced to 9 days.
There is a point when LOS levels off—it is important to maintain
equilibrium between LOS and quality of care.

30

3. Communicate, Educate and
Coordinate

Communicate and Educate
Physicians
Improve outcomes and initiate ownership Case Managers
by informing all stakeholders of:
Regulatory changes and implications Therapists
Operational data
Nurses
Care model changes/care protocols
Care coordination
Administration
Coding changes
Technology adoption
Patients

The rehabilitation staff must be flexible.
Acute care treatments are changing rapidly, which requires customized postacute
patient care plans.
Education is key.
Not only must staff continue to seek education around new care protocols and best
practice, but staff must also understand regulatory and reimbursement changes that
impact care provision.

31

3. Decision Trees Assist in Appropriate
Patient Placement
Yes Yes
Will Insurance permit level of Does patient demonstrate the need for 24 hr availability
Can patient be safely managed
care suggested after patient of a rehab physician, close medical supervision, ie, needs
in a nonacute environment?
information is reviewed? to be examined by a physician every 2-3 days?
No
No No Yes
Delay admission until
Follow criteria for admission outlined Admit to skilled if meets skilled
information is received.
by insurer (advocate when possible). nursing or therapy criteria.

Is there potential for significant
Does the patient require and have the ability to tolerate an extensive level of Does patient
Yes Yes
improvement in a reasonable
therapy (≥2 disciplines) generally ≥3 hrs/day within the first 10 days? Or is require 24 hrs
length of time that is of practical
there the presence of a secondary diagnosis or medical complication that availability of a
value to the patient and may
prevents participation in 3 hrs/day therapy initially but can soon be ramped up? rehab nurse?
result in return to community?
No
Yes Follow SNF criteria.
Yes Yes
After medical necessity is met, Yes Is family/caregiver Is the patient a
is there a qualifying RIC or Does the patient have a cognitive/memory deficit available for recent brain injury
a diagnosis that follow the that impairs/prohibits the ability to learn? teaching with a Rancho
75% rule? requirements? score ≥3?
No
No No
Check with PPS coordinator and Review if appropriate for short term SNF care. If Rancho <3, follow SNF
look at SNF criteria. If not appropriate, do not admit to ESR. criteria.
Yes
If it is expected that the patient
Does the patient require a Does the patient require that a
Admit to No No
will require assist at discharge,
Yes
dialysis, radiation or prosthesis be fabricated within
is there presence of a capable
ESR chemotherapy? initial rehab stay?
care giver?

Yes
Yes
No
Team discussion, if answer still ‘no’, Follow SNF criteria. Follow SNF criteria.
Source: Akron General Edwin
must be approved by med. Dir/or VP.
Shaw Rehab.

32

3. Decision Trees Can Be Tailored to
Specific Conditions
Framework for Rehabilitation Decisions Poststroke
Yes Yes
Is patient medically Does patient have a Is patient able to
Yes
moderately stable? functional disability? learn? Rehabilitation
Does patient have setting with low
No
No endurance to sit
No intensity services
supported for 1 hour (nursing facility or
Delay rehabilitation Provide care in setting
Does not need and to participate No home program)
decision until medical with adequate
rehabilitation actively in
stability is achieved. supportive services. rehabilitation?
Level of Supervision
Moderate/ Maximum
Independent Minimum Assistance Assistance
Can patient manage IADLs, including Is adequate home Can patient tolerate intense
meals, telephone, and transportation? support available? rehabilitation (≥3 hours/day)?

Yes No Yes No
Yes No
Home or OP program, a Does patient
Brief IP Setting with
brief IP program in a need 24-hour
program in
Home or OP lower intensity
Is adequate
nursing facility or hospital medical care or
nursing facility
rehab services services
home support
may be indicated if patient monitoring?
or immediate
as needed (nursing facility,
available?
has multiple complex care facility home program)
deficits.
No
Yes
Yes No
IP rehab hospital nursing facility Setting with intense services and
Home or OP rehab with intensive rehab program
Rehabilitation services in adequate medical coverage may
services as needed capabilities and adequate acute
nursing facility or other be IP rehab hospital, nursing
care coverage
supervised living setting facility or home program
IADL = instrumental activities of daily living.
Source: Gresham GE et al. Stroke 1997.
33

3. Communicate, Coordinate and
Educate

Case Example: University of Iowa Hospitals and Clinics, Iowa City, IA
Relied on Physician Referrals Referrals Based on Consultation of
for Rehab Volumes All Patients by PM&R Physician
Results Results
Wide variation in referrals Determines care plan and coordinates
patterns by physicians appropriate rehab and follow-up
Discharge planning left to primary Does not rely on individual physician
physician, care manager, social prescribing patterns
worker and PT/OT, not rehab Results in early initiation of therapy, which
physician can improve functional outcome
No team-specific rehab team Reduces LOS and improves operating
Underutilization of PT and poor margins
capture of OP PT/OT Increases patient satisfaction, leading to
Prolonged LOS increased utilization of other services
(elective)
Increases utilization of OP rehab services

34

4. Differentiate Your Services

Technology adoption in rehabilitation is expected to be slow,
making differentiation in service and programming key.
Service and comprehensive programming
Patient and family access (location and convenience)
Quality of care
Spa/fitness center
Family education
Support groups
Facilities
Specialized programs (eg, stroke program)
Flexible care model (staffing and bed type)
Continuous survey of the market
Technology

35

4. Differentiate Your Services:
Incorporate a Flexible Care Model

Changes in acute care utilization will impact location and volume
of rehab services.
Technology/Trend Impact on Rehabilitation
MIS approaches
Shifts from IP to OP, OP and
Reduce patient length of stay
home based services increase
Increase patient volumes
and session numbers reduced
Shift care outpatient

Medical therapies
Reduce inpatient admissions
Reduce IP, increase OP
Increase physician office visits
Reduce LOS

Implantable therapies
Increase IP, increase OP
Increase inpatient and outpatient
volumes

36


“We leverage and coordinate the admission to SNF and IRF by using
the decision tree and ruling 85-2. We also negotiate with payers that
tend to place ALL their patients on SKILLED by defending expected
outcomes and data we have for a specific patient population treated on
REHAB. Expertise and programming are very specific on the brain injury
unit for example. To fully execute the brain injury protocol and functional
cognitive training advancements, the patient must be placed on that
unit.”
—Edwin Shaw Rehab

37

4. Differentiate Your Services: Emerging
Technology Advances in Rehab
Technology Considerations
Constraint-Induced Low-tech approach and requires no capital investment
Movement Therapy Utilized in IP, OP and home-based rehab
Robotics High-tech and high capital investment
Various models in development for many different impairments
Could be utilized in IP and OP rehab; home-based rehab in the long term
Virtual Movement High-tech and high capital investment
Spaces Various models mostly for support of occupational therapy
Could be utilized in IP and OP rehab; home-based rehab in the long term
Stem Cell Research Stem cell transplantation combined with exercise training to enhance repair and
regeneration of nervous tissue after spinal cord injury
Genetic Genes turned on/off, simple variation on genotype to produce wide differences in
Engineering phenotype; possible direct implications for the variability among rehab patients and
functional outcomes in patients with the same diagnosis
Response to exercise training determined partially by the activation of certain
genes, therefore matching patients to rehab interventions may be more successful
Tissue Engineering Evaluation of clinical/functional demands on new cartilage, muscle and bone
needed before designing new organs and tissues
Nanotechnology Better materials to fabricate better assistive devices (artificial limbs, orthotics, other
assistive devices)

38

4. Regenerative Medicine Is the Next
Generation of PM&R

Tools of regenerative medicine expand neurorehabilitation.
Neurorehabilitation

Tomorrow
Emerging technologies
Physical medicine and rehabilitation
and approaches increase
Mechanical and electrical implants
demand for physical
Injectable biologics
medicine and rehabilitation
Bionics
specialists, making them
highly sought after in the
Today
2010s and 2020s.
Physical medicine
and rehabilitation

39


Regenerative medicine will create an opportunity for long-term
relationships.
Significant time is required to regenerate neuronal connections.
April
Today:
March
February
Rehabilitation lasts weeks to months. 10
January 10
Short-term opportunity exists to 10 2006
10 2006
capture secondary utilization.
2006
2006
Tomorrow:
January
Rehabilitation lasts years. January
January
10
Long-term opportunity exists to
10 January
capture secondary utilization. 10
2006
2007 10
2008
2009
40

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education company. Sg2 analyzes emerging clinical developments,
technological advancements and market trends to help clients make
informed business decisions, advance clinical excellence, streamline
operations, grow market share and exceed financial goals.

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Sg2 Web Seminar 06012007 Emerging Trends In Irf[1]

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Sg2 Web Seminar 06012007 Emerging Trends In Irf[1]