Long Term Acute Care Transcript

Responses to questions provided by Lee Pickler, D.B.A. Gary S. Clark, MD, MMM, CPE Residency Program Director, Professor and Chair Department of Physical Medicine & Rehabilitation Case Western Reserve University School of Medicine Associate Chief Medical Officer for Education, MetroHealth Medical Center Medical Director, MetroHealth Rehabilitation Institute of Ohio 2500 MetroHealth Drive Cleveland, OH 44109-1998 […]

Responses to questions provided by

Lee Pickler, D.B.A.

Gary S. Clark, MD, MMM, CPE

Residency Program Director, Professor and Chair

Department of Physical Medicine & Rehabilitation

Case Western Reserve University School of Medicine

Associate Chief Medical Officer for Education, MetroHealth Medical Center

Medical Director, MetroHealth Rehabilitation Institute of Ohio

2500 MetroHealth Drive

Cleveland, OH 44109-1998

[email protected]

What is the difference between the Inpatient Rehabilitation Facility (IRF) in the US and the KFW in Japan in terms of stroke patients?

In Japan, all stroke patients go to the KFW.

In the United States stroke patients must meet certain admission criteria.  One major criteria is the patient must be able to tolerate three plus hours of rehabilitation services.

For stroke patients, differences between the IRF in the US and the KFW in Japan include the fact that only a proportion of stroke patients in the US go to IRF’s.  A stroke patient must be evaluated by the rehabilitation physician to determine if he/she meets various admission criteria to be eligible for admission to the IRF.  These criteria include medical necessity (i.e., the neurological deficits post-stroke must be severe enough to warrant the intensive inpatient rehabilitation setting), the projected/predicted ability (based on therapy tolerance in the acute STAC Hospital) to tolerate at least 3 hours of therapy per day, patient preference (i.e., the patient may meet admission criteria for an IRF, but decide to go home or to a subacute rehabilitation program) and, at times, insurance coverage.

Other differences include the timing of admission of stroke patients to IRF’s in the US post-stroke, usually on the order of 10-15 days post-stroke (compared to mean of 31.5 days post-stroke in Japan (per the 2011 Miyai,et al paper in Neurorehabilitation and Neural Repair).  Length of stay (LOS) for stroke patients is typically in the 15-20 day range for IRF’s in the US, compared to 75.9 days in KRW’s in Japan.

Another factor referenced in Miyai’s paper was that the actual number of hours of therapy provided to stroke patients in the KRW’s was rather variable, with less than 20% of stroke patients receiving 15+ hours of therapy per week (between 2006 and 2009), whereas in the US every patient is required to receive at least 3 hours of therapy per day/15 hours of therapy/week.  As Miyai points out in his article, “FIM efficiency was not as high as that of IRF’s in the US mainly because of later admissions and longer stays.”  The latter may be due in part to the variable amounts of therapy received.

How is information sharing in a particular patient’s medical chart carried out among different PACs?

A patient going from an STAC to an LTAC for example does not have a complete medical record transfer.  However the LTAC does have access by request.  What is transferred with the patient is a discharge summary which includes any medications the patient is taking, the status, or diagnosis of the patient and goals for next steps for the patient.  These goals are the physician’s prescription (orders).  The same process happens when the patient goes from an LTAC to another level of care.

There is a standard form (at least in Ohio) that is completed by the referring facility (known as a “golden rod form”) which includes diagnoses, procedures, medications, dietary information, social information, and any continuing treatment recommendations.  The receiving facility also calls the referring facility for a “Transfer Report”, which also addresses similar issues, and any last minute updates or changes, and also includes the patient’s current vital signs, medications already taken that day, etc.  There are some health care organizations with Electronic Health Records where different PAC’s might have access to patient information from other STAC or PAC facilities.

You mentioned that IRF is accredited by Certification Accredited Rehabilitation Facility (CARF) and that STAC hospitals use this information as a reference to decide which IRF they want to refer their patients to.  Does IRF also do similar things with STAC?  In other words, does IRF use the STAC accreditation information as a reference in case they have to send their patients to STAC?  If so, what kind of organization certifies STAC hospitals?

No, IRF organizations do not review STAC certification as a criteria for patient admission.  STAC organizations MUST be accredited by The Joint Commission on Accreditation of Health Care Organizations (JCAHO) which is very recently renamed The Joint Commission (TJC).  LTAC organizations DO NOT HAVE TO BE accredited.  However it is a good certification to have and it is presumed that STAC managers would like to use LTAC organizations which are accredited.

CARF stands for Commission on Accreditation of Rehabilitation Facilities, and as referenced is the “Hallmark of Quality” for rehabilitation organizations, which STAC’s consider when deciding where to refer patients.  With regard to patients going back to a STAC Hospital, most IRF’s will refer the patient back to the STAC from where they were admitted, for reasons of continuity of care, as well as for political considerations and to maintain good referral relationships.  However, if a patient in an IRF is acutely ill/unstable, then they would be taken by ambulance/EMS (Emergency Medical Services) to the nearest STAC Hospital to stabilize the medical condition.  There also may be a patient preference issue if it is an elective return to STAC Hospital.   As noted above, it is assumed that every STAC Hospital in the US is Joint Commission-accredited, as this is necessary to participate in Medicare and Medicaid federal insurance programs and receive payments for care rendered.

As was mentioned that LTAC is in the niche market.  If that is the case, does it not cover the entire specialty treatment areas such as general med/surg or OB/GYN?  Or is it more program oriented rather than medical specialty oriented?

LTAC organizations do not offer all medical services.  Medical/Surgery services are offered but not OB/GYN.  LTAC organizations do not offer services for pediatrics.  However children’s hospitals do not have a Length Of Stay (LOS) requirement.  An example of a children’s hospital is University Hospital’s Rainbow Baby’s and Children’s Hospital which we have visited in prior years.

Many LTACH’s offer specialized services based on the needs of the referring STAC Hospitals – examples include cardiac care post-CABG, or ventilator-weaning programs.  These niche programs typically  fill a gap in available services for the area.

In order to establish a Hospital in a Hospital (HIH) , how does an LTAC interface with its parent hospital which would be a STAC?  What functions in particular need to be established, negotiated, shared and clarified?

The LTAC must be a separate organization with its own management staff and medical staff.   It reports its own financial records, for example income statements and balance sheets.  There can be no co-mingling of funds between the two organizations.  However, the STAC can contract with the LTAC to provide housekeeping services, dietary services, diagnostic services such as lab, radiology, EKG and cardiology services.  One organization may acquire another but they may not merge with each other.  In other words and STAC may purchase an LTAC or vice versa as long as they keep their organizations managerially and financially separate.

There are typically restrictions placed by the government on what proportion of admissions to the hospital-based LTACH can come from the ‘host’ STAC Hospital.  The intent is that the LTACH (and post acute care programs in general) serves the region, not just a single geographic area or STACH.

Does finding or deciding placement of care for the patient in several options in Post Acute Care (PAC) mean that each facility performs a kind of triage of patients based on admission criteria?

The sequence of care is from an STAC to an LTAC then Acute Rehab then Skilled Nursing Facility (SNF) and hopefully to Home Health Care.

Basically, the answer is “yes” – each Post-Acute Care (PAC) program/facility that a patient is referred to must perform their own independent assessment to determine/document that the patient meets their admission criteria.  Due to overlap in admission criteria, any particular patient may be appropriate for two (or more) levels of PAC – each PAC program/facility would evaluate the patient on their own, accept the patient if he/she meets the admission criteria, and then the patient/family would decide which setting to go to.

Could you recommend to us any reference materials regarding more detailed rules, standards or criteria about STAC, LTAC, IRF , SNF?

Good summary is the reference listed on Dr. Clark’s presentation from January, 2012:

American Hospital Association: TrendWatch – Maximizing the Value of Post-acute Care.  November, 2010.


Also, CMS has detailed information regarding levels of PAC and individual program/PAC criteria:

Centers for Medicare and Medicaid Services:   https://www.cms.gov/InpatientRehabFacPPS/