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The Rehab Back Door

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As a palliative care nurse practitioner in a large academic medical center, I’m dismayed when some of my frailest patients get discharged to “rehab”. It seems unlikely they will be able to effectively participate there, so what happens is those who can’t end up becoming long-term care or nursing home patients through the rehab back door.

 

I can understand patients and families wanting to pursue rehab. It sounds so promising: a chance to gain enough strength to resume their previous lives. But, as I’ve blogged before (http://palliativejournal.stanford.edu/?p=45109), that hope is unrealistic for many. And the transition to long-term care/nursing home status can be abrupt. Rehab facilities are required to make a regular determinations of a patient’s performance and so, from one day to the next, patients can “fail” rehab. Reviewing the literature, it looks like 20-30% of rehabilitation patients do so and become long-term care residents. (This is actually a very difficult area to search because there are so many different post-acute options and the patient population is heterogeneous.) In my experience most would refuse to be discharged from the hospital to a nursing home but go willingly to rehab.

 

Part of the problem, again, is that we don’t talk about this possibility in the hospital or when we send patients to rehab. Instead, that falls on our colleagues working in long-term care. I recently met with a wonderfully progressive team at the Genesis Spa Creek facility outside of Annapolis, Maryland http://www.genesishcc.com/SpaCreek . They shared the difficulty they have as the ones who finally have to break the bad news to patients and families that they are not able to go home and that a nursing facility is their only option. Many patients had begged their families never to send them to a nursing home, yet that is where they are.

 

So, my apologies to my long-term care colleagues and to the patients and families who sign onto rehab but end up in nursing homes. Post-acute care is a hot topic in healthcare reform and hopefully someone will come up with better options and transitions for us all.

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  • Brandi, CRNP, ACHPN

    Unfortunately, many patients who are appropriate for hospice or end-of-life care get assigned under “rehab” due to insurance reimbursements. It would be wonderful if medicare would cover the costs of the facility for patients who need hospice. Families who are unable to provide the 24/7 care required for home hospice often do not have any other choice. When patients have advanced stage illness, I will inform them that rehab is to be looked at as a “trial”, but prepare them that it may not go as well as planned. Unfortunately, many patients and families feel they have failed rehab if they are unable to perform the exercises, but often it is due to advanced illness, and should not be forced.

  • typefacepj

    My mother was one of those patients who should never have gone to rehab. After Multiple Myeloma, CHF, and COPD diagnosis, she was discharged from the hospital to rehab where she broke two ribs doing PT. Then was in so much pain she was sent back to the hospital and had a heart attack. Thankfully, she’s doing well now, a year later … but mum was one of the lucky ones … my brother and his wife have an apartment that she stays in. He’s her full-time caregiver. PT works wonders for many, but as you stated above, realistically it’s not.

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