6

Rehabilitation

DEBRA J. SHEETS

INTRODUCTION

Rehabilitation is designed to facilitate the process of recovery from injury, illness, or disease to as normal a condition as possible. Because of population aging, older adults (persons aged 65 and over) are the fastest growing age group needing rehabilitation services. The goal of geriatric rehabilitation is to enable older adults to function at the highest possible level despite physical disability and disease. Geriatric rehabilitation involves an interdisciplinary team that uses a comprehensive geriatric assessment to inform the development of a plan of care to improve or restore function. Rehabilitative services are offered in a variety of settings across the continuum of care, but are most commonly offered in the postacute care (PAC) phase, following an acute illness or hospitalization. Several systematic reviews indicate that appropriate use of geriatric rehabilitation can reduce health care costs while leading to better outcomes that include improved function, reduced admissions to nursing homes, and lower mortality rates (Bachmann et al., 2010; Wells, Seabrook, Stolee, Borrie, & Knoefel, 2003a).

Although advances in medicine and rehabilitative science have reduced the prevalence of disability in old age, these have also contributed to rising health care costs (Schoeni, Freedman, & Martin, 2008). Unfortunately, these gains in health and disability may not extend to the future as the baby boom generation begins to enter the retirement years. Recent trends in disability among persons ages 50 to 65 show significant increases in mobility-related disabilities linked to musculoskeletal disorders, as well as increases in disability related to depression, diabetes, and nervous system conditions (e.g., Parkinson’s disease, multiple sclerosis; Martin, Freedman, Schoeni, & Andreski, 2010). As the numbers of older adults (ages 65 and older) double in the next two decades, these trends will likely drive increases in the need for rehabilitation.

Using rehabilitation resources effectively requires knowing how disability occurs and what is needed to achieve effective rehabilitation outcomes (Hoeing & Kortebein, 2012). It is critical to know who provides rehabilitation, what is available, in what settings, for whom, and how such rehabilitation is funded. This chapter reviews these aspects of geriatric rehabilitation. First is an overview of the evolution of rehabilitation and a discussion of two well-known conceptual models for disability. Next is a description of clients, providers, rehabilitation settings, and levels of care for geriatric rehabilitation. Additionally, interventions and modalities are discussed to support function in older adults. The chapter concludes with an examination of Medicare funding for rehabilitation services.

DEVELOPMENT OF THE FIELD OF REHABILITATION

The field of rehabilitation initially emerged in response to two major world wars. In 1917, reconstruction units were set up in 35 general hospitals and 18 base hospitals in the United States to address the needs of wounded soldiers returning from the battlefields. The programs were regarded positively because they allowed injured soldiers to recover and return to full duty. Strategically, rehabilitation was referred to as the third branch of medicine, which would complement specialties within the primary (i.e., diagnosis and treatment) or secondary branches (i.e., health promotion/disease prevention) of medicine. In the 1920s, the field was developed by physical therapy (PT) physicians. One may be surprised to learn that radiologists were the first to use physiotherapy to treat patients. However, by 1938, the radiologists and PT doctors recognized their different interests. In 1939, the term “physiatry” was coined, which recognized some of the similarities of physical rehabilitation to psychiatry. A physiatrist is a physician who specializes in physical medicine and rehabilitation (also called PM&R) and focuses on the prevention, diagnosis, and treatment of disease or injury.

During World War II, rehabilitation experienced tremendous growth. Bernard Baruch, a philanthropist, contributed funds to develop physiatry programs at selected universities and to award training fellowships to selected physicians in PM&R. This effort resulted in a core cadre of well-trained academicians to direct residencies and PM&R programs. By 1945, the American Medical Association (AMA) had established a section on PM&R, and in 1947, the AMA recognized physiatry as a separate medical specialty. The concept of rehabilitation involved a team’s approach to care led by the physiatrist, and this team included physical therapists (PTs), occupational therapists (OTs), vocational education specialists, and recreation personnel.

Medical rehabilitation got another boost in 1952 with the polio epidemics that affected more than 21,200 Americans of all ages. Until 1955, with the invention of the Salk vaccine, the polio epidemic dominated the attention of PM&R physicians. In 1958, the Vocational Rehabilitation Act added training funds for resident stipends in PM&R. Unfortunately, the 1965 enactment of Medicare and Medicaid did not provide funding for rehabilitation, but in 1972, Medicare coverage expanded to include inpatient rehabilitation.

Medical rehabilitation services and programs grew rapidly during the 1980s and 1990s, driven largely by the Medicare payment system. Prior to the Balanced Budget Act (BBA) of 1997, Medicare reimbursed all allowable charges for rehabilitation services and programs, although payments to a facility were capped at an annual maximum. This payment system served as an incentive for growth, and between 1985 and 1999, the total number of rehabilitation facilities (i.e., rehabilitation hospitals, rehabilitation units, long-term care hospitals [LTCHs], and comprehensive outpatient rehabilitation facilities [CORFs]) grew three-fold from 626 to 1,863 facilities. By 2002, the growth stalled out with implementation of a prospective payment system (PPS) in inpatient rehabilitation facilities (IRFs). IRFs are rehabilitation hospitals or rehabilitation units in an acute-care hospital that are licensed under state laws to provide intensive rehabilitative services. IRFs decreased to 1,165 by 2011 when they served about 371,000 Original Medicare (Part B) beneficiaries at a cost of $6.46 billion (Medicare Payment Advisory Commission [MedPAC], 2012a).

DISABILITY RIGHTS AND THE OLMSTEAD DECISION

In recent decades, vocational rehabilitation has received growing attention as the prevalence of disability has increased and disability has become more visible in society. Many older adults are “aging into disability” in later life because of chronic disabling conditions. In addition, more people are surviving with congenital disabilities (e.g., cerebral palsy) or with disability acquired in adulthood (e.g., spinal cord injury) because of accidents or trauma (Kemp & Mosqueda, 2004). People of all ages are benefiting from assistive technologies (ATs; e.g., electric wheelchairs, augmentative communication devices) that provide mobility and allow them to be mainstreamed into our society. The passage of the Americans with Disabilities Act (ADA) in 1990 assured civil rights protections for persons with disabilities against discrimination and required “reasonable accommodations” to allow full participation in society. In 1993, amendments to the Rehabilitation Act increased access to vocational rehabilitation by requiring “presumption of ability” and offering necessary services and supports, including AT, for employment. Another pivotal moment in disability rights occurred with the Olmstead v. L.C. decision in 1999, when the United States Supreme Court held that the ADA requires that states provide the necessary community-based services to persons with disabilities to allow them to live in the least restrictive setting available. In the years since this ruling, the Olmstead decision has been used to improve the lives of thousands of persons with disabilities of all ages by assuring them of their right to rehabilitation and to continue living in the community rather than being institutionalized.

CONCEPTUAL MODELS FOR DISABILITY

Conceptual models are useful in gaining a clearer understanding of the underlying processes that lead to disability and for which rehabilitative interventions are possible, which can change outcomes by improving function. In the last several decades, our understanding of the causes of disability has changed. Two well-known and widely used conceptual models are described in the following sections.

FIGURE 6.1 WHO ICF model of disability.

INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH

The International Classification of Functioning, Disability, and Health (ICF) model, developed by the World Health Organization (2001), is a classification framework for assessing health and functioning at both the individual and population level. The framework proposes that health conditions (e.g., spinal injury) can cause impairments (e.g., paralysis) that affect the individual’s level of function (i.e., body function, ability to do a task, and participate in activities) within the context of environmental and personal factors (see Figure 6.1). Medical interventions (e.g., medication, surgery) address the underlying health conditions, and rehabilitation services target the impairment, activities, and participation. Personal (e.g., preferences) and environmental factors (e.g., assistive devices, personal assistance) also influence activity and participation. What this means for older adults is that the disablement process will be highly influenced by the number and type of comorbidities and the resulting impairments. Multiple strategies are needed for effective treatment of late-life disability (Hoenig & Kotebein, 2013).

INSTITUTE OF MEDICINE ENABLING–DISABLING MODEL

The Institute of Medicine (IOM) proposed a disability model to illustrate the enabling–disabling process (Brandt & Pope, 1997). The IOM Model draws from the social model of disability that emerged as an alternative to the dominant medical model of disability in which disability was viewed as a deficit that needs to be “fixed.” The social model suggests that although physical, sensory, intellectual, and psychological factors can cause functional limitations, it is environmental and societal barriers that cause disability. According to the enabling–disabling process, disability results when there is a gap between individual capacity and the demands of the environment. For example, an older person with presbyopia is disabled in a restaurant if he or she lacks corrective glasses to allow reading the menu. According to the ecological model, disability can be addressed through interventions that increase the individual capacity or reduce task demand. Returning to the former example, reading glasses can be provided to increase individual capacity. Alternatively, the environment can also be modified by providing a food menu with larger print (Figure 6.2).

FIGURE 6.2 The IOM enabling–disabling model of disability.

GERIATRIC REHABILITATION

CLIENTS

Traditionally, rehabilitation programs were designed for young adults or children. Today, the majority of rehabilitation clients are older adults with an average age of 66 years; only 10% of rehabilitation patients are 44 years of age or younger (Nelson et al., 2007). Women comprise 57% of rehabilitation clients. About 90% of patients who need rehabilitation are discharged from an acute-care hospital to a PAC setting (i.e., inpatient rehabilitation hospital/unit [IRH/U], home health care, or skilled nursing facility [SNF]). The key areas of focus in the rehabilitation process are identified in Exhibit 6.1.

EXHIBIT 6.1 Key Areas of Focus with Geriatric Rehabilitation

The most common conditions in old age that require rehabilitation are stroke, hip fracture, and limb amputation. Another group of conditions includes patients who have been deconditioned because of serious illness (e.g., heart attack, surgery). One caution is that older adults can become discouraged if they compare themselves to younger clients. In addition, older adults often have different treatment goals (e.g., activities of daily living [ADLs] and instrumental activities of daily living [IADLs]), need a lower intensity of rehabilitation, and require different types of care (e.g., cardiac monitoring). The very old and even cognitively impaired elders can benefit from rehabilitation, although progress may occur more slowly than with younger populations. Unfortunately, many older adults who could benefit from rehabilitation do not receive it and suffer a marked decline in quality of life. For example, a survey by the National Stroke Association (2006) found that only 15% of stroke survivors see a physiatrist for poststroke care; 38% said they lacked information on rehabilitation and recovery after stroke.

REHABILITATION PROVIDERS

The cornerstone of effective rehabilitation is an interdisciplinary team providing a comprehensive approach to care (Prvu Bettger & Stineman, 2007). Most geriatric patients have complex and multiple interacting problems and contextual factors that require interventions from several disciplines (Hoenig & Kortebein, 2013). The rehabilitation team typically includes a physician, nurse, social worker, physical therapist, and occupational therapist. Other disciplines, such as speech pathology, clinical psychology, pharmacology, or nutrition, may be requested for consultation as needed.

Members of the rehabilitation team bring expertise that overlaps and supports the interventions of each other. Team members complete a comprehensive geriatric assessment with patients using standardized tools to aid diagnosis, assessment, and outcome measurement (Wells et al., 2003a). Typically, geriatric clients must be medically stable and able to actively participate in a rehabilitation program. The client must also have sufficient cognitive function to allow participation in rehabilitation programs or have a caregiver who can prompt and support rehabilitation. On the basis of the initial assessment, the rehabilitation team must be able to identify achievable rehabilitation goals that improve or maintain the client’s self-care, function, and mobility. Typically, the geriatric client must require at least two or more team members to achieve therapeutic goals. Older adults often have complex health needs, such as impaired balance, inactivity, depression, dementia, lack of endurance or strength, limited joint mobility, poor coordination, and reduced agility, which must also be identified and addressed in order to make progress in achieving rehabilitation goals. Thus, a specialized team approach is essential to be effective. An example of a typical rehabilitation teams’ (e.g., nursing, PT, and OT) short-term goals for a geriatric client is provided in Exhibit 6.2.

EXHIBIT 6.2 Common Short-Term Rehabilitation Goals for a Geriatric Client and Team Member

Coordination of care is managed through team conferences and by updating each other through routine charting or by leaving e-mail or voice mail messages. Each member of the team is responsible for the interventions appropriate to his or her skills and area of specialization (see Exhibit 6.3).

Physicians

As noted previously, physiatrists are physicians who specialize in PM&R. They focus on restoring function to patients who have experienced catastrophic events resulting in paraplegia, quadriplegia, or traumatic brain injury, as well as individuals who have suffered strokes, orthopedic injuries, or neurologic disorders such as multiple sclerosis or polio. Physiatrists also treat patients with acute and chronic pain and musculoskeletal problems, such as back and neck pain, tendinitis, pinched nerves, and fibromyalgia. Orthopedic surgeons may supervise the rehabilitation of patients with musculoskeletal problems that have been corrected by surgery, such as hip fractures, knee and other joint replacements, and broken backs. Neurologists may manage the rehabilitation of patients recovering from a stroke, spinal cord injury, or traumatic brain injury.

EXHIBIT 6.3 Primary Roles and Functions of Members of the Multidisciplinary Rehabilitation Team

Nurses

Nursing staff members conduct the initial assessment of the patient, implement the rehabilitation plan, monitor the course of treatment, and chart the progress of the patient. They coordinate the team and ensure that care is appropriate for the patient who usually has other medical problems. The nurse reinforces the goals and techniques of therapy, provides patient and family education, and is responsible for ensuring continuity of care. Nurses are licensed by the state in which they work and may have a specialized certification in rehabilitation. Registered nurses are generally trained at the baccalaureate level.

Physical Therapists

Physical therapists evaluate and treat people with limitations in gross motor function. The goal of treatment is to restore or maximize functional capacity by improving muscle strength, joint motion, and endurance. PTs use hot or cold compresses, ultrasound, or electrical stimulation to relieve pain, reduce swelling, and improve muscle tone. PTs also teach clients how to use crutches, prostheses, and wheelchairs for mobility. PT practice requires a clinical doctorate from an accredited PT program, passing a national registry exam, and obtaining state board licensure. Reflecting this advanced professional training and expertise, 32 states allow PTs to provide services to clients without requiring a physician referral.

Occupational Therapists

Occupational therapists evaluate and assess functioning in self-care, work, or leisure/play activities. Clients may have cognitive–perceptual difficulties, visual limitations, or social dysfunction that interferes with carrying out life skills. OTs teach clients how to perform essential daily activities such as dressing, bathing, and eating. They help individuals develop skills important for living independently, obtaining an education, maintaining employment, and participating in leisure. OTs conduct home safety assessments and teach clients how to use adaptive equipment (e.g., splints, aids for eating, and dressing) to perform ADLs. OTs must complete a master’s degree from an accredited OT program and pass a state board licensing exam.

Speech–Language Pathologists

Speech–language pathologists (SLPs), informally speech therapists, are trained in the diagnosis of speech, voice, and language disorders. Speech therapists help patients relearn language skills. Disorders may result from hearing loss, stroke, cerebral palsy, mental disability, or brain injury. Speech therapists also help patients with difficulty in swallowing or dysphagia to regain their ability to take foods orally. Speech therapists complete a master’s degree from an accredited speech and language pathology program and take a state licensing examination. Speech therapy programs are moving toward requiring a clinical doctorate for entry-level practice. Entry-level practice for an audiologist requires a doctoral (e.g., AuD) or other graduate degree.

REHABILITATION CONSULTANTS

Rehabilitation teams include other specialists (e.g., social workers, nutritionists) as needed to consult on specific problems (Exhibit 6.4).

EXHIBIT 6.4 Rehabilitation Consultants

Social Workers

Social workers assess the patient’s social and psychological behaviors, living situation, financial resources, and availability of family support. They often function as case managers or discharge planners to help to ensure that a patient’s course of treatment is appropriate and cost-effective. Social workers arrange for community-based services as needed and may provide counseling to patients and/or family members. Social workers may have a baccalaureate or master’s degree in social work (MSW). Clinical social workers (e.g., licensed clinical social workers, LCSWs) are licensed by the state.

Clinical Psychologists

Clinical psychologists assist the patient in coping with behavioral and emotional issues that arise in adjusting to a disability. They are trained to assess intelligence, personality, cognitive skills, and perceptual–motor skills. Clinical psychologists play an important role in the rehabilitation of individuals with impaired cognitive ability and behavioral changes because of traumatic brain injury, stroke, or spinal cord injury. Psychotherapy can help a patient cope more effectively during the course of the treatment process, which increases the effectiveness of rehabilitation. Clinical psychologists are trained at the doctoral level and are licensed by the state in which they work.

Pharmacists

Older adults are often on numerous medications after an acute illness—many of them new. The role of the consulting pharmacist is to review medications, identify medication problems, and convey recommendations for changes to the physician and the rest of the team. Pharmacists can ensure that older adults are taking their medications correctly and consistently. Pharmacists can also screen for and reduce risks of drug interactions.

Dietitians

The nutritional status of older adults can range from being undernourished and debilitated to situations in which there are complications from obesity (e.g., coronary artery disease, stroke). In addition, older adults often have special nutritional issues such as poor intake, poor chewing abilities, and swallowing difficulties. A dietitian can assess nutritional status and make recommendations to optimize a person’s diet.

REHABILITATION SETTINGS

Rehabilitation is delivered across the care continuum in a variety of settings. The intensity and nature of rehabilitative services differ depending on the setting. Postacute settings include rehabilitation hospitals and units, LTCHs, SNFs, outpatient facilities, and the patient’s home. Rehabilitative services often begin in the hospital with a focus on early mobilization starting on the first day and involve the integration of activities with a focus on discharge planning. The purpose of rehabilitation is to help maximize recovery for older adults. Early and intensive PT/OT is particularly beneficial in improving functional outcomes (e.g., toileting independently, walking) as well as in lowering mortality (Horn et al., 2005; Siu et al., 2006) for patients with a stroke or a total joint replacement or hip fracture.

INPATIENT REHABILITATION FACILITIES

IRFs include rehabilitation hospitals and units, LTCHs, and SNFs. In 2012, there were about 1,166 IRFs in the United States. The types of clients needing rehabilitation in IRFs are shown in Table 6.1. Over the past decade, the patient mix for IRFs has changed significantly with increases in clients with stroke, brain injuries, and neurological disorders. A significant decrease in inpatient rehabilitation for major joint replacement of lower extremities is also evident.

TABLE 6.1 Changes in Patient Mix for Inpatient Rehabilitation Facilities (2004–2013)

Rehabilitation Hospitals and Units

Intensive inpatient rehabilitation programs are provided by rehabilitation hospitals and units. A typical rehabilitation hospital has 60 to 100 beds, whereas units have 10 to 40 beds. Patients must be capable of participating in a high-intensity (generally more than 3 hours per day) program. Some rehabilitation hospitals or units specialize in specific kinds of impairments, such as spinal cord injury or stroke.

Long-Term Care Hospitals

LTCHs focus on patients who need more than 25 days of medical and rehabilitative care. They are certified as acute-care hospitals, and the majority of LTCH patients transfer from an intensive or critical care unit. Common LTCH services include comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management. In 2011, Medicare recognized the existence of 436 LTCHs.

Skilled Nursing Facilities

Most SNFs are part of a nursing home that provides custodial care to long-term residents whom Medicare does not cover (see Chapter 11). Medicare-covered SNF patients usually represent a small share of an SNF’s total patient census (e.g., 12% of total patient days in 2010), but represent a larger share of facility revenues (e.g., 23% of payments; MedPAC, 2012b). SNFs offer Medicare-certified therapy services (e.g., PT, OT, and speech–language pathology) through less intensive rehabilitative programs that average 1 to 3 hours of therapy per day up to 5 days a week.

COMMUNITY-BASED REHABILITATION

Home Health Care

Home care has become a major setting for rehabilitation services (i.e., PT, OT, and speech–language pathology) in the past decade, and home care agencies employ a significant number of rehabilitation professionals. Original Medicare (Part A) covers services from a Medicare-certified home health agency for a 60-day period, called an “episode of care.” Therapy services must be reasonable and necessary with the expectation of improvement in the identified condition. Rehabilitation in the home is preferred by older adults and is often more effective because the therapist can assess the performance of the individual in the environment in which he or she actually lives. Seeing the home care setting makes it easier to determine the appropriate mix of home modifications (e.g., ramps, grab bars), AT (e.g., walkers, shower chairs), and therapeutic exercise (e.g., strengthening activities). However, Medicare will only cover 80% of Medicare-approved durable medical equipment (under Part B) that has been ordered by a doctor, such as a wheelchair, walker, or oxygen equipment.

Most licensed HHAs provide physical, occupational, and speech therapy services. Medicare authorizes PT as a stand-alone service; however, occupational and speech therapy may be ordered in conjunction with nursing services. The most common rehabilitation diagnoses seen by home health care providers include congestive heart failure, hip and knee surgeries, open heart surgery, and stroke. For a fuller discussion of home health care, see Chapter 5.

Outpatient therapy

Outpatient therapy is appropriate for stable patients who can travel to outpatient rehabilitation clinics, doctors’ offices, or other community-based settings. These patients often have uncomplicated conditions or present with minimal disability. Outpatient rehabilitation programs have traditionally served patients with orthopedic, neurological, or back conditions. More recently, outpatient rehabilitation services for older adults include pain management and incontinence. Outpatient therapy is provided in private practice, CORFs, adult day health care, and hospital outpatient departments. Adult day health care is a new setting for outpatient rehabilitation that targets services to frail older adults and those with disabilities (see Chapter 7). Older adults attending adult day health care arrive in the morning and participate in several hours of intensive rehabilitation therapy. At the end of the day, patients return to their homes. Some adult day health care programs qualify for reimbursement from Medicaid waiver programs designed to maximize the independence of those who are “at risk” for institutionalization.

REHABILITATION INTERVENTIONS

EXERCISE

After an injury or surgery, an exercise conditioning program can help older adults regain their independence and return to daily activities. Exercise programs are commonly implemented in rehabilitation recovery programs for heart conditions, orthopedic, and neurosurgery procedures. PTs and physiatrists can tailor an exercise program to address the needs of each patient. Specific patient populations, such as those who are frail, can benefit from certain types of exercise. For example, a systematic review of research on strength training found significantly improved muscle strength and function in frail older adults (Liu & Latham, 2009). As noted previously, early mobilization of patients during hospitalization can improve outcomes for most, including those with hip fracture, acute pneumonia, or stroke.

ASSISTIVE TECHNOLOGY

Assistive technology refers to any item or equipment used to increase, maintain, or improve functional capacity. AT services help people select, acquire, or use AT by providing functional evaluations, training, demonstration, and purchasing or leasing of devices. A growing body of literature supports the effectiveness of technology; AT may reduce decline associated with disability by one-half (Hoenig, Taylor, & Sloan, 2003; Schoeni et al., 2008; Verbrugge, Rennert, & Madans, 1997). An excellent resource on assistive devices is AbleData (www.abledata.com), which provides information on almost 40,000 assistive devices and rehabilitation equipment. Other good resources are the State Assistive Technology Programs (www.resnaprojects.org/nattap/at/stateprograms.html), funded under the Assistive Technology Act of 1998, which works to improve access to AT (see Chapter 8). Exhibit 6.5 offers an overview of the types of AT, their purpose, and specific examples of equipment and devices.

Mobility Aids

Mobility aids are one of the most common types of ATs used by older adults. In 2000, 10% of older adults used canes, and 4.6% used walkers (Bradley & Hernandez, 2011). Canes are light and versatile, but are most useful for a mild gait problem, as they require upper extremity strength and cannot support more than 20% of body weight (Hoenig, 2004). A quad cane can provide more support, but is often harder to use. Canes can help improve balance or reduce pain from an arthritic joint. Improper fit or incorrect use of a cane can increase an older adult’s risk of falls. Canes should be used in the hand opposite the impaired leg.

EXHIBIT 6.5 Examples of Assistive Technology

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