Scope of Service

Inpatient Rehabilitation

Scope of Service – General

ADMISSIONS AND REFERRAL PROCESS

1. Referral Process

A. Patients may be referred by physicians, discharge planners, allied health professionals, third party payers, patients or family members. Persons referred to the program will be screened according to admission criteria to determine their potential to participate in and benefit from a comprehensive inpatient rehabilitation program. The screening may be performed by the Admission Coordinator, Rehabilitation Physician or designee.

B. Preadmission screening is performed prior to admission. It is inclusive of the referred patient’s medical necessity, acuity, medical stability, activity limitations and impairments, psychological and behavioral status, cultural needs, ability to benefit, ability to tolerate, and willingness to participate in an Inpatient Rehabilitation level of care. During the preadmission process, primary sources of funding are identified. The patient is notified regarding the extent of insurance coverage to help in their decision making. Admission to the Rehabilitation program is based on this preadmission assessment and not based on payer source or lack thereof.

2. Admission Process

A. Patients who are candidates for Inpatient Rehabilitation are reviewed and approved by the Medical Director, Rehabilitation physician, or his designee. Funding sources often require authorization and include Medicare, Worker’s Compensation, Medicaid, commercial insurance and other payers. Patients are assigned rooms according to the clinical needs of the patient.

3. Persons Served

A. The HealthCenter Inpatient Rehabilitation services are provided for adolescent, adult and geriatric patients of varying cultural backgrounds. Patients are typically ages 14 and above, age 13 and younger will be considered on a case by case basis by the medical director in coordination with the child’s pediatrician. Typical diagnosis of patients include, but are not limited to stroke, spinal cord injury, brain injury, orthopedic problem(s), amputation(s), major multiple trauma, and/or a neurological impairment. These conditions are of recent onset, or a regression, that has resulted in a loss of function in mobility, activities of daily living, cognition or communication. Patients admitted to Inpatient Rehabilitation services are medically stable, but have the medical acuity to warrant an inpatient hospital stay with 24 hour Rehabilitation nursing. The patients must demonstrate a potential for functional improvement, a need for an interdisciplinary team approach and a medical history and present medical condition that can tolerate a comprehensive rehabilitation program.

B. A comprehensive rehabilitation program requires the ability and willingness to participate in at least 3 hours of therapy a minimum of 5 days a week. Patient must require coordinated treatment by at least two therapy disciplines’. If capable, the patients should exhibit the psychological status and behavioral status to allow them to participate in the rehabilitation process. Some patients will demonstrate confusion, agitation, and behavioral issues due to neurological trauma. The program typically does not accept patients with traumatic brain injury below the Rancho Los Amigos scale IV(confused/ agitated), patients requiring ventilator support, or patients receiving IV chemotherapy and/ or radiation treatments.

C. The patient should have a potential for discharge to a community environment. Typical discharge settings include home with home health or outpatient therapy services, family members home, assisted living, and occasionally skilled nursing facilities.

SERVICES PROVIDED

We provide rehabilitation care to inpatients on a 24-hour, 7 days a week basis. Typically a weekend day is set aside for patient and family time. A patient-centered philosophy is the foundation of all of our programs. Rehabilitation nurses are an essential part of the interdisciplinary team and they are involved in all decisions regarding patient care and the rehabilitation program. Therapists and nurses work closely with the patient, their family and other members of the team to develop and implement the plans of care for each patient. Our social workers play a key role as the coordinators of care for each patient by facilitating team conferences, meeting with patients / families, and ongoing communication with insurance companies.

Patients are provided comprehensive, integrated services through the coordination with all hospital support departments. This may include, but is not limited to pharmacy, radiology, lab and pathology, respiratory, and emergency medical services.

1. Medical Supervision

All patients are medically supervised by a licensed doctor of medicine or osteopathy who is a member of the hospital staff. The medical management of the patients is provided by a physiatrist or rehabilitation physician. The attending physician provides 24 hour, on call coverage and is responsible for completing admission orders and a history and physical for each patient. The Rehabilitation physician leads the team conferences to coordinate the care of the patients and the completion of the plan of care. All physician activities are governed by the hospital Medical Staff By-Laws and Rules and Regulations.

2. The Rehabilitation Program

A. An evaluation /assessment is conducted by each of the involved team members. Services provided are based on the assessed needs of the patient including cultural, religious, and developmental considerations. The evaluation will assess impairments, recommend activity limitations, and assess and recommend participation restrictions. Patient progress is assessed on an ongoing basis and changes in the treatment plan are discussed and agreed upon in team conferences weekly. Educational needs, if applicable, are addressed by the team with the school’s integration coordinator.

B. Treatment plans are based on input provided from the evaluations of all the professional team members, including rehabilitation nursing. All team members are responsible for carrying out the interdisciplinary treatment plan. The patients and their families assist in the development and implementation of a patient centered treatment plan which is unique to the patient based on the individual’s goals including the environmental factors that impact their lives after they transition from the inpatient rehabilitation facility.

C. The Rehabilitation Unit has 13 inpatient beds and is located on the second floor of The HealthCenter building attached to Kalispell Regional Medical Center. HC is a CARF accredited Inpatient Comprehensive Rehabilitation program.

  1. The SW/Care Coordinator is responsible for counseling, coordinating the care for each patient and integrating patient and family goals.
  2. Team conferences are led by a physiatrist and treatment changes are decided by the treatment team.
  3. Family conferences are held as frequently as requested by the team and the patient and family.
  4. Orientation to rehabilitation is initiated the day of admission by the rehabilitation nurse.
  5. Formal evaluation is completed within 3 days of admission by treating team members.
  6. Patients are reassessed by the treatment team at least weekly to evaluate progress. Input from the team will be utilized to update the Goals and Outcomes and Plan of Care and to establish and/or confirm the anticipated discharge date based on a patient centered philosophy.
  7. In order for patients, families, and caregivers to be capable of providing the necessary support, they must have an understanding of the disease process, the patient’s functional disabilities, the rehabilitation process / goals and knowledge of resources available to them after discharge.
  8. Training and support for patients and others occur on a one-on-one basis or in formalized team groups and are the responsibility of every member of the team. Successful reintegration of the patient into the community requires the support of family members and/or significant others.
  9. Discharge planning begins during the intake and admissions phases and continues throughout the program. Responsibility for discharge planning is shared by all members of the treatment team. Referrals are made as indicated and follow up contacts are made to facilitate successful return into the community.

3. Transition / Discharge Criteria:

A. The patient has received maximum benefit from the program by achieving all of the rehabilitation goals.

B. After comprehensive evaluation, the patient is determined to have no potential to benefit from and/or ability to tolerate our comprehensive inpatient rehabilitation program.

C. The patient is unable to make further progress toward rehabilitation goals.

D. The patient no longer requires inpatient services to achieve rehabilitation goals.

E. The patient experiences a major intervening surgical, medical or psychological problem that precludes benefit from a continued intensive rehabilitation program.

F. The patient and/or the family are no longer willing to be active participants in the program.

G. The patient/family exercises legal rights and denies the services offered.

H. The patient’s needs demonstrate the ability to benefit from an extension or continuation of services at our comprehensive inpatient rehabilitation program.

Scope of Service – Stroke

ADMISSIONS AND REFERRAL PROCESS

1. Referral Process

A. Patients may be referred by physicians, discharge planners, allied health professionals, third party payers, patients or family members. Persons referred to the program will be screened according to admission criteria to determine their potential to participate in and benefit from a comprehensive inpatient rehabilitation program. The screening may be performed by the Admission Coordinator, Rehabilitation Physician or designee.

B. Preadmission screening is performed prior to admission. It is inclusive of the referred patient's medical necessity, acuity, medical stability, activity limitations and impairments, psychological and behavioral status, cultural needs, ability to benefit, ability to tolerate, and willingness to participate in an Inpatient Rehabilitation level of care. During the preadmission process, primary sources of funding are identified. The patient is notified regarding the extent of insurance coverage to help in their decision making. Admission to the Rehabilitation program is based on this preadmission assessment and not based on payer source or lack thereof.

2. Admission Process

A. Patients who are candidates for Inpatient Rehabilitation are reviewed and approved by the Medical Director, Rehabilitation physician, or his/her designee. Funding sources may require authorization and include Medicare, Worker's Compensation, Medicaid, commercial insurance and other payers. Patients are assigned rooms according to the clinical needs of the patient. Futon rooms are available if family members are staying with the patient.

B. Patients who are non-english speaking can utilize interpreter services.

3. Persons Served

A. Inpatient Rehabilitation Stroke Specialty services are provided for patients who have experienced recent onset of stroke that has resulted in loss of mobility, diminished activities of daily living, cognition or communication. Patients admitted to Inpatient Rehabilitation services are medically stable, but have the medical acuity to warrant an inpatient hospital stay with 24 hour Rehabilitation nursing. The patients must demonstrate a potential for functional improvement, a need for an interdisciplinary team approach and a medical history and present medical condition that can tolerate a comprehensive rehabilitation program.

B. A comprehensive rehabilitation program requires the ability and willingness to participate in at least 3 hours of therapy a minimum of 5 days a week. Patient must require coordinated treatment by at least two therapy disciplines'. If capable, the patients should exhibit the psychological status and behavioral status to allow them to participate in the rehabilitation process. Some patients will demonstrate confusion, agitation, and behavioral issues due to neurological trauma.

C. The patient should have a potential for discharge to a community environment within a reasonable period of time. Typical discharge settings include home with home health or outpatient therapy services, family members home, assisted living, and occasionally skilled nursing facilities.

SERVICES PROVIDED

We provide rehabilitation care to inpatients on a 24-hour, 7 days a week basis. Typically a weekend day is set aside for patient and family time. A patient centered philosophy is the foundation of all of our programs. Rehabilitation nurses are an essential part of the interdisciplinary team and they are involved in all decisions regarding patient care and the rehabilitation program. Therapists and nurses work closely with the patient, their family and other members of the team to develop and implement the plans of care for each patient. Our social workers play a key role as the coordinators of care for each patient by facilitating team conferences, meeting with patients / families, and ongoing communication with insurance companies, psychosocial coping skills, identification of community resources and durable medical equipment (DME). Our recreation therapists provides community reintegration, outings, and stroke support groups. They identify resources and promote return to leisure activities.

Patients are provided comprehensive, integrated services through the coordination with all hospital support departments. This may include, but is not limited to pharmacy, radiology, lab and pathology, respiratory, and emergency medical services.

1. Medical Supervision

All patients are medically supervised by a licensed doctor of medicine who is a member of the hospital staff. The medical management of the patients is provided by a physiatrist or rehabilitation physician. The attending physician provides 24 hour, on call coverage and is responsible for completing admission orders and a history and physical for each patient. The Rehabilitation physician leads the team conferences to coordinate the care of the patients and the completion of the plan of care. All physician activities are governed by the hospital Medical Staff By-Laws and Rules and Regulations.

2. The Rehabilitation Program

A. An evaluation/assessment is conducted by each of the involved team members. Services provided are based on the assessed needs of the patient including cultural, religious, and developmental considerations. The evaluation will assess impairments, recommend activity limitations, and assess and recommend participation restrictions. Patient progress is assessed on an ongoing basis and changes in the treatment plan are discussed and agreed upon in team conferences weekly. 

B. Treatment plans are based on input provided from the evaluations of all the professional team members, including rehabilitation nursing. All team members are responsible for carrying out the interdisciplinary treatment plan. The patients and their families assist in the development and implementation of a patient centered treatment plan which is unique to the patient based on the individual's goals including the environmental factors that impact their lives after they transition from the inpatient rehabilitation facility.

C. The Rehabilitation Unit has 10 inpatient beds and is located on the second floor of the Health Center Northwest with futon rooms available. The HealthCenter's Inpatient Rehabilitation is a CARF accredited Inpatient Comprehensive Rehabilitation program.

1. The SW/Care Coordinator is responsible for counseling, coordinating the care for each patient and integrating patient and family goals.

2. Team conferences are led by a physiatrist and treatment changes are decided by the treatment team.

3. Family conferences are held as frequently as requested by the team and the patient and family.

4. Orientation to rehabilitation is initiated the day of admission by the rehabilitation nurse.

5. Formal evaluation is completed within 3 days of admission by treating team members.

6. Patients are reassessed by the treatment team at least weekly to evaluate progress. Input from the team will be utilized to update the Goals and Outcomes and Plan of Care and to establish and/or confirm the anticipated discharge date based on a patient centered philosophy.

7. In order for patients, families, and caregivers to be capable of providing the necessary support, they must have an understanding of the disease process, the patient's functional disabilities, the rehabilitation process / goals and knowledge of resources available to them after discharge.

8. Training and support for patients and others occur on a one-on-one basis or in formalized team groups and are the responsibility of every member of the team. Successful reintegration of the patient into the community requires the support of family members and/or significant others.

9. Discharge planning begins during the intake and admissions phases and continues throughout the program. Responsibility for discharge planning is shared by all members of the treatment team. Referrals are made as indicated and follow up contacts are made to facilitate successful return into the community

3. Transition / Discharge Criteria:

A. The patient has received maximum benefit from the program by achieving all of the rehabilitation goals.

B. After comprehensive evaluation, the patient is determined to have no potential to benefit from and/or ability to tolerate our inpatient rehabilitation program.

C. The patient is unable to make further progress toward rehabilitation goals.

D. The patient no longer requires inpatient services to achieve rehabilitation goals.

E. The patient experiences a major intervening surgical, medical or psychological problem that precludes benefit from a continued intensive rehabilitation program.

F. The patient and/or the family are no longer willing to be active participants in the program.

G. The patient/family exercises legal rights and denies the services offered.