Rehab at Home’ provides the services of a hospital
Patients recover in their own environment
When managed care payers began sending patients home instead of to a rehab hospital, Bryn Mawr Rehabilitation decided to take the rehab hospital into the home.
The Malvern, PA, provider is pioneering a new concept: a program that provides all the services a patient could expect to receive in a rehab hospital in the home setting.
What makes the Bryn Mawr "Rehab at Home" program different from traditional home health services or even existing home rehabilitation services is that treatment is directed by a physician who makes house calls. In addition, the team works with patients in their homes throughout the day, up to seven days a week, based on individual need.
"Rehab has to be looked at as a process, and we have to find the best place for it to happen. One option is that it could happen at home. It’s a good way to expand rehabilitation into the community. We are looking at the hospital as not just a place filled with beds, but as a place filled with expertise," says Jay Portnow, MD, PhD, medical consultant for Bryn Mawr Rehab at Home.
The program is designed to recapture some of the patients who bypass rehab by going home or to subacute services after surgery or treatment for trauma in acute care hospitals. It provides a less expensive alternative to hospitalization for patients who have a good family support system and prefer to recover at home.
Bryn Mawr staff spent more than two years planning and developing the concept, says Dana Trainor, CRRN, CCM, program manager of Bryn Mawr Rehab at Home.
The program started July 1, 1997, with one interdisciplinary team. Based on the response from payers, Trainor anticipates adding two additional teams by fall. The teams will be expected to treat four or five patients at a time, she adds.
"The basic idea is that with rehab, you are trying to get people to become independent and functional in their own environment. There is something artificial about doing it in a rehab facility. If you want them to be independent in their own home, why not work with them in their own home?" Portnow says.
Rehab in the home provides treatment in the real-life situations a patient will encounter every day. Staff exercise their creativity to translate rehab concepts into the patient environment, says Helen Cioschi, MSN, CRNP, CRRN, administrative director of the ortho-medical section of Bryn Mawr Rehabilitation.
"Everything is ideal for the patient in the rehab hospital. Then they go out into the real world. As health care providers, we assume the patient can easily make the transition from the institution to the home setting, but that’s not always the case," Cioschi points out. That’s where rehabilitation at home can help. Other benefits of rehabilitation at home include the following, she says:
• Patients with compromised immune systems or in fragile conditions are not exposed to infections at home as they would be in a hospital.
• The entire family becomes part of the rehab team. In the hospital, usually only the spouse participates in family training. Children are almost never involved in the hospital setting although, in reality, they can help.
• Patients are more motivated in their own environment. They will work harder for tangible goals, such as being able to get from a favorite chair to the refrigerator.
As many as 70% of patients at a typical rehabilitation hospital could be treated at home, Portnow estimates.
"Rehab hospitals are not getting complete occupancy because of managed care. This is a way of recapturing the patients and providing rehab," says Portnow, who has operated a physician-directed rehabilitation in the home program in the Boston area for seven years.
Rehab at home can work for almost all types of patients now treated in the rehabilitation hospital, he asserts.
Agitated brain injury patients with signifi-cant safety issues, some spinal cord patients with complex medical needs, and other multi-ple trauma patients may not be appropriate, Trainor says.
Younger spinal cord patients may benefit emotionally from being in the hospital with other patients who have similar injuries and seeing how they have progressed, Portnow adds.
In the past, rehab hospitals took only medically stable patients, but now with the push to get patients out of the acute hospital sooner, patients are being admitted to skilled nursing facilities and rehab hospitals when they are ot medically stable, Portnow says. Patients treated at home do not have to be medically stable, but they should not be acutely unstable, he adds. For instance, patients can be treated at home if they are on IVs, ventilators, or oxygen, he says.
Bryn Mawr Rehab at Home staff anticipate that the most common diagnosis-related groups treated will include those involving stroke, hip or knee fractures, joint replacement, neuromuscular disorders, amputation, deconditioning, cardiopulmonary disorders, head injury, and spinal cord injury. Providers in California have told Bryn Mawr staff that some spinal cord injury patients are being discharged to their homes after only five days in the hospital and might be appropriate for rehab at home.
"If this acute trend moves to our market, we are positioning ourselves to respond," Cioschi says.
In the meantime, the program is starting with less intense patients, such those with orthopedic problems and mild strokes.
Rehab at home isn’t for everyone, however. For instance, some patients are uneasy about being sent home and prefer to stay in the hospital, Portnow says. Others have families that are unwilling or unable to take on the extra burden of caring for them at home. Some are initially admitted to the hospital for a few days, then transferred home when the emotional trauma has abated.
Because rehab at home costs about 30% less than providing the same services in the hospital, the concept is popular with payers, Cioschi says.
In a hospital, costs escalate because of overhead and expenditures for equipment and bricks and mortar. Travel time for the treatment team is the only additional cost in home care, Portnow points out.
Bryn Mawr chose to work first with managed care payers and commercial carriers. Medicare recognizes only hospital-based rehab or traditional home health services, Portnow says.
The team at Bryn Mawr began marketing Rehab at Home to managed care payers through direct mail campaigns, presentations at managed care conferences, and individual follow-up with managed care case managers.
Now that the program has attracted some significant managed care contracts, it is being marketing to referring physicians. At present, the staff are confining marketing efforts to insurers, physicians, and other rehab professionals, but they expect to do some direct consumer marketing with a year.
The program uses the Functional Independence Measure (FIM, administered by the Uniform Data System for Medical Rehabilitation in Buffalo, NY) as the basis for measuring outcomes. Staff are looking at other tools to give them more information about the burden of care and other issues not measured by the FIM.
Once the program has been under way for a while, Trainer will study program efficiency, productivity expectations for therapists, and costs. Once there are several teams in place, she plans to compare the cost per team, length of stay, and other efficiency measures.
[For more information on Bryn Mawr Rehab at Home, contact Helen Cioschi at (610) 251-5611 or Jay Portnow at (617) 871-7995.]
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