|CHAPTER 5: PHYSICAL AND REHABILITATION MEDICINE IN HEALTH CARE SYSTEMS
|Year : 2019 | Volume
| Issue : 2 | Page : 87-92
5.4 Physical and rehabilitation medicine in health-care systems: Postacute levels of care
Peter A Lim
Department of Rehabilitation Medicine, Singapore General Hospital, Singapore; Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
|Date of Web Publication||11-Jun-2019|
Prof. Peter A Lim
Department of Rehabilitation Medicine, Singapore General Hospital, 169856, Singapore
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Lim PA. 5.4 Physical and rehabilitation medicine in health-care systems: Postacute levels of care. J Int Soc Phys Rehabil Med 2019;2, Suppl S1:87-92
|How to cite this URL:|
Lim PA. 5.4 Physical and rehabilitation medicine in health-care systems: Postacute levels of care. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2019 Aug 20];2, Suppl S1:87-92. Available from: http://www.jisprm.org/text.asp?2019/2/2/87/259346
| Curative, Preventive, and Rehabilitative Medicine|| |
For much of the history of health care, the curative imperative has dominated and associated specialties have flourished. In pharmaceuticals, the early potions and antibiotics have progressed to biologically-active drugs and stem-cell therapy. The quick-handed barbers with sharp blades capable of performing amputations within seconds have advanced to complicated surgical reconstructions and multiple-organ transplants. The rudimentary microscope and Roentgen X-ray machines have gone on to computerized tomography, magnetic resonance imaging, positron emission tomography scans, and DNA testing. They all have in common a focus on finding the cause of disease or injury, and curing it.
It was subsequently recognized that much more has been achieved in preventive medicine and public health. Clean water and proper sanitation have saved millions of lives, and vaccinations have prevented the loss of many more. Public health strategies and policies such as quarantine and contact tracing of infected patients has been successful in limiting catastrophic epidemics in more recent times. Laws including safety belts and restraints, crash helmets have mitigated the impact of trauma. Public education on issues ranging from eating right, smoking cessation to exercising have had good albeit sometimes only partial success.
In the continuum of health care however, it is only relatively recently that rehabilitative medicine has received deserved attention. Across the world, economic development and cultural changes with improving health indices are resulting in the phenomenon of aging populations. As life expectancies lengthen, so has incidence of disabilities with a direct correlation between age and number affected. In addition, society increasingly values bigger, faster, and higher. Motor vehicle accidents, violent sporting pursuits, work-related trauma, injuries, and falls may result in brain, spinal cord, and back injuries, repetitive stress disorders and other related health problems that require rehabilitation.
| Physical and Rehabilitation Medicine in the Health-Care System|| |
Physical and Rehabilitation Medicine (PRM also known as rehabilitation medicine [RM]) is part and parcel of a good health-care system. Depending on the type, level, and case mix of the hospital, potentially 5%–10% of patients will require inpatient rehabilitation services. A recent study from Canada using a Stroke Rehabilitation Candidacy Screening Tool (SRCST) revealed that 37% of stroke patients were appropriate candidates for inpatient rehabilitation. The SRCST included the AlphaFIM® score, ability to follow commands, rehabilitation goals, functional improvement demonstrated over time, verbal consent to participate, and rehabilitation readiness including tolerance to sitting and medical stability.
The South Australia Government has stated that as its population ages, the need for rehabilitation services will increase, and that rehabilitation is part of all patient care. It should be provided acute care, ideally for a short length of stay (LOS) with a straightforward program before discharge home, or until transfer to a specialist rehabilitation unit where a formal multidisciplinary program is provided to facilitate independence and attainment of goals.
In a large multicenter cohort analysis on 5739 patients with acquired brain injury, spinal cord injury, peripheral and progressive neurological conditions undergoing specialist rehabilitation in England, functional outcomes, care needs, and cost efficiency were evaluated. All groups showed significant reduction in dependency between admission and discharge on all outcome measures used, with reduction in weekly care costs of 760, 408, and 130 pounds/week in the high-, medium-, and low-dependency groupings, respectively.
PRM plays an important role in the development of new approaches and strategies for improving the care and rehabilitation of patients with disabilities. This includes clinical trials, and the difficult but crucial task of data collection and rehabilitation database analysis.
| Services Provided by Physical and Rehabilitation Medicine|| |
The classic RM physiatrist has two main distinct roles:
- Management of the complicated “fragile” or potentially unstable rehabilitation patient with specialized needs, for example, spinal cord or traumatic brain injuries, severe strokes, multiple sclerosis, cardiopulmonary diseases, cancer, and renal failure patients on hemodialysis. These patients require physician supervision and specialist intervention for complications such as spasticity, thromboembolism, anticoagulation, and depression while undergoing an intensive multidisciplinary rehabilitation program. Typically, the goal is for a discharge home within a relatively fast time period
- Consultation and management of the rehabilitation needs and complications of more stable patients though the continuum of care from community hospitals, day rehabilitation centers, and to nursing homes. This will require a close collaboration and coordination with the therapists, geriatricians, palliative care, and family medicine physicians who may be a part of the rehabilitation care.
There are also PRM physicians who work mostly or exclusively in the clinic or ambulatory care setting. These include specialists in nonoperative pain management, sports medicine, and outpatient occupational injuries. They are well suited for undertaking this role in comprehensive assessment and diagnosis as well as rehabilitative management of such patients.
- The training of a physiatrist or PRM physician includes not only medicine but also a neurological and musculoskeletal emphasis that includes anatomy, physiology, psychology, and biomechanics. This enables a comprehensive holistic assessment and treatment plan based on the functional as well as medical perspective. An X-ray is not seen as only bones, joints, and soft tissue but also its potential for range of motion, strength, endurance, spasticity, and pain.
- The PRM physician is trained in and has a good understanding of many “languages” including that of a physician, surgeon, psychiatrist, therapist, social worker, orthotic and equipment specialist, and prosthetist. This enables the PRM physician to function as the ideal orchestra conductor of the medical rehabilitation team.
| Postacute, Acute, Subacute, and Long-Term Care Rehabilitation|| |
The terms acute and subacute rehabilitation are often difficult to precisely define and delineate. The term “postacute” rehabilitation may more suitably cover the continuum of care though which rehabilitation occurs, from the hospital into the community. The PRM physician may initially be involved in rehabilitation triage and care while the patient is still in the hospital intensive care unit (ICU), with prehabilitation prior to surgery, and in the optimization of a patient's condition before chemotherapy. A period of inpatient rehabilitation stay may subsequently be needed where the patient receives intensive comprehensive rehabilitative therapy intervention of 3 hours or more, while medical management continues under the physiatrist. For patients requiring lower intensity or “slow-stream” rehabilitation, a skilled nursing facility (SNF) or step-down community hospital stay for a longer period may be appropriate. Some patients require physiatrist follow-up in the settings of nursing homes/extended or long-term care (LTC) facilities for maintenance rehabilitation programs to avoid deconditioning and physical deterioration. Occasionally, the physiatrist may be involved in home-based care and assisted living programs.
| Settings for Postacute Care|| |
The US National Stroke Association's Complete Guide to Stroke (1st Edition, 2003) refers to the option for rehabilitation at different locations including: (i) rehabilitation unit in the hospital, (ii) subacute care unit in the hospital or extended care facility, (iii) a rehabilitation hospital, (iv) home with outpatient therapy, (v) stroke day program, (vi) LTC facility providing therapy and skilled nursing care, and (vii) home therapy.
The US model allows differentiation for postacute rehabilitation interventions and the following is based on Centers for Medicare and Medicaid Services (CMS) publications.
| Inpatient Rehabilitation Facility|| |
Inpatient rehabilitation facilities (IRFs) may be freestanding rehabilitation hospitals or rehabilitation units within acute care hospitals. They provide an intensive rehabilitation program with patients able to tolerate 3 hours of intense rehabilitation services per day. Group therapy may be included but not be the majority of therapy provided and must be well documented. At least 60% of a facility's total inpatient population must require treatment for one or more of 13 conditions, namely, (i) stroke, (ii) spinal cord injury, (iii) Congenital deformity, (iv) Amputation, (v) Major multiple trauma, (vi) Fracture of femur (hip fracture), (vii) Brain injury, (viii) Neurological disorders, including multiple sclerosis, motor neuron diseases, polyneuropathy, muscular dystrophy, and Parkinson's disease, (ix) Burns, (x) Active polyarticular rheumatoid arthritis, psoriatic arthritis, and seronegative arthropathies, (xi) Systemic vasculitides with joint inflammation, (xii) Severe or advanced osteoarthritis involving two or more major weight-bearing joints (elbow, shoulders, hips, or knees) with joint deformity and substantial loss of range of motion, atrophy of muscles surrounding the joint, (xiii) Knee or hip joint replacement (with bilateral joint replacement surgery, extremely obese with Body Mass Index of at least 50, or age 85 or older).
In general, there must be significant functional impairment of ambulation and other activities of daily living (ADL) that has not improved after an appropriate, aggressive, and sustained course of outpatient therapy services or services in other less intensive rehabilitation settings immediately preceding the inpatient rehabilitation admission. However, the patient has potential to improve with more intensive rehabilitation. Patients with comorbidities secondary to the principal diagnosis may also be included under certain conditions, e.g. significant decline in functional ability requiring intensive rehabilitation treatment unique to IRFs that cannot be appropriately performed in another care setting. IRFs provide intensive rehabilitation services using an interdisciplinary team approach in a hospital environment and for patients with complex nursing, medical management, and rehabilitative needs. The patient must:
- Require multiple therapy disciplines (physical therapy (PT), occupational therapy (OT), speech-language pathology, or prosthetics/orthotics), at least one of which must be PT or OT
- Require an intensive rehabilitation therapy program, generally 3 hours/day at least 5 days/week; or in certain well-documented cases, at least 15 hours within a 7-consecutive day period
- Reasonably be expected to actively participate in and benefit significantly from the intensive rehabilitation therapy program
- Require physician supervision by a rehabilitation physician, with face-to-face visits at least 3 days/week to assess the patient both medically and functionally and to modify the course of the treatment as needed
- Require an intensive and coordinated interdisciplinary team approach to the delivery of rehabilitative care.
| Long-Term Care Hospital|| |
LTC hospitals (LTCHs) are certified under Medicare as short-term acute care hospitals, but generally treat medically complex patients who require long-stay hospital-level care. For Medicare purposes, they are generally defined as having an average inpatient LOS >25 days.
LTCHs use the Medicare Severity-LTC-Diagnosis Related Groups (MS-LTC-DRG) as a classification system. This is similar to the MS-DRG; the CMS uses under the Inpatient Prospective Payment System but weighted to reflect the different resources used by LTCHs. Each patient stay is grouped into an MS-LTC-DRG based on diagnoses (including secondary), procedures performed, age, gender, and discharge status, and has a predetermined average LOS which is the typical for such a patient.
| Skilled Nursing Facility|| |
The terms SNF, nursing facility or home, and convalescent home may often be used interchangeably. They all describe residential facilities that provide on-site 24-h care, but the SNF is a facility with a higher level of care provided by trained individuals including registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech-language pathologists or audiologists, and medical social workers. These services may be for a period of rehabilitation from an illness or injury, or for those needing LTC on a continuous basis due to chronic medical conditions. Skilled nursing and skilled rehabilitation services are those services furnished according to the physician orders.
| Comprehensive Outpatient Rehabilitation Facility|| |
Comprehensive outpatient rehabilitation facilities (CORFs) provide coordinated outpatient diagnostic, therapeutic, and restorative services at a single fixed outpatient location, for rehabilitation of injured, disabled, or sick individuals. PT, OT, and speech-language pathology services may be provided in an off-site location. Core services to be provided include consultation and medical supervision of nonphysician staff, establishment and review of the plan of treatment and other medical and facility administration activities, PT services, social or psychological services.
| Postacute Care in Singapore|| |
Singapore is a city-state in Southeast Asia with a population of 5.6 million. Although an island only 720 km2 in size (smaller than New York City), Singapore is a major international city engaging in activities such as trade and transshipments, information technology products, financial services, and biotechnology. From a third world country at the time of achieving independence about 50 years ago, Singapore in 2016 had a per capita gross domestic product (GDP) of SGD 73,167.
Health-care statistics are excellent with an infant mortality rate of 2.4 deaths/1000 live births, and life expectancy of 82.9 years in 2016. It has a doctor to population ratio of 1:430, nurse ratio of 1:140, dentist ratio of 1:2550, and pharmacist ratio of 1:1950. There are a total of 1693 physiotherapists, 1067 occupational therapists, and 524 speech therapists. This was achieved on a national health-care expenditure of 4.6% (2011) of GDP. However, Singapore has committed to increasing expenditures significantly to cope with one of the fasting aging populations in the world, with those aged 65 years and over expected to grow from about 11% currently to almost 20% in the year 2030.,
About 80% of acute and hospitalization care takes place in the public sector under the charge of the Ministry of Health Singapore, and only 20% in the private sector. The reverse is true for primary care services where 80% is provided by private practitioners and 20% by the public sector. The step-down care sectors including nursing homes, community hospitals, and hospices are often run by voluntary welfare organizations, although most are funded to a large extent by the government. There are three medical schools in Singapore: the Yong Loo Lin School of Medicine, National University of Singapore (NUS) founded in 1905 is a leading medical educational and research institution in Asia, the Duke-NUS Medical School which emphasizes medical research and education follows a US curriculum in collaboration with Duke University North Carolina, and the Lee Kong Chian School of Medicine has a curriculum developed and implemented in partnership with Imperial College London.
Nurses receive diploma-level training from two polytechnic institutes, and undergraduate degrees from NUS and overseas tertiary institutions. Postgraduate qualifications for rehabilitation may be obtained locally or overseas. Physiotherapists and occupational therapists may earn undergraduate degrees from the Singapore Institute of Technology or overseas. Speech therapists typically obtain undergraduate degree from overseas, but a masters' level degree is available at NUS. Prosthetists and orthotists are usually trained overseas and the de facto national prosthetic and orthotic center is sited at the Foot Care and Limb Design Centre. There are also several legacy private practitioners with recognition based on apprenticeship programs.
All Singaporeans are covered under the 3Ms of Medisave, Medishield, and Medifund. Medisave is a national medical savings scheme into which individuals put aside part of their income. This personal health savings account can be used for hospitalization, day surgery, and approved outpatient treatments. Medishield is a low-cost voluntary catastrophic medical insurance plan. Medifund provides for needy Singaporeans to pay their medical bills and is based on household income for eligibility and amount of assistance. The government provides large subsidies for hospitalization as well as other medical and rehabilitation expenses, based on the patient's choice of hospital bed class. The “A” class private bed is single room, air-conditioned, with attached bathroom and the patient's choice of doctors - the patient pays full fare. On the other end is the “C” class where there are multiple beds in a cubicle with shared bathroom and assigned doctors. However, this bed choice carries a 65%–80% subsidy.
In addition, the government has several other programs relevant for those with disabilities. The Interim Disability Assistance Programme for the Elderly provides SGD 150–250 monthly for up to 72 months for those unable to perform three or more out of 6 ADL including washing, feeding, dressing, toileting, mobility, and transferring. Elder Shield pays SGD 300–400 monthly for 60–72 months for those with inability to perform at least three of the six ADLs. The Home Protection Scheme is a mortgage insurance that protects members and their families against losing their public housing apartments in the event of death, terminal illness or total permanent disability. The Dependants' Protection Scheme is an opt-out term insurance scheme, which covers for a maximum payout sum of SGD 46,000 for death, terminal illness, or total permanent disability.
Through its Agency for Integrated Care, the government coordinates day rehabilitation centers across the island, Day Care and/or Rehabilitation Facilities, Senior Activity Centers, Community Health Centers with general practitioners, Home Medical, Home Nursing, Home Therapy, Home Personal Care, and Meals on Wheels. There are also Caregivers Training Grants, Seniors' Mobility and Enabling Fund (for assistive devices such as wheelchairs, transport, and home health-care consumables), Pioneer Generation Disability Assistance Scheme of SGD 100 monthly for those with disabilities and born before 1950, Medical Escort and Transport, Community Health Assist Scheme to subsidize doctor and dentist visits, Foreign Domestic Worker (FDW) Grant of SGD 120 monthly, FDW Levy Concession for Persons with Disabilities, and Medical Fee Exemption Card.
Rehabilitation medicine in postacute care
PRM or RM in Singapore has a relatively recent history. Singapore is a country with capability for biologic transplants, readily available joint replacement surgery, state-of-the-art cardiac and cancer treatments, as well as being a center for cutting-edge genetic and stem cell research. It is home to international collaborations of academic medical and health-care institutions such as Duke University and Johns Hopkins from the USA, Imperial College London from the UK, and Curtin University from Australia. There is however a situation of expanding needs and insufficient capacity, partly because of rapidly changing demographics and culture. As an Asian country with a culture based on Confucianism, families and neighbors have traditionally taken care of the elderly and those with disabilities. Along with the country's rapid development however, family sizes have plummeted (fertility rate of 1.24 children per female in 2015) to where the previous situation of many adult children and family available at home to provide care rather than being out in the workplace (female workforce participation rate of 58.1% in 2013) no longer exists. Neighborhoods have also changed, from the communal spirited, care-providing kampungs (villages) to fast-paced high-rise living where next-door neighbors may not know each other's names. Rehabilitation which emphasizes function and independence has hence become an important part of the health-care continuum.
The first specialized RM unit in Singapore was founded at the Tan Tock Seng Hospital in 1973 with a focus on providing rehabilitation for orthopedic and spinal cord injury patients. The pioneering RM physicians then were sent by the Ministry of Health for diploma-level training at RM rehabilitation centers in Australia or the United Kingdom. RM physicians with training and certification from Australia, UK, US, and Canada were also eligible for licensing and specialist accreditation. To cater for patients with amputation, the Artificial Limb Center was established in 1981 with prosthetic staff sent to Japan for training or recruited from Taiwan and Hong Kong. In the early 1990s, a post-Internal Medicine (IM), 3-year RM specialist training program was established locally. On successful completion of the program, the graduate was eligible for the title Fellow of the Academy of Medicine Singapore (RM) and recognized as a RM physician. This program incorporated an elective year of clinical fellowship internationally, with most graduates going to major rehabilitation institutions in the United States including Baylor College of Medicine Houston and Harvard Spaulding in Boston. In 1998, RM was formally accredited as a distinct medical specialty by the Specialist Accreditation Board, Ministry of Health, Singapore.
Subsequent RM departments or units providing comprehensive multidisciplinary rehabilitation were established at other public hospitals across the island: Changi General Hospital in 1998, Singapore General Hospital in 2000, and National University Hospital in 2008. These physiatrist-led units have a full complement of rehabilitation staff including nurses, physical therapists, occupational therapists, speech pathologists, medical social workers, and prosthetists/orthotists as needed. They have the capacity to manage medical care and rehabilitation of the most complicated patients including severe strokes, tetraplegic spinal cord injuries, traumatic brain injuries, renal dialysis, multi-trauma, and cancer patients. There are presently a total of 37 credentialed and accredited physiatrists in Singapore, with 14 more in training. Almost all practice in the public health care and academic sector with the largest numbers based at Tan Tock Seng Hospital and Singapore General Hospital, both major tertiary teaching hospitals and the main training sites for RM in Singapore. The rehabilitation physicians also work in the community with a presence in the smaller community care hospitals, day rehabilitation centers, and nursing homes.
There has been a recent shift of approach from the traditional British-based system of medical training and Membership or Fellowship with the Royal College of Physicians or Surgeons, to one that is more American. In 2010, the residency system was established in Singapore with Accreditation Council for Graduate Medical Education – International (ACGME-I) recognition. As of 2014, trainees who choose to specialize in RM must first complete a residency in IM before competing for a 3-year RM Senior Residency (PGY 4–6) training position.
With the compulsory IM residency as a prerequisite to RM training, rehabilitation physicians are trained and able to manage patients acutely from the ICU into the medicosurgical wards. The main RM departments have early reach-in arrangements with other departments, go into the ICU and acute wards to assess and triage patients for rehabilitation, as well as help manage early complications of immobility. There are comprehensive RM units led by physiatrists and equivalent to IRFs at all the major public hospitals. Patients discharged from the hospitals and new patients referred for rehabilitation assessment and management are seen in the specialist outpatient clinics or ambulatory care clinics of the hospitals. The RM physicians also have visiting consultant privileges at the step-down community hospitals which are similar to LTCHs and SNFs, and at day rehabilitation centers which are similar to CORFs. The RM presence is currently limited in the nursing homes, and typically their residents are assessed and reviewed in the hospital ambulatory care clinics. Nursing and therapy interventions prescribed are then provided within the nursing home or by way of a readmission to the RM unit when more intensive intervention is needed.
Singapore has many foreign domestic workers (FDWs) or “maids,” who live within the home and are primarily hired for housework, cooking, and childcare. They however frequently take on or are hired for the role of primary caregivers for disabled patients and provide some of the postacute care. The initial rehabilitation program may hence also need their training as caregivers, including care of feeding tubes, bowel and bladder management, transfers, range of motion, and simple exercises.
| Conclusion|| |
The need for rehabilitative care gains importance with aging populations across the world in conjunction with increasing rates of acquired disability. Up to 5%–10% of a hospital's patients may require inpatient rehabilitation services, with 37% of stroke patients being appropriate candidates. In a large cohort analysis with spinal cord injury, acquired brain injury, and other neurological diagnoses undergoing specialist rehabilitation, there was shown to be significant reduction in functional dependency and weekly care costs.
The physiatrist or PRM physician may work in the ambulatory care or clinic setting with nonoperative pain, sports medicine, or occupational injuries. The classic role of the PRM physician, however, focuses on in-hospital management of complicated rehabilitation patients with specialized needs, extending this expertise along the continuum of care into the community and LTC facilities. Care may hence occur at different postacute locations including the IRF, LTCH, SNF, and CORFs.
Postacute rehabilitative care in Singapore is quite well developed and includes organized physiatrist – led rehabilitation units and programs at different levels and locations, including public, private, and academic sectors. There are also strong national health-care funding systems and professional training institutions for health-care providers in most rehabilitation disciplines.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
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