Geriatric rehabilitation settings and reimbursement

INTRODUCTION — The primary purpose of rehabilitation is to enable people to function at the highest possible level despite physical impairment. Rehabilitation includes a vast array of interventions provided by a diverse group of providers across the continuum of care.

This topic will review aspects of geriatric rehabilitation related to types of providers, reimbursement in the United States, and care settings. Geriatric rehabilitation interventions as well as indications for rehabilitation and patient assessment are addressed separately. Driving rehabilitation is discussed elsewhere. (See "Geriatric rehabilitation interventions" and "Overview of geriatric rehabilitation: Patient assessment and common indications for rehabilitation" and "Approach to the evaluation of older drivers", section on 'Communicating with patient and family'.)

TYPES OF REHABILITATION PROVIDERS — Disability has many diverse causes and often occurs through the interaction of one or more medical conditions with both personal and environmental contextual factors. Therefore, a variety of providers may be involved in helping individuals to recover from an injury and/or illness and regain functional independence.

A list of types of rehabilitation providers, typical rehabilitation interventions used by providers of various disciplines, and the aspect(s) of the disablement process targeted by the provider types is provided in a table (table 1). Treatment by a provider in a single discipline is often sufficient for patients with uncomplicated conditions or with minimal disability (eg, physical therapy [PT] for osteoarthritis of the knee or a home safety evaluation by an occupational therapist for a patient with a fear of falling). However, for more complex or catastrophic disability, a multidisciplinary team of providers is optimal to address the rehabilitation needs related to progressive disability and the interaction of multiple contributing health conditions and contextual factors.

Multidisciplinary care is a cornerstone of rehabilitation. The efficacy of coordinated multidisciplinary rehabilitation for a number of conditions affecting older adults, including stroke, rheumatoid arthritis, falls, and frailty, is supported by numerous studies [1-7]. Geriatric evaluation and treatment units provide multidisciplinary care with medical, social service, nursing, and rehabilitation personnel (typically PT and occupational therapy [OT]) working together in a coordinated fashion [1]. For example, inpatient stroke rehabilitation teams include a variety of rehabilitation personnel (eg, speech therapy [ST], PT, OT) to develop rehabilitation interventions targeting the specific stroke-related deficits, as well as medical, nursing, and other staff [2]. Coordination of care may be achieved with weekly team meetings and/or scripted protocols to facilitate care coordination.

Benefits from coordinated multidisciplinary rehabilitation accrue from systematically targeting multiple factors that interact to cause and exacerbate disability. For example, stroke may adversely affect visual perception, speech, and cognition as well as cause paralysis. Members of the multidisciplinary team often have both unique and overlapping expertise, reinforcing the interventions of each other.

REHABILITATION SETTINGS — Rehabilitation therapy services can be delivered in a wide variety of settings across the care continuum. Settings for rehabilitation therapy include the acute hospital (eg, critical care units, general medical or surgical units) and postacute locations including transitional care units in hospitals (eg, inpatient rehabilitation units), rehabilitation hospitals, nursing homes/skilled nursing facilities (SNFs), outpatient facilities, and the patient’s home. The intensity and nature of services delivered differ across settings.

When not delivered in a dedicated rehabilitation unit, rehabilitation treatment is often limited to services by a single discipline (eg, physical therapy [PT] or occupational therapy [OT]). Even when more than one rehabilitation service is involved, the degree of coordination that is possible (ie, in the hospital, largely through progress notes or discharge planning rounds) is less optimal than the coordination through in-person contact and physician-led weekly conferences that are standard in an inpatient rehabilitation facility.

Acute hospital rehabilitation

Early inpatient rehabilitation — Rehabilitative services for patients on medical and surgical units typically focus on mobilization and discharge planning. However, data indicate the merits of early mobilization for diverse acutely ill patient populations [8-10].

●There is good evidence showing benefit from early intensive PT/OT in the hospital for stroke patients [11] and patients with a total joint replacement or hip fracture [12,13].

●Older patients admitted with medical problems such as pneumonia benefit from dedicated efforts to promote early mobilization, with resultant reductions in length of stay and improved likelihood of community discharge [14,15].

●Some programs are starting PT on postoperative day 1 or even in the recovery room, with apparent benefits on length of stay and physical function [16-18].

●Early mobilization, beginning the first day of intensive care unit (ICU) hospitalization and while the patient is still on a ventilator, can shorten length of stay and improve functional outcomes [19-21].

Standing protocols for analgesia and preemptive analgesia before PT can increase participation in PT and improve clinical outcomes [8].

Determining ability to participate — It is necessary to determine if a patient has the capacity, both physically and mentally, to participate in PT or OT. Close coordination of medical care can help, for example, by reducing delirium and ensuring optimal pain management [8,22]. Suggestions for parameters to determine the hospitalized patient’s ability to participate in PT or OT are shown in a table, with focus on the patient’s cognitive, hemodynamic, musculoskeletal, and pain status (table 2). (See "Delirium and acute confusional states: Prevention, treatment, and prognosis" and "Approach to the management of acute pain in adults".)

Even for patients who can’t participate in therapy, involvement of PT and OT is a necessary component of discharge planning in any adult for whom there is concern about the ability to return home (eg, limitations in self-care or mobility are present). This is particularly important for older adults, as they are vulnerable to adverse effects from care transitions and often require care in multiple settings over the course of illness and recovery [23].

Postacute rehabilitation

Setting — A common critical decision for inpatient providers is determining the type of setting in which postacute rehabilitation will be delivered. Ideally, rehabilitation during the postacute period will help to ensure maximal recovery for patients after an acute illness.

Postacute rehabilitation may take place in a number of different venues with differing advantages for various types of geriatric patients. These sites include:

●Inpatient rehabilitation facilities

●Long-term acute care hospitals

●SNFs with Medicare-certified therapy services (sometimes referred to as "subacute" or "transitional care" units)

●The Geriatric Evaluation and Management inpatient rehabilitation program or community living center (within the Veterans Administration)

●A patient’s home delivered in-person by rehabilitation therapists or using telehealth technology

●Outpatient facilities in-person by rehabilitation therapists or using telehealth technology

Postacute settings differ in the types of available rehabilitation therapies, intensity of therapy, the level of medical and nursing support, and reimbursement (table 3).

Telehealth technologies increasingly are being used in rehabilitation. Telerehabilitation may use a variety of technologies for remote delivery or rehabilitative services. Such technologies include eHealth, which uses internet-based technology for provision of health care (eg, video visits) and/or heath informatics, and mHealth, which refers to use of health applications on mobile devices. These technologies may be used to provide remote monitoring, remote measurement, synchronous (ie, real-time) and asynchronous (ie, store and forward) audiovisual communications [24-26]. Importantly, emergency legislation from the Centers for Medicare and Medicaid Services (CMS) provides coverage for telehealth services by rehabilitation providers [27].

Multiple factors are to be considered when determining an appropriate location for postacute rehabilitation for a specific geriatric patient. Key factors to consider include (see "Hospital discharge and readmission", section on 'Determining the post-discharge site of care'):

●Medical diagnosis

●Functional abilities (premorbid, admission, and current)

●Medical stability

●Cognition

●Therapy tolerance and motivation

●Types of therapy services needed

●Psychosocial factors such as patient/family preference, social support, geographic location

●Third-party reimbursement

Medical diagnosis — The medical diagnosis is an important determinant of eligibility for admission to an inpatient rehabilitation facility. Under the CMS guidelines, 60 percent of patients admitted to an inpatient rehabilitation facility must have 1 of 13 medical diagnoses (table 4). These guidelines therefore influence the availability of beds and acceptance of particular patients referred for inpatient care.

Diagnoses that often warrant a higher level of postacute care (ie, intensive rehabilitation) include stroke, spinal cord injury, and traumatic brain injury. General orthopedic patients (eg, patients recovering from hip fracture, ischemic amputation, or total joint replacement) may not gain particular benefit from intensive rehabilitation and may recover function just as well with rehabilitation in a subacute or skilled nursing facility [28-30]; each patient should be evaluated individually to determine their most appropriate postacute rehabilitation setting. For example, frailty in patients with hip fracture or ischemic amputation may limit their ability to tolerate more intensive rehabilitation, while patients with an elective total joint replacement may have good general health and be able to rehabilitate with home health therapy followed by therapy in an outpatient facility. By contrast, patients with traumatic amputation often have other concomitant injuries requiring intensive rehabilitation.

We note that coronavirus disease 2019 (COVID-19) is an important condition for which acute and post-acute needs and optimal therapies are still evolving [31,32]. CMS has adopted a variety of flexibilities to help inpatient rehabilitation facilities meet the evolving needs [33].

Optimal level of postacute rehabilitation — Even within groups of patients who can benefit from intensive postacute inpatient rehabilitation, a variety of considerations are important when determining the optimal level of postacute care. The following describes some key considerations across most diagnostic groups that pertain to determining the optimal level of postacute rehabilitation.

●Prehospital and current functional abilities – Information about functional abilities may be obtained from PT and/or OT evaluations and from the nursing service, although a history of prehospital function is best obtained from the patient/family directly. PT/OT consultations should be made early on during an acute hospitalization. This will help to ensure optimal clinical outcomes and allow sufficient time for the evaluation, for the equipment to be obtained if needed, and for the patient to be trained in its use.

Therapy assessments should include an evaluation of ambulatory function and the patient’s ability to perform basic activities of daily living (table 5 and table 6). At a minimum, it should be determined whether the patient is independent or requires assistance from another person. For example, most individuals who resided in a nursing home setting prehospitalization will return to a nursing home, as it is unlikely they would make sufficient functional gains to become independent again and would be unlikely to have an independent living situation to return to after rehabilitation. Rehabilitation for such patients would best be met in an SNF–level setting, rather than in an inpatient rehabilitation facility or with a home health service.

●Medical stability – Medical stability assists in determining both the patient’s ability to participate in therapy while in the hospital and the type of postacute setting most appropriate after discharge. Inpatient rehabilitation facilities have physicians on staff to see patients daily and treat complex rehabilitation medical problems (eg, spasticity, autonomic dysreflexia). By contrast, an SNF has skilled nurses on staff to monitor patients’ conditions and provide skilled nursing services with intermittent support (eg, once weekly) from medical staff who typically have general expertise in geriatric medicine. Thus, patients with active medical problems requiring close clinician and nursing care are best discharged to either a long-term acute care hospital or an inpatient rehabilitation facility.

●Cognition – Participation in therapy is dependent, at a minimum, on the ability to follow one-step commands and to sufficiently recall so that learning is possible and therapists are not repetitively instructing the same task. Therapeutic goals are constrained when such abilities aren’t present, with interventions limited to recommendations for equipment, environmental modifications, and caregiver training to enhance safety with functional tasks (eg, ambulation and bathing) and caregiver training on interventions to help maintain physical/functional abilities (eg, range of motion exercises, proper use of splints and braces).

●Therapy tolerance and motivation – While rehabilitation therapy in and of itself can help reduce depression and restore confidence, patients must be willing to participate. The patients’ motivation may be gleaned from their participation and motivation during therapy sessions in the acute hospital setting and their willingness to work with nursing staff during daily care. Tolerance for the more intensive therapy program required in an inpatient rehabilitation facility (three hours of therapy per day, five days per week) may also be inferred from patient participation with PT/OT during their acute hospitalization.

●Types of needed therapy services – Patients discharged to an inpatient rehabilitation facility must have a demonstrated need for at least two therapy disciplines (ie, PT/OT/speech therapy [ST]). These services may be offered in other settings, but anticipated use of these therapies is not a requirement for admission to other settings.

●Psychosocial factors – For many patients recovering from an injury/illness, social factors including education, social support, housing, access (financial resources/insurance), and personal preference (eg, facility close to home) are important considerations in determining the best location for postacute rehabilitation. In addition, psychological factors such as motivation, anxiety, and depression may also be influential considerations.

REIMBURSEMENT (UNITED STATES)

Reimbursement for providers — Reimbursement models continue to evolve in the United States. Examples of some common payment mechanisms used by public payers are provided here. Specifics can vary considerably over time depending on the particular clinical situation and evolving approaches to reimbursement. Medicare uses a “prospective payment" system for rehabilitation in many postacute settings, for which a predetermined amount is provided for particular diagnoses, with consideration for the severity of the condition and comorbid conditions (eg, mild stroke versus severe stroke with diabetes and hypertension).

A general example of these considerations for a stroke patient is as follows: Medicare prospective payment for intensive inpatient rehabilitation after an acute stroke (without additional comorbid conditions) is approximately 12 to 14 days. By contrast, the same stroke patient may receive up to 100 days of therapy (20 days at 100 percent coverage and 80 days at 80 percent coverage) in an SNF. Thus, if the patient is likely to benefit from prolonged therapy, but at a lower intensity, an SNF for rehabilitation might be the better choice.

Prospective payment is also in place for home health services. In that setting, a stroke patient might receive three weeks of therapy (PT, OT, and/or ST) up to three times per week, then another one to two weeks with less frequent visits per week. Previous treatment in an inpatient setting does not preclude payment for home health therapies or outpatient therapies after discharge home.

In all three of these settings (inpatient rehabilitation, skilled nursing, home health), the patient must require "skilled" services to qualify for Medicare payment. To receive coverage for home health care, a skilled service must be needed by a “qualifying” provider, typically either a registered nurse or physical therapist. For example, if the only visit was by an occupational therapist (eg, for a home safety and falls assessment), it would not be covered. Additionally, services of a home health aide, in the absence of other skilled nursing or therapy series, would not be reimbursed. Further, home health care is only covered for "homebound" patients, defined as patients unable to leave home except for medical care and infrequent nonmedical reasons such as to go to religious services. There is also a requirement for a face-to-face visit with the patient within a certain period, with documentation [34]. Such documentation must be provided by a certifying physician or mid-level provider (who practices either in collaboration with or under the supervision of a physician, eg, physician assistant or nurse practitioner). Specifically, this face-to-face visit must occur within the 90 days prior to the start of home health care, or within the 30 days after the start of home health care. In situations when a physician orders home health care for the patient based on a new condition that was not evident during a visit within the 90 days prior to start of care, the certifying physician or mid-level provider must see the patient within 30 days after admission. Additional information is available online [35,36].

Rehabilitation services provided in outpatient facilities covered by Medicare are often paid for as "fee for service." The total number of visits for all conditions used to be limited; the limits could be exceeded for some medically necessary therapies with appropriate justification from the medical provider and/or when the care was provided in hospital emergency departments or outpatient departments [37,38]. In contrast to OT delivered in the home health setting, there is no requirement for "skilled services" by PT or nursing in order for therapy services in the outpatient setting to be covered.

Effective January 2018, Medicare no longer has a hard cap on rehabilitation therapy services reimbursed in one calendar year (also referred to as “therapy caps”). However, for Medicare to pay for rehabilitation therapy services, the therapist must track total claim amounts for the patient and confirm that therapy services are medically reasonable and necessary when they exceed a predetermined amount each calendar year (eg, USD $2010 for 2018).

Medicaid also covers rehabilitation services with variation from state to state. The Veterans Health Administration (VHA) provides rehabilitation throughout the continuum of care with either no charge for services or a modest copay (depending on level of service connection and/or finances).

Technologies for remote delivery (telehealth) of physical and occupational rehabilitation are covered by CMS. Effective March 2020, CMS announced expansion of telehealth services to Medicare beneficiaries to address the COVID-19 pandemic. This new reimbursement flexibility builds on expanding telehealth coverage and codes for reporting use of telehealth (eg, remote monitoring of physiologic parameters, device supply with daily recordings or programmed alerts transmission, or remote physiologic monitoring treatment management services). Specifically, telehealth rehabilitation coverage is now available through all CMS programs (eg, Medicare fee-for-service model as well as bundled payment programs, such as the Comprehensive Care for Joint Replacement model).

Reimbursement for mobility aids — Medicare/Centers for Medicare and Medicaid Services (CMS) will pay for "durable medical equipment" (DME), including all types of mobility aids, but it is important to follow their guidelines to ensure coverage (table 7) [39]. Medicare guidelines for "mobility assistive equipment" (MAE) favor use of a cane or walker over a manual wheelchair and a manual wheelchair over a power mobility device (eg, power wheelchair or scooter), approving the higher-level device only if the patient has a mobility limitation that is not adequately compensated with the lower-level device [40]. Generally, Medicare reimbursement is limited to one type of mobility aid per qualifying illness (ie, the patient isn’t provided both a quad cane and a wheelchair for mobility needs after a stroke). Face-to-face evaluation by a certifying physician or midlevel provider and substantive medical justification is required by CMS for power mobility devices [41].

Some medical supply stores and vendors employ a certified assistive technology professional (ATP) with added training in these specialized devices, especially for provision of high-tech devices (eg, power wheelchairs). Medicare/CMS covers consultation with an occupational or physical therapist for fitting and training in use of any type of durable medical equipment, including mobility aids.

The VHA will also cover most types of mobility aids and without some of the restrictions in the Medicare system (eg, more than one type of mobility aid may be provided for a particular medical problem so long as it is medically necessary), although medical justification by a VHA medical provider is required and training in use of the device by a VHA rehabilitation provider is also usually required.

Typically, Medicare will pay for rental of a standard manual wheelchair, with the patient owning the wheelchair after 13 months of rental [42]. Wheelchairs for nursing home residents are provided by the institution rather than Medicare/CMS, so it can be difficult to obtain a specialized wheelchair in that setting. Veterans own the mobility aids provided to them by the VHA, and they do not need to be returned when they are no longer needed, although they may need to be returned to get a new or replacement device.

Reimbursement for assistive devices — Medicare/CMS will not pay for bathroom safety devices such as raised toilet seats, tub/shower seats, or grab bars, considering these items not medical equipment and/or needed for "personal convenience," although Medicare will pay for a freestanding "bedside" commode (table 7) [43]. The VHA, however, will reimburse for most assistive devices.

Similarly, Medicare/CMS will not pay for assistive devices related to self-care (eg, specialized eating utensils), although the VHA does provide these items. Consultation with a rehabilitation therapist (eg, occupational or physical therapist) for evaluation, fitting, and training in use of any type of assistive devices is paid for by both Medicare and the VHA, and such consultation can help assure the prescribed device will meet the patient’s needs and that they can use it safely [44].

Reimbursement for prosthetic and orthotic devices — Medicare/CMS provides coverage for many prosthetic and orthotic devices, although generally the patient is responsible for a 20 percent copay (table 7) [39].

●Medicare will cover fabrication of a prosthetic limb and related follow-up visits with a prosthetist, as does the VHA. Per Medicare guidelines, the anticipated functional level of the lower-extremity amputee (K-level) must be considered and specified in the prescription for the prosthetic limb.

●Typically, both Medicare and the VHA will pay for a splint fabricated by an orthotist or occupational therapist and many prefabricated braces as well.

Reimbursement for adaptive devices — The VHA will pay for ramps and some home renovations (with a monetary cap that varies with "service connection"), and some veterans are eligible for a "specially adapted housing" grant [45]. Medicare does not cover environmental modifications.

SUMMARY AND RECOMMENDATIONS

●Types of rehabilitation providers – Rehabilitation treatment by a provider in a single discipline is often sufficient for patients with uncomplicated conditions or with minimal disability. However, a diverse group of allied health providers are often involved in providing rehabilitation services. (See 'Types of rehabilitation providers' above.)

•Occupational therapists have expertise in self-care skills and the person-environment interface within the home environment and can recommend the most beneficial assistive devices and home modifications.

•Physical therapists are particularly helpful with mobility impairments and equipment, as well as exercise interventions to treat physical impairment.

•Prosthetists have specialized expertise in fitting training and use of prosthetics and orthotics.

•Rehabilitation physicians have expertise in provision of rehabilitation in generally and may have specialized training in particular conditions (eg, spinal cord injury, pain) and in a variety of specialized procedures (eg, electromyography-guided botulinum toxin injections for spasticity).

•Speech and language pathologists (speech therapists) have expertise in treatment of impaired speech and swallowing. Low-vision specialists provide unique expertise for older adults coping with low vision. A variety of other specialized personnel may provide rehabilitation care in particular settings (eg, recreational therapists, rehabilitation nursing). (See "Geriatric rehabilitation interventions", section on 'Environmental modification'.)

●Rehabilitation settings – Rehabilitation therapy services can be delivered in a wide variety of settings across the care continuum. Settings include the acute hospital (eg, critical care units, general medical or surgical units) and postacute locations including transitional care units in hospitals, rehabilitation hospitals, nursing homes/skilled nursing facilities (SNFs), outpatient facilities, and the patient’s home. (See 'Rehabilitation settings' above.)

•Inpatient rehabilitation – Early mobilization, beginning postoperative day 1, the day of admission, or while in the intensive care unit (ICU) and still on a ventilator, can shorten length of stay and improve functional outcomes. Involvement of physical therapy (PT) and occupational therapy (OT) is a necessary component of hospital discharge planning, particularly for older adults and patients for whom there is concern about the ability to return home (eg, limitations in self-care or mobility are present). (See 'Acute hospital rehabilitation' above.)

•Postacute hospital rehabilitation – A common critical decision for inpatient providers is determining the type of setting in which postacute rehabilitation will be delivered. Ideally, rehabilitation during the postacute period will help to ensure maximal recovery for patients after an acute illness. The options and considerations when considering continued rehabilitation upon discharge from the acute hospital setting are summarized in a table (table 3). (See 'Postacute rehabilitation' above.)

●Reimbursement – Reimbursement in the United States for mobility aids and other assistive devices varies based on the provider. (See 'Reimbursement (United States)' above.)