By Richard C. Senelick, MD
“Secondary to dying, nursing home placement for an older person who was in the community is the worst possible outcome.” Kramer et al
You or one of your family members are in the hospital and your doctor has just told you that you will need a course of rehabilitation. Your doctor has been your family doctor for years, and all of your children have been born at the same hospital, but no one in your family has ever needed rehabilitation.
A short time after your doctor leaves your room a case manager enters and gives you three choices. One is an inpatient rehabilitation hospital and two are skilled nursing homes that provide rehabilitation services. How do you choose? Will your choice influence your ability to improve and reach your maximum potential? Absolutely!
What is the Difference?
My first article in this series spoke about the importance of “Dose-Function–Motivation.” Which will give you the greatest dose of therapy that performs functional tasks in a setting that motivates you to get better – an inpatient rehabilitation hospital or a skilled nursing facility (SNF)?
You have to ask some questions: Does a stroke patient do as well in a SNF as in an inpatient rehabilitation hospital? Is that patient as likely to be discharged home and back to the care of their loved ones? The answer to both questions is, “definitely not!” I don’t just say this because I work in an inpatient rehabilitation hospital, but because the medical literature supports this position. I know that my position will upset some very good people who work in skilled nursing facilities, but the facts support my statements.
Evidence-based medicine is the gold standard for clinical decision-making, whether we are deciding what medicine to use or what is the best choice in rehabilitation. Just as you wouldn’t take a pill that had not undergone rigorous testing, you need to follow the evidence when making a decision about rehabilitation. As early as 1997, a major study in the Journal of the American Medical Association compared stroke patients who received their rehabilitation at a rehabilitation hospital (IRF) versus a SNF. Those who received their rehabilitation at an IRF were three times more likely to be discharged home. That’s right, three times more likely to sleep in their own bed, eat with their families, and kiss their grandchildren goodnight. Knowing this, where would you want to go if you had a stroke?
Noted researcher Pam Duncan, PhD, looked at the same problem of poorer outcomes in patients who went to nursing homes for rehabilitation and determined that the practice of utilizing nursing homes “is now shown to be potentially cost ineffective and detrimental to patient recovery.” Not just less effective, but detrimental.
Similar data has been published for joint replacements, hip fractures and medical diagnoses such as cardiopulmonary conditions. People are being sent to skilled nursing facilities to save insurance companies money, but the price in what it means in outcomes is being paid by the patient.
What We Know
Intensity of Rehab Drives Success: The evidence is clear that success with rehabilitation is dose-related. The intense therapy provided in a rehabilitation hospital is superior to the less intense setting of a skilled nursing facility.
Functional Focus of Rehab is Crucial: Animal and human research demonstrates that it takes functional tasks to “rewire” the brain and restore function. Most skilled nursing facilities do not have access to the many technological advances described in my last article that promote repair of the nervous system.
Even Modest Functional Improvement Affects the Future of the Severely Impaired: Too often, healthcare providers assume that severely affected patients are not candidates for an IRH. This is not true. If these people are provided proper rehabilitation, the majority of patients are returned to their homes and families.
Rehab Hospitals Are Superior to Nursing Homes for Achieving Greater Gains and Going Home: The data speaks for itself. Patients who go to an IRH achieve higher functional gains and are more likely to go home than those who go to a skilled nursing facility (nursing home).
Hopefully, you are now a better informed consumer. In our final article on this topic, I will give you a checklist to use when deciding how to choose a rehabilitation facility and some tips on how to obtain the best possible care for yourself or your loved ones.
Richard C. Senelick, MD is a physician specializing in both neurology and the subspecialty of neurorehabilitation. He is the Medical Director of HealthSouth RIOSA, The Rehabilitation Institute of San Antonio, and an associate clinical professor in the Department of Neurology at the University of Texas Health Science Center in San Antonio. He has authored several books on stroke, spinal cord injuries, and brain injuries. Dr. Senelick is an expert in the WebMD Stroke Community