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HEART Insight:
doi: 10.1097/01.HEARTI.0000319863.87202.cd
Features: Heart-To-Heart/Making The Grade

Help Your Loved One Get Into The Right Rehab Facility

Fields, Lisa

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Finding the right stroke rehabilitation facility fsor a spouse or parent is, in some ways, like choosing a college for your teen. In both cases, you'll want the best possible program, since the important skills he'll learn will profoundly affect the rest of his life. While you have months to consider colleges, choosing a rehab facility is typically a rushed decision — the average hospital stay for stroke patients is just five or six days, giving you less than a week to evaluate various rehab programs and facilities.

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Stroke patients generally begin rehabilitative therapy at the hospital within 24 to 48 hours after they are admitted, but many patients will need additional physical, occupational and/or speech therapy before being discharged to home care. There are three types of rehab facilities: acute, subacute and long-term care. Doctors, nurses, therapists and social workers will recommend the type of rehab that can provide the therapeutic support your loved one will need.

“Our recommendations are based on the patient's prognosis, prior functional level, what the family support is like, the patient's level of participation and motivation,” says Dawn Wicker, P.T., a physical therapist at Yale-New Haven Hospital's (YNHH) Primary Stroke Center.

Here's what you can expect with each type of facility:

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ACUTE CARE FACILITY Think of these centers as the Ivy League colleges of rehab facilities. The programs are demanding — at least three hours a day — and are typically supervised by neurologists and physiatrists who specialize in rehabilitation therapy. However, not all stroke patients are strong enough or functional enough to handle the pace and intensity of an acute program. “People are used to getting a shot and getting fixed,” says Katie LeMaster, R.N., L.C.S.W., a social worker at Mayo Clinic's Comprehensive Stroke Center in Jacksonville, FL. “But stroke rehab is very slow and painstaking, especially acute care.” Patients typically spend three weeks in acute rehab care.

SUBACUTE CARE FACILITY This type of rehab center is comparable to a middle-of-the-road state college. Your relative will still get a solid — but less intensive — program: Two hours of slower-paced rehab daily, supervised by nurses and therapists instead of doctors. Patients who have diabetes, heart disease, kidney disease or another chronic condition may do better in subacute than acute care, says LeMaster. A pre-existing chronic condition “makes rehab just a little more complicated,” she explains. These patients “may need more time to achieve the same level of recovery [as would be achieved in a more intensive program],” adds Geoff Twohill, O.T.R., a YNHH occupational therapist. Patients typically spend three to four weeks in subacute rehab care.

LONG-TERM CARE FACILITY These facilities — typically nursing homes — are most like adult education classes offered at the local community college. Therapy occurs at a relaxed pace, and is not aimed at “graduating” a patient to home care. During the course of their recovery, stroke patients may move up or down a level of care. Even though you may want your relative to get intensive therapy, listen to the hospital staff if they think he can't hack it. “Sometimes, three hours of therapy would make the patient fatigued, and if he doesn't do well, he'll be discharged to a subacute facility,” says Heather Lisitano, M.A., C.C.C.-S.L.P., a speech therapist at YNHH. Keep in mind that if your loved one doesn't respond to rehabilitative therapy after several days, the insurance company won't pay for more of something that's “not working.”

Some patients who start off in less intense programs can be bumped up to the next level if the pace and level of improvement necessitates more intensive therapy. “Sometimes, families will say, ‘I don't want to put my mother through that intense therapy, let's just put her in a skilled facility,’” says LeMaster. The problem is, a patient won't regain full function if the exercises aren't physically challenging enough, which will limit future health, as well as potential, independence and even self-esteem. “Rehab has to be done pretty quickly,” says LeMaster, adding, “There are better outcomes if you do it sooner.”

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FIND THE BEST FIT

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Once you know what type of facility and rehabilitation program is best for your loved one, the next step is to find the best one. Your first step is to ask the hospital staff for their recommendations. “Our responsibility is to answer questions,” says Twohill.

Look at brochures and Web sites to see what the facility looks like inside and out — the grounds, lounges and other common areas, the dining room — and most important, the room where the rehab exercises are done. Call the facilities to ask about amenities (for instance, can a spouse who wants to stay with a patient round-the-clock be housed and fed at the facility for an additional fee). Make sure to go in person to see the facility for yourself, either by scheduling a formal tour of the facility or by visiting unannounced and asking for a tour. When asking questions, keep the patient's condition, goals and personal preferences top of mind, since he or she will be the one living there for a while.

LeMaster recommends asking about these quality-of-care indicators: Does the staff help relatives learn how to turn the patient in bed or how to help the patient go to the bathroom at night? How often are patients bathed? How often is a patient's room cleaned and the bed linens changed? How are special dietary needs or food preferences accommodated? How often are residents checked on — are there regularly scheduled rounds?

Finally, a word about insurance coverage: Once you know that the facility is covered by your private carrier or by Medicare, find out what types of therapy and services insurance will pay for, and for how long. Benefits vary by insurance plan and/or by state, but patients typically stay in rehab facilities for three to four weeks. “A study in Connecticut found that the average acute rehab stay was 3.5 weeks and the average subacute stay was 4.5 weeks,” Twohill says.

If steady progress is being made, but more time is needed in a rehab facility, you can appeal to the insurance company. “It may help to go outside your standard benefit,” advises LeMaster. She adds that if someone is covered for nursing home care but not for acute or subacute rehab, the insurance company may be able to make a substitution. Ask the social worker or case manager at the rehab facility to write a plan of action to enhance your odds of a successful appeal. “If you're getting nowhere, contact your state insurance commissioner's office to see if there are any other avenues,” says LeMaster.

When Anne Reese, 45, of Denver, investigated acute rehab facilities for her father, Thomas Young — who had a stroke last September at the age of 76 — she sought out facilities that accepted Medicare, offered a variety of therapy and had qualified doctors and therapists on staff.

Her father's left side was paralyzed, and he needed physical, occupational and speech therapy, as well as help with swallowing. She began calling and visiting nearly every facility listed in the Yellow Pages, asking about their gym equipment and the staff's credentials. But the more facilities she considered, the more she found it helpful to speak with a facility's therapists.

“You'll have a good idea if they'll be able to relate to and motivate your relative,” she says. “Rehab is hard work for the patient, so this is the most important thing.” Anne was very satisfied with the care her father received in the acute care facility she chose, but was concerned that he didn't get to stay long enough when Medicare stopped covering his therapy in the facility after 23 days. But he continued his therapy as an outpatient after he went home. Now 77, Thomas lives at home with his wife — who helps him with his therapy “homework.”

While it's true you don't have a lot of time to make a decision about rehab care, if you know what to look for and what questions to ask you can efficiently rule a facility in or out — and feel confident that you made the right choice. “Visit as many places as you can,” Anne says. “Great equipment doesn't always make for great therapy — we learned that it is the therapist and not the gym that makes for successful therapy. And keep in mind that if a therapist or facility is not working, you have the right to make a change.”

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© 2008 American Heart Association, Inc.

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