Cardiac, pulmonary rehab attractive market niches for some providers
Providers say programs reduce acute LOS
Payer trends to cut inpatient acute care lengths of stay have made the prospect of cardiac and pulmonary rehab more appealing to some rehab providers. Rehab facilities can provide an important service that reduces emergency department visits and repeated hospitalizations and improves the continuum of care to patients.
Grossmont Hospital, serving the San Diego area with 320 beds, has a 30-bed rehab facility that opened a pulmonary rehabilitation program earlier this year. Providing inpatient and outpatient services, the pulmonary program admits patients mostly from the acute hospital and has helped Grossmont reduce acute care lengths of stay by three to seven days for pulmonary patients, says Bill Goodwin, RRT, pulmonary rehab coordinator and respiratory therapist. (See story on Grossmont’s pulmonary program, p. 66.)
"Medicare has cut down on the amount of reimbursement for some acute rehab services, where you get a global rate per day based on the diagnosis," Goodwin says. "So you have to justify the fact that No. 1, you’re serving the patient better clinically, which we are, and their time on the medical floor or time in the hospital in general is a lot shorter overall."
St. Francis Hospital of Greenville, SC, which has a 19-bed rehab facility, opened its cardiac rehab program in May 1999 after the 218-bed acute care hospital opened a heart center, providing open-heart surgery, says Joe Golob, PT, director of the inpatient rehab center.
"We just felt that there were likely to be some patients who, simply because of their debilitation due to cardiovascular disease, would require intensive inpatient rehabilitation," Golob says. "For the most part, these folks are followed up on an outpatient basis, and even those that come to us will likely continue in an outpatient program."
But hospital administrators saw there was an important inpatient rehab niche to fill, Golob adds. "If their ability to do activities of daily living and being mobile has been compromised so much that they need more than outpatient care, then we wanted to be able to provide that part of the continuum of their care."
HealthSouth New England Rehabilitation Hospital in Woburn, MA, started its inpatient cardiac rehab program in 1993 with the goal of decreasing cardiac patients’ lengths of stay in acute care facilities, says Julie Jones, PT, physical therapy supervisor for the cardiopulmonary unit and cardiac program co-manager at the 188-bed rehab facility. (See story on St. Francis Hospital’s and HealthSouth New England’s cardiac rehab programs, p. 68.)
Cardiac rehab patients typically include those who have had cardiac bypass surgery or valve replacement, or they are cardiac medical patients, including post-myocardial infarction patients, Jones says.
"The patients aren’t ready to be home yet, but the problem was that established outpatient cardiac programs are not usually allowed to start at the level of intensity they need until six weeks post-surgery," she explains. "So there are these six weeks that they’re home, and patients have this huge fear factor of should they overdo or underdo their activities."
Because so many of the patients became deconditioned or were rehospitalized, cardiac physicians were looking for a place to refer patients discharged from acute care to keep them from floundering before they could begin outpatient rehab, Jones says. "These patients are a tenuous group medically and are actively changing," she adds. "They can experience arrhythmia a week or two out from surgery or the cardiac event and are fairly medically complex."
For those reasons, a rehab cardiac program may be a better place to care for the patients than a subacute or skilled nursing facility (SNF), neither of which may have telemetry monitoring as patients begin to exercise, Jones explains.
Also, subacute and SNF settings may not have 24-hour in-house physician coverage, which can affect cardiologists’ trust in the care provided, she adds. "We’ve discovered that cardiologists in town trust us according to how comfortable they are that we can manage them because they don’t want their patients bouncing back to acute care," Jones says.
HealthSouth New England is participating in a study that will evaluate the cost-effectiveness of cardiac rehab care when compared with a Midwestern hospital that has a large cardiac program but no follow-up inpatient rehab program, she says. The study will assess the number of repeat hospitalizations in the cardiac rehab and control groups and compare other cost measures. The results should be available in 2001.
Meanwhile, HealthSouth New England relies on anecdotal data showing that patients have benefited from inpatient cardiac rehab services and that repeat hospitalization rates have declined among those patients. For example, some congestive heart failure patients were hospitalized two to four times within a year before being enrolled in the program. "They were having trouble managing their disease at home," says Jones. After going through the program, many had two or fewer hospitalizations, she adds.
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