All right. Can you all see my screen? Yes. All right. Hi, everyone. This is Lauren Shapiro. I'm the current chair of the inpatient rehab member community. And welcome to our third annual member community session. Tonight's topic is medical complexity, finding the sweet spot. Before we get started, if you're not already a member of our inpatient rehab member community, please go ahead and join us on phys forum. It's a very collegial group. It's a great place to get information. If you have a question or share any concerns, please go ahead and join us. We are particularly welcoming for people who are still in training, who are interested in inpatient rehab. And in fact, if anyone would like to serve as a resident or fellow liaison for our community, please get in touch with me. We'd love to have one. For those heading to Baltimore next week, please come and stop by our in-person networking event. It will be Thursday between 10 and 11 Eastern at the Baltimore Convention Center in room 349. Our in-person event will not have any formal agenda. It's just a chance for us to meet in person. It's been a number of years since we've been able to do that. And it will be nice to see people again. A great place to meet other people doing inpatient rehab across the country, talk about what concerns people are having and plan future sessions. Objectives for tonight's program, since we are offering CME, are to identify trends in person served in inpatient rehab facilities or IRFs, describe measures IRFs can take to improve their ability to provide care to medically complex patients, list three potential interventions that may improve a medically complex patient's ability to participate and progress in therapy, and outline best practices to prepare medically complex patients to return home following inpatient rehab. Lauren, are you sharing some slides? Oh, did that drop off? Okay. Sorry, guys. Hold on one second. I don't know what just happened here. There's always technical issues. Is my screen up? We can see it. Sorry, everyone. All right. Well, I'm very happy today to be joined by some distinguished speakers tonight. Dr. David Steinberg is an Associate Professor and serves as Chair in the Department of PM&R at the University of Utah and serves as Executive Medical Director at the Craig H. Nielsen Rehabilitation Hospital. Dr. Craig DiTommaso is the Medical Director at Post Acute Medical in Humboldt, Texas, and also serves as the Director of Early Career Physician Development for U.S. Physiatry. And last but not least, Dr. Jegi Tennyson is an Associate Professor in the Department of Palliative, Rehabilitative, and Integrative Medicine in the Division of Cancer Medicine at UT MD Anderson Cancer Center. We have no very relevant current financial disclosures. I have asked each of the speakers to talk a little bit about where they're working currently, describe the IRFs that they're working in and what patients they serve, just for context, as some of the things they may describe doing may be secondary to having additional resources that may not be available elsewhere. So the agenda tonight, I'll get started with a brief presentation discussing the needs and challenges in providing care within IRFs to those who are medically complex. I'll be followed by Dr. Steinberg, who will talk to us about ensuring the rehab program can meet the patient's needs. Dr. Tennyson will then discuss preparing medically complex patients to return home. And then Dr. DiTomaso will finish up the presentations discussing optimizing the patient for participation and progress. And we will have our Q&A and discussion at the end. We will be monitoring the chat throughout the evening as well. And we may take one or two questions after each presentation. If we don't get to them, we will certainly come back to them at the end. We're a small group tonight, and we hope to keep this as interactive as possible. Yes, absolutely. And if I could just mention one thing for everyone's reference, you can raise your hand with a feature on the bottom of the webinar control panel. And there also is the option to submit your questions through a Q&A option as well at the bottom of the screen, which will come through to the hosts that are facilitating the event. Devin, there was a message saying that the chat is disabled by Genevieve Jacobs. Yes, yes. So any questions, we'll just go through instead of that chat feature, we'll go through a Q&A feature. If anyone does not see that at the bottom of their screen, please feel free to send one of the chats as well. Oh, sorry. Please go ahead. So it's really helpful to know who's joining us tonight. So if you could let us know via the poll, are you an attending physician, resident or fellow, medical student, or other health professional? All right, so excellent. So we have a nice mix of attending physicians and residents and fellows. So 71% attending and 29% resident or fellow, great. And our next poll, in what type of inpatient rehab facility do you provide care? Is it a hospital unit, freestanding IRF, in close proximity to an acute care hospital or a freestanding facility not co-located with an acute care hospital? So that poll should pop up. All right. I think we have 80% or now it's going down. 80% or now it's going down. All right, 67% in a hospital unit, 17% freestanding IRF in close proximity to an acute care hospital and 17% freestanding facility. All right. And then I'm gonna close that out. One last poll before we enter the talks. Do you feel that the patients you're caring for in IRFs are more medically complex than they were a few years ago? Yes, no, or no basis for comparison. All right, we'll give it just a few more seconds. Okay, so it looks like we're about 50-50 yes and no basis for comparison. Okay, so let's move on. So I'm gonna give the first presentation which will be very brief and very introductory. I'm Lauren Shapiro. I'm an associate professor in the Department of PM&R at the University of Miami Miller School of Medicine. I also serve as vice chair for quality, safety and compliance. And I currently medically direct the Stroke Rehabilitation Service at the Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis at UHealth slash Jackson Memorial, which is certainly a mouthful. We are a 72-bed inpatient rehabilitation facility. We are attached via a hallway to a tertiary care hospital that has a level one trauma center. So several months ago, I reached out to our community and I asked for what topics they thought would be a good topic for our event. And a number of people, some of whom are on the panel tonight, responded we should talk about medical complexity. And I thought it was a great idea, but I was a little concerned about doing that because it's hard to even decide what makes one medically complex. There is this rehab impairment code or category called medically complex conditions that most of us have been instructed to avoid whenever possible in terms of using, not necessarily patients with these, we don't avoid patients with these conditions. But I think many of us recognize that many patients are medically complex who don't fall within these categories. So for the purpose of tonight, we'll consider medically complex as referring to those with a condition or conditions that require very close medical management and put one at high risk for complications. In my mind, this definitely includes those with advanced heart failure, including, but not limited to, those with left ventricular assist devices, those who've had organ transplants, those with cancer, survivors of severe sepsis, and many persons with other rehab diagnoses. Though, again, we don't necessarily think of them as the medically complex. Patient population are in fact medically complex. Thinking about some of my stroke patients, some of them have AFib, but they've had GI bleeds and they're at risk for hemorrhagic conversion, and then they get a DVT. So even though their rehab impairment category is still stroke, I would still consider such persons medically complex in that they're at very high risk for complications and they require close medical management. It's also really important that we don't equate medical complexity with medical instability. I think there is a fine line that sometimes gets a little blurry, and I'll be presenting a case later today where one could debate whether it was medically complex or medically unstable. All right. So first of all, is it really just our imagination? So 50% of us tonight thought, hey, the patients we're seeing in IRFs are becoming more complex, and the rest didn't really have a basis for comparison. So case mix index has been rising in IRFs. So this is data from UDSMR. I have to thank Dr. Susan Maltzer, who shared it with me. But between 2010 and 2019, there was the steady rise in case mix index within IRFs. And then of course we see a pretty big jump between 2019 and 2020 that I suspect COVID had a big role in for sure. And we see that in the same time period, the growth in number of cases within IRFs that fall under cardiac, pulmonary and debility really grew considerably and outpaced growth in total number of cases. So you could see the total number of cases in this time period went up 22.5%, but cardiac cases went up 54%, pulmonary cases went up 38%. And I know you're gonna be like, well, 2020, of course there were more pulmonary cases, except it was about the same in 2019. Debility cases went up 40.3%. Now, if you look at the medically complex rehab impairment category cases, that actually went down, but I think that really reflects changes in coding patterns rather than a decline in the medically complex patient population. So why is this? Well, largely because there's a tremendous need for care for these individuals. With regards to cancer, there are almost 2 million new cases of cancer expected to be diagnosed in the US this year that doesn't include non-melanoma skin cancers. At the same time, there's declining death rates. As we all know, the cancer itself, as well as the treatment, can result in a number of disabling conditions and impairments. We're often called upon to help optimize patients functionally to ready them for additional treatment. And when no additional treatment is possible, sometimes we're called in to help get them home safely, train their caregivers so that they can enjoy whatever time they have left in their home environment. And this patient population, they often need close lab monitoring, pain management, symptom management, that can be hard to provide in a lower level of care. Then we have our transplant population, and each year is a record year for transplants in the US, and last year was no different. These patients often have significant functional impairments following surgery, particularly those who've had liver, heart, and lung transplants who were often quite ill and deconditioned prior to their transplants. And they require very close medical monitoring and management of their immunosuppression. Again, that's very difficult in a lower level of care. There are also an estimated 6.2 million American adults who have heart failure, and this is expected to rise with the aging of the population. Some are hospitalized, of course, with CHF exacerbations and have very poor endurance afterwards, but it's also an important comorbidity in many of the other types of patients that we see, particularly stroke and anoxic brain injury, but others as well. Patients and their caregivers may need to learn how to care for new equipment if they're going home with a device like an LVAD or a LifeVast, and they frequently need ongoing medical management for their cardiac meds, diuretic therapy, anticoagulation, et cetera. Again, another population that often has care needs that are difficult to meet in a lower level of care. And then, of course, we have the pandemic. So here's some data from the Vizient Clinical Database. Between April 1st, 2020 and June 30th, 2021, there were over 7,900 adults hospitalized for COVID-19 at academic medical centers in this database who were discharged to IRFs. Many more have since been discharged to IRFs. And then, even with non-COVID-19 hospitalizations, some IRFs face pressure to offload acute care hospitals to deal with surges and may have taken more complex patients than they had prior to the pandemic for that reason. So our speakers today are gonna be giving us a great how-to. So how do we take care of these patients? How do we get them safely home? How do we prepare our teams? It is important that we all think about the considerations before we decide whether to do this. And I think most of us should take on the medically complex patient population, but it really depends on what resources you have available. You need to think about your location, staffing, not just nursing ratios, but also what is the expertise of your team? Do you have consultants available? Do you have rapid response teams, co-teams that can help you out in an emergency? How easy is it for you to transfer a patient out if they need it? 60% rule compliance may be a challenge, particularly if you're focused on cardiac and pulmonary cases. Now, some of these cases may actually fall under another category that would be 60% rule compliant, but you do need to be careful and you need to document very well. And then payer sources. Many payer sources will authorize inpatient rehab for patients with some of the diagnoses we're gonna speak about, but for some, it's gonna be more challenging. If you fight them, you may get it. I find that it's relatively easy to get transplant patients authorized from our experience, but sometimes cardiac cases can be a little bit more challenging. So I'm gonna talk a little bit about the challenges. Again, not to dissuade anyone, but just to lay them out so we can have a good discussion on this later. So one, can we even get these patients admitted? Sometimes, yes. Sometimes you're gonna hit some barriers and you may need to make more peer-to-peer calls. Will they tolerate and benefit from the therapy? Many of them will. Some may need a reduced intensity schedule and CMS does give us the flexibility to do 15 hours over seven days, but that would necessitate having therapists available on Sunday, which many facilities have, but not all do. It's important to consider if we're bringing them at the optimal time to benefit from our programs. So as we've all kind of experienced at this point, some insurance plans only cover a certain number of days and won't let us exceed that. So it's really important that each day in the IRF really matters. And if they're really sick at the beginning and they're having trouble to participate, that may be time wasted. Will they require a return to acute care? So we do know that the medically complex patient population are more likely to return to acute. There've been a number of studies on this. Dr. Tennyson, who will be speaking later tonight, did a really nice study. And in her cohort, 19% of cancer patients in IRF had an unplanned return to acute care. And we certainly found that when we started taking more and more cancer patients to our inpatient rehab facility, our return to acute care was higher and that's okay. But, you know, I think some of the administrators initially were pretty concerned, but that's certainly to be expected. And then of course, will we be able to safely discharge these patients to a community setting? We need to make sure we're appropriately staffed to meet their needs. We need to make sure our teams are equipped to handle these types of patients. And Dr. Steinberg will be talking more on how we prepare them to do this. I think an important consideration increasingly of late is do they want to? And I think many of us have experienced sort of the great resignation, particularly among our therapy staff. And when I talk to our therapists, some of the feedback I get is like, hey, you know, I love taking care of patients with stroke, TBI, and spinal cord injury, and now I'm taking care of a really sick population and it's maybe not always what they envision doing and it's challenging for them. So when recruiting new therapists, and increasing your medically complex patient population, it's important to look for people who really have a desire to serve that patient population. And there may be some trade-offs with regards to expertise and or time. I don't necessarily think that's a bad thing. I just think it's important to acknowledge. So when I look at our brain injury and stroke program, we certainly value our nurses' bladder and bowel management skills, how they address neurobehavioral issues. We expect them to teach wound, trach, and PEG care to patients' families. And on our medically complex rehab program, which is on a different floor, they do some of that. We still expect that, but we also kind of want people with some telemetry experience. We expect them to learn how to access chemoports increasingly, although not all of our nurses have that skill. And they need to sometimes help us coordinate all these follow-up care things with acute care, coordinating biopsies, bronchoscopies, et cetera. We don't want to lose potential referral sources. We know this patient population can be very difficult to place, right? Because they need intensive medical monitoring and sometimes their endurance is poor. And there can be pressure from our parent healthcare systems. And we want to be good citizens, particularly during the pandemic, because we know that hospital capacity is sometimes strained. But it's important that we strive to get people to understand that there are things we can do on rehab to keep patients from needing to be transferred that we shouldn't maybe be doing on admission. And that kind of brings me to my case here. And I think I wrote this in a very leading way, and I don't mean to lead anyone in the poll because I think all answers are valid here. But here's a case that was referred to me a few months back. He still is a 50-year-old man with severe dysphagia, right hemiparesis, and cortical blindness following a right vertebral artery occlusion. He received TPA and unfortunately had a subarachnoid hemorrhage. His hospitalization was really complicated. He had angioedema, he had COVID-19, he had AFib, he also had a GI bleed at one point, and he had a PEG place. So again, this is not a patient that would fall under the medically complex rehab impairment category. He would still qualify as a stroke, but he's certainly medically complex and at high risk for complication. Now, the problem was he was referred for IRF and that day he was newly tachycardic and he hadn't been despite his recent COVID and he was hypotensive. His systolic blood pressures had been in 120s to 130s and was now in the 80s. So unfortunately, I felt like I had to refuse the case on the basis of medical instability at the time. And I felt he needed more of a workup to evaluate the cause for a change and further treatment. I then received a barrage of calls and texts and emails, both from the team and someone claiming to be a physician advisor telling me, oh, he's not medically unstable, he's medically complex. You guys have a medically complex rehab program. He's like, let's do this today. You can get a medicine consult there and give him fluids there. So I asked our participants today, would you accept the patient to IRF that day? So yes or no, and we can have a discussion about it. All right, so we're pretty universal, no. So I'm glad everyone agreed with me, but feel free to challenge me at any time. So no, yeah, so he did not come that day. I fought, made some enemies. I did eventually take him, he did great in rehab. I saw him recently in clinic. He remains medically complex, but he's medically stable. He needed a sepsis workup and fluids and all of that. And I'm glad everyone agreed with me. He needed a sepsis workup and fluids and all of that. And I can do that in rehab. So if I have a patient with new tachycardia, new hypotension, I can usually at least initiate the workup and start fluids. If they respond to fluids, I don't necessarily need to transfer them out, but I would be doing a patient a tremendous disservice by bringing him to a lower level of care when he in fact needed to remain in the hospital. So this was just a case where that line was maybe misunderstood by individuals who were not working in the rehab facility where medical complexity and medical instability are two very different things. And just finally, we may be making ourselves sometimes vulnerable to medical legal problems, but I think with careful care and close involvement of consultants, we're probably okay. We are probably gonna hurt some of our quality indicators. So it's always important to look at your case mix index, look at your diagnoses separately. Lengths of stay may be longer for some of these patients. Discharges to the community may be a little bit lower, and that's just fine. Just make sure that you keep an eye on how diagnosis affects that. And we may endanger our compliance a little with the 60% rule. I do think in a lot of these cases, there are opportunities to use other impairment codes, particularly neurologic impairment codes when appropriate that allow us to take on more of these patients. Again, good documentation though is very much key. So I'm gonna turn things over to our other speakers in just a moment, but in summary, there's tremendous need for post-acute rehabilitation care for the medically complex. IRFs are increasingly caring for patients with cardiac and pulmonary conditions as well as debility, but one needs to ensure the multidisciplinary team has the skills, knowledge, and equipment they need to safely care for these patients. I think this is a nice segue for Dr. Steinberg to talk about the environment, but as a physician, there are a lot of things that I feel comfortable caring for in this environment, except that other members of my team may not have been trained yet in a device or how to care for a certain condition. So just because I can personally doesn't mean that we as a program should until everyone is appropriately trained. So with that, I thank everyone for their attention. I'm looking forward to interacting more with the group. Please feel free to reach out to me at any time. And I am going to stop my share and turn things over to Dr. Steinberg. Great, thank you, Lauren. I very much appreciate that, very nicely done. I just wanted to say hello to all the participants. I see a couple of very familiar names, so I'm so glad to connect with everybody. Hopefully, can someone nod their head that they see my screen? Excellent, great, I'm so glad. So this is where I work and spend most of my life out here in Salt Lake City these days. I've been here for four years as the chair of the Department of Physical Medicine Rehabilitation. I spent 23 years prior to this in Ann Arbor, Michigan at St. Joseph Mercy Hospital, which is one of the Trinity Health Hospital's flagship for Trinity Health, and did my residency training at the Rehab Institute of Chicago back when it was the Rehab Institute of Chicago. So we can talk about rebranding at another time. But when I was coming out of my residency, I thought I was really well-trained at RIC, connected to Northwestern. I remember the most stressful time at RIC was when I was a resident on call, and I knew that if there was a code, it was gonna take about four and a half minutes for the code team to arrive through the tunnels at Northwestern. We had to run that code, and it was very, very challenging and stressful, and we were worried all the time. So running the consult service, we felt that our job was to block, block, block. You know, just like Lauren was talking about, look for those patients who are medically at risk and medically unstable. And even back then we felt like, oh my gosh, the complexity is increasing dramatically. So here I am at a quaternary care center attached by a skybridge to the acute care medical center, University Hospital. And that's not how it is for many of you around the country. When I came out of my training, there were a couple of things that were really important for me and probably important for many of you. Number one is that the rehab doctor should be the comprehensive doctor for the patient. That was my belief. There were some places where I would be the consulting doctor. And I also wanted to be at a top tier medical center where I knew I had partners, nurses, therapists, and other members of the medical staff who are exceptionally good and strong. And so I looked for a hospital that provided really amazing care. And I found that at St. Joe in Ann Arbor, and I found it here at the University of Utah. That's not always the case, but many places are organized in different ways. And a lot of it just starts in that mindset. So I'm gonna be going over a few topics here. I'm gonna spend about 15 minutes to talk about staffing, equipment, relationships, and quality and safety. It's gonna be a lot of it from my perspective at a university academic medical center, but know that I have a lot of experience in a community teaching hospital, in an integrated rehab unit, in a much larger level one trauma center. But I can't speak to what it's like really to be in a freestanding unit many, many miles away from the resources of an acute care hospital. So just a few facts that Lauren kind of already touched base on. Things are changing quickly. We're getting sicker patients. They want us to take them sooner. We know that CMI is rising dramatically. Here at Utah, our CMI, I just looked at it today, for our stroke patients are over 1.7. For our spinal cord patients are close to two or above. We have very complex patients. And we do take those LVADs and multiple organ transplants and burn patients and some of the most complex. We run a program with Trach Vents and we're very hard pressed to say no to patients to come over to our rehab center. But this is a trend that's occurring across the country. So, okay, rehab patients are supposed to be stable. They're supposed to be able to participate actively in a intensive rehab program, but that's not always the case. We are asked to take very complex patients who have multiple comorbidities earlier in their course. And we've literally taken patients directly from the ICU to our rehab hospital. And in some cases have patients who are like in early phases of sepsis. And we say, you know, we think we can manage this patient short of putting them on pressers. We could probably put them on a cardiac monitor here. We have nursing staff who are trained and skilled in many aspects. But we, as the rehab doctor, and if you're a medical director, you have to be able to call those cases as if that patient was near and dear to your heart. You would treat someone the way you would wanna be treated yourself or your family members. And not everyone is prepared to sail through the rocky courses and things that can happen along the way. So we think long and hard about our staffing structures. And I told you that it was important for me to be the rehab doctor in charge of the team. And our process here is very similar to where we were at St. Joe, is that we have an APC and or a resident, and we have diagnostic teams that generally have a census around 12. Sometimes our census can be bumped up to 15, but it can be very challenging for one attending to really do a good job of managing very complex patients with if your census gets too high. So you've gotta really think about how to structure it. For us, when we were moving from an integrated rehab unit to this freestanding hospital, we have 75 beds in our hospital, very similar to what Miami has with Dr. Shapiro, is we needed an in-house night float system. Previously, the residents were taking call from home. And so that was an evolution that we had to integrate into our model. And it's actually a major, major advantage. The time for response and our readmission rates really decreased once we got in-house residents here. We also hired a pulmonologist to be our medical director of complex care. That's not the case every place to be able to do that, but it was very important for us if we're gonna be taking care of some of these most complex patients. And that was before we had COVID. Boy, were we so lucky to have an intensivist on our staff to do curbsides and to be immediately available. And then with the SkyBridge, the acute care hospital, we have that subspecialty consultation immediately available and they're automatically consulted to follow patients that are in the most complex cases. So we also, I wanna emphasize how important it is to have an aligned structure. Does this feel like where you are? Silos, that you're not really integrated with all the other structures within rehab? Well, that's also true with acute care hospitals and rehab. And that's even true here when we have a freestanding hospital, we're much more aligned, but not entirely. So many times nursing wants to float nurses, med surge nurses over to the rehab hospital. And they view all nurses in some regard as kind of like transferable, that the skill sets can kind of cross over whether they're pulled to the cancer hospital or to the rehab hospital, but that's obviously not the case. So it's really important that we have some control over staffing levels and training. And I see Ash, I think you had asked a question, at least I saw your hand up, so. Yeah, I'm having trouble with the technology, the button keeps flipping. No problem. But the question I had was, the specialists that have come over to your center being separate, but not separate, do they require having to go through the, getting affiliated with your facility, filling out the paperwork, getting reaccredited given that you're a separate hospital? That's actually a great question. And the truth is we're not a separate hospital. In fact, we have the same designation for the main hospital. So all physicians in our system are faculty of the University of Utah. So if they're privileged at the main hospital, they're privileged at all the hospitals. So we don't need special status for patient, for those physicians to come here. That's obviously not the case in many organizations where they'll need special privileges to be able to consult in your rehab facility. Ours is quite unified. In fact, we have no community physicians on the staff here. So all physicians who are gonna see patients within the university walls must be on the staff and part of the faculty. Thank you. Good question. But this is obvious. Everybody knows that we went into rehab because rehab is not an individual sport. It's a team sport. So it's really important for us to hire people who fit the mold, who are gonna get along well with others and that the world doesn't really revolve around them. And for those who know me, I'm a rower. So I always think about the rehabilitation team as being composed of many, many individuals who are able to work well with each other. And I really believe in the Lencioni business book that talks about hiring the right type of team members. And I'd recommend this to all of you who are looking to achieve great quality outcomes is it starts with who you hire and how you create a culture that people work well together. So I look for these three criteria for people who are gonna hire, whether they're gonna join us as faculty, they're gonna join us as nurses, therapists, environmental services. I'm relentless and just talk about looking for people who are humble, hungry, or another word to say that they're hardworking and smart, but really smart with other people. Is creating a really healthy culture is critical to caring for more and more complex patients. We are not playing fantasy football here. So people should be resilient, strong, aligned well, trusting and trustworthy. And I'm looking for behaviors that really kind of like follow through so that we know that we can count on each other as the complexity of patients gets more challenging. That starts with a really solid education plan for our residents. And these are just part of the curriculum for our residents who are gonna be joining, rounding in the inpatient hospital. Where we want everyone to be able to see themselves as a future leader, to be able to run a rehab team and to learn the components of everything that Dr. Shapiro was talking about. Starting from how to evaluate patients on the consult service and manage very complex patients within the walls of the rehab hospital. So I think that it really begins with this, but also including other members of the team in the didactic curriculum, so that we really embed ourselves. So the physician faculty are engaging really closely with training our resident, excuse me, our therapists and our nurses and everyone within the rehab hospital to manage the complexity and looking at all the factors because they're gonna be our eyes and ears. When they see a patient in therapy who's becoming orthostatic, they're gonna be the ones to raise a hand and call for medical evaluation. And the nursing staff at the bedside needs to know when a patient is having a change in sensorium or the vital signs to trigger, to bring a physician to the bedside or call for a rapid response. So having the partnership with nursing and therapies is critical and having the right educational structures is really, really important for us. We've worked really hard in quality improvement projects. Again, this is part of that culture. So a culture of continuous quality improvement is really important for all of our rehab systems. And if you're in a larger organization in a larger hospital, it's very, very important that rehabilitation sees themselves as part of that quality and safety process with quality specialists who are working with you all the time, that you create a culture where it's safe for people to speak up, where it's safe for people to identify errors and to take accountability and not to have a culture of retribution, but a culture of continuous learning and continuous improvement. It's really, really important to do that. And I think I learned a great deal from my times in a community hospital and going through multiple accreditation cycles with the joint commission then, and here we're DNV, but making sure that you're very much involved with that. We really celebrate our CARF accreditation because it helps us raise our standards for quality improvement and constantly focusing on outcomes. And having the right equipment helps you do that. So the most important piece of equipment, I think I already told you, is having an in-house doctor and a critical care consultant. The next most important piece of equipment is the SkyBridge, the acute care hospital. I mean, having that close availability of the code teams and the rapid response teams is really critically important to caring for the most complex patients. And you have to know your systems. We also have constant process of communication between nurses and physicians with our rounding quality improvement projects, focusing on reduction of CAUTIs and CLABSIs. I just saw that our latest data showed an 82% reduction in falls because of our focus on quality and safety teams that were working all the time. Do you know what the number one factor was that was leading to higher falls when we moved into this rehab hospital was that we hired a lot of staff very rapidly. It turned out that new staff had higher rates of falls. So nursing staff and aides were not trained well in transfer techniques. And if you're gonna be taking care of sicker and sicker patients, you need to make sure that it starts and stops with the bedside care team being well-trained in transfer techniques and otherwise. So we work hard on quality improvement and multiple, multiple levels. We get on the same page. We talk about standardizing our processes. We talk about maintaining really, really strong relationships with the consulting teams and within our discipline. So within your organization, I really emphasize how important it is for you to be able to do this. I'm looking at my clock to make sure that we're good on time. So we have a quality council that we created. We were blessed with sort of a blank slate that we could recreate things when we moved from the acute care hospital over here to this freestanding hospital. We also then, we have our internal reporting, a process called RLs. I'm sure each of you have those as well. Confidential system for people to report quality concerns, but we revamped how we review those. So we actually review them in a multidisciplinary meeting every other week. We look at every RL that's been entered and we don't, we look for patterns when we look for system improvement opportunities. We also have a culture that doesn't blame individuals when something goes wrong. We first look for system opportunities. So that's called just culture. And we had that at Trinity's. I'm sure many of you do as well. So I just want to really emphasize how important that is. And we also look to be well integrated in our acute care models so that our medical director in the rehab unit participates and knows all of the other consulting leadership in the hospital. So if there's a problem, we know who to call 24 seven. And we have a faculty on call throughout the evening and on the weekend so that we first seek to help, you know, solve the problem before we start pointing our fingers. We've also looked at process improvement through doc-to-doc calls before a patient's admitted. So just like Dr. Shapiro did when she blocked a patient, we don't just sort of like, you know, do things on our own in isolation. We pick up the phone and we call the referring physicians and we talk about the cases and we always do a doc-to-doc so we know what the critical elements are to follow up on individual patients. And we also love checklists. So if any of you have checklists or you know about them, I really recommend that you just emphasize this a great deal. So if you haven't read Atul Gawande's checklist manifesto, I recommend it highly. And there's many other resources that you can reach out to to think about quality improvement and admission process. We have a very kind of in-depth process all the time that we talk about how the day unfolds for our admissions. And I remember back at RIC, we had something similar and I'm sure that every one of you has done a lot of thinking about how you work to make sure that patients arrive earlier in the day, that they've been carefully evaluated to make sure that they're meeting medical stability and that there's great communication. And that's really important to have a focus on communication quality and safety. Doc-to-doc calls are also critically important. And I'm just showing you this as an example of what we've worked on within our system of care. It involves all the specific types of patients and what the care plan is to make sure that things don't slip through the cracks. There are lots of solutions, but having patient safety grand rounds is one of those solutions that helps to ensure that we learn when something doesn't go well and that we think about how the Swiss cheese model really, really works. And I know Lauren knows this really well since that's her daily life is quality and safety. And I'd encourage all of you in leadership roles within acute care hospitals to really learn about a quality and safety structure with M&M and quality assurance processes to make sure that you're learning when things don't go well. We work very hard on a lot of this to make sure that the reports, you can tell that I really emphasize this. We know that rounding works very, very well to make sure that we're at the bedside with leadership and that we understand that we are constantly trying to have our nurses grow and love where they work. We talked before about the challenges with staffing and that's true across the country and here at Salt Lake as well. We are growing like many programs. Our average daily census has risen since we've opened this hospital. We have two of the three floors open and we have a census today of 50. Traditionally, we were in the mid thirties and our patients are sicker. Our CMI has risen over the last 12 months just like everywhere else and our volumes are growing. And yet through the processes that I've outlined, our outcomes are improving, including hospital-acquired pressure injuries have reduced by 82%. Our falls have reduced by 28 to 29%. It's really dramatic improvements through these type of team processes. So we're really excited about being able to give better, safer care. And it all starts with identifying challenges and barriers very proactively as a team, working together to be willing to challenge the status quo, looking for a safe culture and a culture that recognizes those who are willing to constantly improve. That's really helped us within two years of opening our doors achieve really great outcomes with patient experience, with U.S. News and World Report and other great outcomes. So it takes a village and I just wanted to thank all of you for joining us today on this discussion about how to make our hospitals safer and more capable. Appreciate your time. I'm gonna stop sharing and we'll probably be able to ask some questions at the end. In the interest of time, we're gonna, thank you so much. That was a great presentation. We're gonna move right into Dr. Tennyson's talk, but I will continue to monitor the chat and we should have plenty of time for questions at the end. Thank you. Dr. Tennyson, take it away. All right, thank you, Lauren. I am pulling up my slides here. Just making sure I'm on the right slide. Okay, sorry about that, I'm trying to share this. Okay, are you guys able to see my slides? We see presenter view. Okay. Let me try again. I couldn't hear you, Dr. Shapiro, but I think I saw a thumbs up. Sorry, someone just said the chat is disabled. All right. So if instead of the chat, if you post questions in the Q&A, we should be able to see that. Thank you. I'm sorry about that. Okay. So, yes, thank you, Dr. Shapiro. And thank you for this opportunity to present on this topic. So my section is to cover how to prepare medically complicated patients to return to home. And this is a topic of great interest to me. And I've kind of researched in this area. I do practice cancer rehab specifically. I'm an associate professor at the University of MD Anderson Cancer Center. So about halfway through the talk, I'll have some specific information for the medically complicated cancer rehab population to share with you. I have no disclosures. So for this talk, I have it divided into some background information that I was going to go over. So really trying to go over transition versus continuity of care before getting into transition of care, because we're really talking about that timeframe transition of care when patients are vulnerable. And I have some outcome measures that's been recommended in the literature. And so we have used these outcome measures to research the medically complicated cancer rehab population to see what's happening in this transitional transition of care period. And then I was going to end up with some tips on preparing these medically complicated patients to return to home. So first, this is a poll that I have. So I think you should be able to see a poll come up. I do have that question on the slide. Are you guys seeing the poll? Yes. It's supposed to be a separate poll. OK, it popped up for me, too. So I see it. So really, this is just to get the group to just think about this concept of continuity of care. The question is, what is continuity of care? It's not a complicated question. It's pretty straightforward. And if you want to answer, we'll see what everyone's thoughts are. Yes. So yes. So it is all of the above. And the definition is actually from American Academy of Family Practice.org. So they have it defined as quality of care over time. The goal is to have cost-effective medical care. Purpose is to reduce fragmentation of care and to improve patient safety. So in comparison to continuity of care, transition of care, I got this definition from AHRQ.gov. That stands for Agency for Healthcare Research and Quality. And this is actually a site, an agency that have surveys. And at our institution where I practice at MD Anderson, we do yearly patient safety surveys. And so they actually pull the survey from this agency. So according to AHRQ.gov, transition of care, as defined by the use of CMS definition, is that time frame when you have movement of patient from one setting to another. So this transition of care period is a vulnerable period for patients because it does, it can put the patients at risk for an adverse event because there's a potential for miscommunication. And a common transition of care period is hospital discharge period. And so that's why having really safe, effective transfer of information, responsibility from one healthcare team to the other is really important. And it's very much dependent on good communication about those discharge instructions or discharge summary and everyone involved in the care, including the patient understanding of the discharge summary. So AHRQ.gov had recommended a couple of ways to measure transition of care period. And it has to do with assessing communication about discharge information and even assessing hospital 30 day readmission rate, which is a really hot topic in the literature. So the reason that the readmissions or assessing or knowing about readmission is important is because it can be costly. When you have unplanned readmissions, it's very costly, $15 to $20 billion annually. And also hospital readmission has been reported to be a marker of inpatient quality of care. So as a quality of care metric, readmissions is an important topic for our government. And so trying to decrease this rate of hospital readmissions has been important enough that our government does apply financial penalties for excess readmissions. But these penalties don't actually apply to cancer hospitals, specifically where I practice, because they consider these patients to be challenging to compare to other hospitalized patients. Still CMS recommended to go out and report these cancer readmissions, and they cited the Promote Effective Communication and Coordination of Care domain under the CMS's Meaningful Measures Initiative. And then there are some reports and concerns in the literature about using readmissions as a quality metric and how valid it is, but still readmission rate is still used as a high stake measures for a lot of programs. So if you look in the literature about 30 day readmission studies, there's actually a lot of information. So I have focused in on inpatient rehab studies, and then compare that to maybe some of you have experience with the cancer population. So the studies involving cancer patients and without even looking into inpatient rehab programs, these are just cancer patients. The reported range was from three to about 37%. So majority of the rates came from the systematic review, but another study the same year reported a higher rate of 37%. So it could be as high as 37% for 30 day readmissions. And then we had our colleagues in the internal medicine department do some studies on readmissions too, and they reported a 30 day readmission rate of 16 to 22% between 2015 to 2022. And then to compare those numbers with what you would see in an inpatient rehab setting, so general inpatient rehab mixture, there's actually been a lot of studies about 30 day readmission rate, and they all kind of reported around 12 to 13%. Some of these were like really large studies and published in great journals. And then there was a study specifically looking at the debility rehab impairment category, and that study reported a higher rate of 30 day readmission. And so we looked into our cancer inpatient rehab population that were discharging to the community to see what our 30 day readmission rate was, and we found a rate of 21%. So as you can see, the medically complicated cancer rehab population, they do have a higher rate of 30 day readmissions compared to the general inpatient rehab mixture, but it kind of falls in with our colleagues in the internal medicine service who did studies on this topic. And we also looked in to see the reason, the 21% readmission rate and the reason for readmission, and the top reason was infection. And infection has been reported in a lot of studies in the cancer rehab population for transferring back to acute care too, so we saw similar reason for 30 day readmissions too. And we looked at risk factors to see what put them at risk, if we can detect some through some statistical analysis, and what we saw was that lower motor scores, increasing number of medications, lower hemoglobin at discharge, these were all risk factors independently associated with 30 day readmission rate. And so this lower motor scores have actually been reported in the literature before in inpatient rehab patient population, this one was specifically looking at the medically complicated rehab population, but a couple of other studies again kind of relating the functional scores with readmission in all of these studies. And then when it comes to the other risk factors that we have picked up for cancer patients, the increasing number of medications and decreased hemoglobin at discharge, it's been reported, not necessarily in the inpatient rehab population, but in those studies that looked at cancer patients. So, in this topic of transition of care period, if you look in the literature, and this was a really nice systematic review that I wanted to include in, this one talked about how assessing this area can be kind of difficult because there are a variety of factors that you can assess. So some studies not only just looked at the hospital readmissions, they might have looked at the ER visits too. And then there were other studies that were just focusing on the communication from inpatient to the outpatient healthcare, involving discharge summaries or specific information like medication errors and so forth. And then there's also studies that looked at perspectives from hospital staff to patients or sometimes both patients and hospital staff. So there's a lot of heterogeneity between all of these studies. But when it comes to what was recommended, we stuck with what AHRQ had recommended, which was to look at the hospital 30-day readmission rate, which that I covered already, and then assessing communication around discharge to try to assess to see maybe what is causing these readmissions. So we did do a study to see communication and how that might have affected discharge. So in order to actually look at continuity of care and in assessing communication around discharge, the literature actually recommends evaluating these three aspects of continuity of care. And then the specifics are not really important for this talk. I do have it listed here if anyone's interested. But I just wanted to mention that we look for a tool that captured these three aspects to make sure that we're assessing continuity of care. And so there's a questionnaire in the literature that's been studied and reported by multiple studies showing that it is reliable and validated. So we use this questionnaire, patient continuity of care, to let the patients answer from their perspectives about how it was for them to discharge and what that transitional period was like. So we did a prospective study having the patients answer these questions using the patient continuity of care checklist. We also added some questions that were more specific to rehab, to assess any sort of rehab concerns. And we administered both of these surveys when the patients were getting discharged and then about a month after discharge to see if the patients had changed their answers about a month later. And the study was done a little bit over a two-year period. We had close to about 200 patients. And majority of the patients, 99% of them, upon discharge and a month after discharge, when it comes to rehab and functional status, they all reported feeling safe to function in the home. They no longer had fear of falls. It seemed like acute inpatient rehab was quite helpful for them. And then when it comes to continuity of care, there were no major concerns, but minor concerns by 10 or 5% of the patients. It involved reports by patients about lack of adequate communication among the different providers. So it kind of makes sense because we are inside the acute care hospital. We're just on one of the oncology floors, and we actually share with the neurosurgery team also. But when the patients come to us, they're coming from all kinds of different services, solid tumors, liquid tumors. They're all cancer patients. And so they've had some sort of oncology care, some sort of reason for medical admission, some sort of debility or a new impairment after a surgery that requires inpatient rehab. So there's a lot of providers involved in the patient's care before they even come to us and then stay with us. And then there's the whole rehab team, and then we discharge them to the community. So it makes sense that there might have been some reports of inadequate communication. We also looked to see if there were any reports of falls within that one month after discharge, and that was actually kind of low. It was 9% for falls and 4% for near falls. These were reported by the patients within that one month timeframe. Total of 13% for falls and near falls. And these were associated with brain mets, comorbidity of depression, and prior history of falls. And some of these risk factors have been reported before in patients with cancer and systematic review. So prior falls and cognitive impairment have been reported as consistent predictors of falls. But again, in this timeframe of immediately after discharge, if you look at other studies to compare what we saw with our medically complex cancer rehab patients, we saw a rate of 9% falls within about one month after discharge. And then other studies in the literature have reported higher rate of falls for specific population. Like these were the elderly population, 15% fall rate. This was actually inpatient rehab stroke patients, 14% fall rate after one month. These were patients already falling in the hospital, so they had higher risk of falls one month after discharge. So different population. And then I just wanted to mention that we do outpatient rehab team meetings. These are done on a monthly basis, kind of mirroring like the inpatient rehab team meetings. Physiatrists, PT, and OTs are involved to discuss patient status and barriers to progress, but we do detect discontinuities of care during those meetings too. So to give you an example, we had written this up to provide an example of what's usually done. So in this report, we had looked over a seven month period of 42 patients and 30 of them had received some sort of recommendation. So that was about 71%. So these discussions resulted in coordination of care for patients and some of them are discharge related discontinuities. And so these are some examples. So not having nursing supply after being discharged or PTOT team not knowing certain precaution by the surgical team, patients needing more referrals, like referral to lymphedema or pelvic rehab. So these were things that were picked up during these outpatient rehab team meetings. They also resulted in more follow-ups to our PM&R clinic and oncology clinic too. To summarize for specifically for this medically complicated cancer rehab population, we did see a higher rate of 30 day readmission rate. I think it's just because our patients are just sick and so they tend to have higher readmissions. It was higher than the general inpatient rehab case mix. From patient's perspective, there were no major concerns with continuity of care and patient reported falls were lower compared to a lot of the other study population out there within about one month after discharge. And also outpatient interdisciplinary rehab team meetings may be helpful in improving coordination of care. And this one item that I wanted to mention is about handoffs at transition of care. So I-PASS is something that's been reported in the literature. This was published in the New England Journal of Medicine as a tool that can be used for handoffs. This is how it looks in our system. We have Epic. And so this was captured from my screen and you can see my name here. So I-PASS is something that stands for I standing for illness severity, and you just type that in. So this may be a tool that can be used to capture all of the major issues that may be going on with the patient. P standing for patient summary, A for action list, and S for situational awareness and so forth. So this has been reported by a couple of studies decreasing the rate of adverse events, 30% specifically. And then this is my last slide. Just some tips that I have noticed have been helpful, but I think any of you practicing in patient rehab, I'm sure these are all very familiar. So I just wanted to mention the more familiar ones and then you can add in more that maybe you're doing at your institution that I might not have mentioned so that it may be helpful to put that in the chat box or Q&A, whichever is available. So just talking to family about discharge planning at every opportunity seems to work better. And then thinking ahead about steps training, car transfer training, patient caregiver training, whether it's for functional issues or medication administration or nursing issues and making sure they have the supplies before they go home, DME, where they're picking up medications, follow up appointments, community resources. And then these may be other optional things to consider. We do have a discharge phone calls that was instituted a few years ago, which I think is helpful to assess any sort of discontinuity of care. So these are done by the nurses after the patients get discharged. I think these meetings have been helpful too, but you really need a larger group of physiatrists and the practice to be able to attend these meetings because these meetings are not reimbursed. It's not anything that you can chart like you would in your inpatient progress note. And then considering these structured handoffs at transition of care, they may be helpful for transitioning patients to home. And any other tips that I might've missed out that if you want to add in, please feel free to add in. That's it from me. Thank you so much for a great talk. Let's please put any comments or questions in the chat, which is now working. And now Dr. D. Tomaso will be talking about optimizing the rehab admission. All right, thank you so much. I'm Craig D. Tomaso and I hope everybody can hear me. A little bit about me. I'm board certified in CMNR and CBI and my interest is sort of as a consciousness rehabilitation. After an illustrious academic career, I've been in private practice since 2019. I work in a variety of settings, I'm adjunct faculty at a local medical school and I have some industry related activities. So what do I really do though? Really, I'm very, very clinically busy. I'm the medical director of a large, well, 46 bed private, for-profit inpatient rehabilitation hospital. CMI is about 1.7. We do spinal cord, brain injury, DOC, LVADs, all of that stuff. Consult at a local skilled nursing facility and run their pulmonary rehab program. Consult at an LTAC that focuses on disorders of consciousness rehabilitation and they do acute care consult. So I think when we're talking about rehabilitation and modern healthcare, number one, I think patients are really appropriate for lots of different levels, depending on how you frame them. I think sometimes we like to pretend we know what a rehab patient looks like, but from one perspective, they're gonna look one way, from a different perspective, they're gonna look different. And I think that it's naive to consider that patients really have a perfect fit. Two, if you're working in private practice, you know that economic factors are really the thing that drives patients where they go a lot of times, which is unfortunate, but it's the truth. Adding to that, of course, the stressor that hospital stays are shorter, rehab stays are shorter, who gets into SNF is changing. So there's a lot of pressure in this to begin with. And then we know from lots and lots of research and published in the AAPNNR and other sources, that the biggest factor that predicts outcome is usually socioeconomic factors, more so than what level they go to or what rehabilitation interventions we administer. So I'm gonna ask you, what does a rehab candidate look like? Does it look like the guy on the far left, the middle or the far right? Think about it for a second. No right or wrong answer, of course. Well, if you look at the CMS criteria, if you really look at it and you digest it, it's really very vague and it does not tell you in any detail who's the real rehab criteria, who meets rehab criteria. It says a lot of fluffy things about meeting a multidisciplinary team, meeting in psychotherapy and so on and so forth as I listed here, but there's really not a lot of hard criteria about who can and cannot come in. So that's up to us, really. That should be our role, working through different levels of care and understanding what the different levels of care do best and what the strengths and weaknesses of different post-care settings are. It's how we as psychiatrists make sure we get the right patient, the right level of care at the right time. This is important for a number of reasons, of course. Number one, we want the patient to have the best outcome. And if you can match the right patient to the right level of care at the right time, by all accounts, the outcome should be as good as it can get. Number two, by keeping patients at the right level of care and optimizing their recovery, you're going to decrease the overall cost. And that's cost not just to the system, which is somewhat important, of course, but it's also cost to the patient, right? More and more of these insurance plans are getting sneaky about dumping the cost onto the patient. They have pretty high co-pays in those levels of care. If you're using them inappropriately, you're not going to really optimize what the patient's able to afford either. And then lastly, we want an efficient level of care, right? We know that there's no zircomial issues. We know that there's problems keeping people in the healthcare system for too long. If we can be efficient in how the patient uses the different levels of care, we can get them home healthier, faster, and with greater levels of independence, or at least that's the goal, right? So I think a great place for this discussion to start is in consulting. And I do a lot of acute care consults. I do LTAC consults, and of course, still nursing consults. Number one, I think consulting is important because it's a great way to prepare that patient for the next level of care. It doesn't matter which level of care they're going to. Having a physiatrist involved in that transition from where they are now to the next, I think, always helps. Two, as I think my colleagues have already elaborated on in great detail, the continuity of care is really assisted by having a physiatry involved. Ideally on both sides of the equation, the handoff and the receiving, but that's not always possible. But there are still things you can do to make that handoff better. And then lastly, in private practice, of course, we need referrals, we need income. If you're an academic, I suppose you need RBUs. So by seeing patients continuing this level of care, keeping patients connected and moving through that, there is some financial benefit on the back end, of course. All right, so what to do as a consultant. Maybe you haven't done this, maybe you're starting a new time, maybe you're a resident or fellow. I know we have some of them. Number one, I think you have to start with an open and honest conversation with the patient. Explain to them what you do, what they expect from you, and how those two things are going to work together. If you can't start with an open and honest conversation with them about post-acute care, then you're really not going to accomplish anything after that. Number two, from my perspective, and especially because I deal with severe traumatic brain injury so often, prognosis is so important. You've got to be able to give them an idea, hey, you're not walking out of here and back to work in three days. That's just totally unrealistic. Let's start to put in some realistic plans. Well, you know, or maybe the opposite. Hey, realistically, you're going to be much better in three days. A long, prolonged inpatient rehab stay is probably not in your best interest. Let's get you home and into outpatient activity. Next, I think you need to talk about multiple options for rehab. As I mentioned already, one, we may see it one way, but the case manager might see it another way. The internal medicine doctor might see it another way. And it's really hard, even though I think we're the experts, even though I believe in my heart, we should be the ones driving the choice to insist the patient only go to one particular level of care. Even when all of those things are aligned, oftentimes the insurance company is not there as well. I think most of us have been in that boat. So even if we think we've got the perfect level for the patient, the insurance company isn't on board with that, then oftentimes that's another challenge as well. And that's difficult. So I think keeping the discussion open about, hey, there's different ways we can get this done. We're going to work through this together, it's important. And then as I was kind of alluding to under prognosis, beginning even in those early discussions with a consultant in acute care or an LTCH, they talk about what is the next three months, six months, one year look like, it's so important. Oftentimes patients are so focused on the here and now, on the medical issues, on the sudden changes they've experienced. They have no reference or thought about what this is going to look like in three or six months. I think the COVID pandemic really drove this home because so many times when I was talking to these individuals in the ICUs and the LTCHs trying to come up with a plan, a rehabilitation discussion with them, it was like, what's it going to look like when you go home? Where do you get oxygen from? Who's going to help you with this? No one had brought it up. All of the focus had just been on getting over COVID, getting the breathing, getting the next steps. And I can't tell you how many patients broke down crying or family members crying and saying, well, we never even thought of that. We had never made plans for that. This is totally not discussed with us. So I think that's really important for a team in our consultation. To say that in another way, I broke it down into a couple of different flavors. One, you want to engage and engage early and not just engage with the patient. So that's very important, but oftentimes, especially in my severe disorders of consciousness patient with the family, but also in those other patients, the COVID patients, their families had tremendous responsibilities when those individuals went home. Preparing them early for that was very helpful. Also, I think, again, you need to engage with your primary and consulting services. It's one thing to have a great relationship with the patient, but if you're alienating some of the other services, you're doing the patient a disservice. And then it's a great way to kind of engage with therapists and nurses and get everybody's expectations aligned and everybody on the same page. Two, I think you need to really talk about resources. What is it that their insurance typically covers? Do they have the ability to harness any community resources? Are there churches or family members who can help? Trying to get some resources marshaled from those very first days is really important to help the patient traverse through the medical system. Discuss community resources. I think that's really undervalued by most physicians. It's something you've got to talk about. Here in Houston, we have a lot of really big, powerful, well-to-do churches, and they have done amazing things for patients, more than just build ramps or buy wheelchairs and provide caregivers and things that have really helped patients to transition to their home. Other people have other social connections and groups that can help out. So things need to be explored. And then developing a plan. Again, I think I've covered that. So unless there's specific questions on this slide, I'm gonna move forward. All right, so when you can really put that all together, when you can come in as that acute care consultant and get these things together, bam, you really get that big bang and things really start to move forward and then become helpful to your patients. No matter how medically complex, no matter how difficult, now you can start to work as a team towards a goal. And that's something that acute care hospitals just don't see the way that we rehab doctors do. And it's important for us to be there and be that voice. Just as important as what to do, there's also some what not to do. So if you're dealing with very complex patients, you have to be very careful, I should say, not to give false hope, right? These patients are tenuous for a reason. Things could go south in a minute. As much as you wanna press them towards health and wellbeing and rehabilitation, sometimes it's not possible, or even sometimes things come out of left field. So I think you have to make sure that you're always humble in medicine, right? Number two, don't ever purposely undermine or contradict other physicians. We all need to play together. There's a lot of egos in medicine, I'm sure all of you already realize. If you can keep everybody on the same team, working together and happy, that's very important for the patient's wellbeing as well as your sanity and the sanity of those around you. I think it's generally a bad idea to run right tons of orders and make wild recommendations on a consult. That being said, I'm probably the most likely of this all to make tons of orders and wild recommendations on acute care consults. So a little bit do as I say, not as I do, but especially if you're just starting out, if you don't know your fellow physicians well, tread lightly. Less recommendations, but more powerfully implemented are much better than tons of recommendations or orders that aren't implemented or executed at all. And then lastly, and this is something I've certainly learned the hard way, never insist on a specific location. You may work at a particular rehab, LTAC or SNF that you're very fond of, and you may really think the patient is the best fit there and you wanna take care of them, but in the end, the patient has choice. And honestly, there's lots of great rehabs, LTACs and SNFs out there, and the patients get to make the choice of what they think would be best. As a rehab consultant, you may push for a specific level of care, but I think pushing for a specific institution is usually a bad idea. All right, pop quiz. Of course, I had to make it about a traumatic brain injury. I give you the case of Mr. Edward Cohen, a 25-year-old gentleman in a high-speed motor vehicle accident. He went to the acute care hospital and then moved to a step-down unit. When you evaluate him, he does open his eyes spontaneously. It seems that he groans, maybe in pain, but he's not really moving or doing much otherwise. His family, however, pleases their hands to command, but the nurses and therapists do not document his support. So my question, if we can get it pulled up, what would you, as the acute care consultant, feel is the most appropriate next level of care from Mr. Cohen? Well, I think the time is getting short. May I just move forward and end it there? So it looks like there's a group of believers out there who want to do inpatient rehab. And that just tickles me, of course. So other people put LTAC and SNF. And the right answer to this, of course, is there is no right answer. The answer to this is that the patient needs to go where he can be supported. And that could be an LTAC, a rehab, or a SNF, wherever this patient finds the best quality of care and whether there's a team together that can adequately address his disorder of consciousness needs. OK, so we go back to this gentleman. And he is, of course, a real patient. This is Danny Fernandez. He signed all the HIPAA papers. Don't worry about that. We still remain very close with him and his family. I saw him in acute care, LTAC, rehab, and then as an outpatient. And he's doing phenomenally well, despite a prolonged disorder of consciousness, not yet back to work. But the point of the message, meaning, is that society can help with this whole process. No matter how complex or difficult, there's a way to achieve what you need to do. So I ask you to take that back to something we talked about earlier. What makes criteria for inpatient rehab? Well, again, there's this very vague list of issues that CMS kind of outlines. And does someone in disorders of consciousness who's not really following commands or doing much else fit it? And of course, they can frame it right if you move the needle to make it work for you. But maybe another better way of looking at that is what are the seven most common reasons for rehab denial? Well, here are the things that are listed. And I think one reason why the chart on the CMI continues to increase is because, boy, the more complex they are, the easier it is to kind of answer these questions, the less likely that you're going to be called out for this. So I think we, as rehab providers and rehabilitation hospitals, have evolved to take some of those higher complexity patients and manage them well in part to kind of avoid the rehab denial. So I think there's multiple things going on there. But I think if you look at this list of reasons for denial, you can see why maybe it's pushing us to take more complex patients. And I think in a lot of ways, it's a good thing. Getting back to the consult service, how do you time the admission? How do you get that patient right when they're ready to go into your inpatient rehab to perform their best? Well, unfortunately, if you're working in the private sector like me, this is often dictated by the acute care hospital trying to keep their length stable and then number two, by insurance company. Two, I would say with timing it, again, avoid trying to get a round peg in a square hole. I know if you work in inpatient rehab, sometimes that's the only possible answer. But again, remember, for most of us, there's great LTACs and SNFs around, and we can utilize them and bring them back to rehab later. Similarly, another way of saying that if your only tool is a hammer, maybe everything looks like a nail, you've got to try and avoid that thought process if possible. And then finally, when you're timing the admission, know that you're setting, right? It'd be great to bring every severe traumatic brain injury to your rehab, but if your insurance company is only getting you 14 days and your rehab is going to take two or three days to get up to speed with the DOC patient, then maybe that's not the most appropriate time or place for him. Maybe that patient needs to marinate in acute care or go to an LTAC or the rehab to get a little bit better if you can maximize that 14 days. Knowing the approximate length of stay that you're going to get and the strengths and weaknesses will feed well into making sure that you're timing that admission appropriately. Other things that you can do to kind of time the admission and make things flow quickly, neatly, and appropriately, number one, clean up the medication list. It's always more difficult and there's more risk of problems if the med list is a mess, and most of the time you're free to do that, especially if meds aren't being used frequently in acute care. Number two, educating the patient again. I think I've hopefully beat that dead horse already, but I'll continue to mention it because I think it's just so important. You can't talk to the patients and their families enough about what to expect and what comes next. And then finally, really start to prepare that patient to perform their best. And we're all very smart individuals. We all think we have our ways of doing that, but I would be amiss if I didn't tell you that because I think, of course, I'm very good at that as well. So in my opinion, how do you prepare those patients for success? Well, number one, a big part of my acute care consult is just establishing a daily routine. Get an alarm clock or have the family or the nurse or someone wake them up at the same time every day. Starting to have that routine is so important. Getting them out of bed. If you don't have an early mobilization team in your ICU, no problem. Nurses can do it. PCAs can do it. Physical therapists can do it. If they're afraid or unclear, there are checklists, as Dr. Steinberg mentioned, really nice checklists out there already of who and who cannot be mobilized based on vitals and medical diagnoses and things. Anybody can fill it out. It doesn't take five minutes. Set a bedtime. They should be in bed asleep at a particular time. And please encourage your nurses to monitor the sleep quality at night. If you can, try and improve that day-night protocol, exposing them to daylight. Some hospitals just don't have daylight. If that's what you're up against, then that's what you're up against. But as much as you can, try and get them in front of a window. Get a therapist or a nurse to take them outside. Work on the sleep hygiene if you can. It's really not expensive for these hospitals to buy earplugs, to buy sleep masks. Those kinds of little things can make a huge difference. Families can bring in white noise machines. There's all kinds of things there. And of course, you aren't going to come to one of my talks without hearing about college. Getting low on time, so I'll go quickly. Everybody has their own voodoo. There's very little evidence on this, of course. But most people, I think, would agree the problem is wakefulness, modafinil, and metformin are often reasonable interventions. If it's consciousness per se you're struggling, obviously, we have one nice, large, randomized control trial for amantadine and severe traumatic brain injury. There's also ways to use the naphazyl, momantam, and glonocrystine that are beyond the scope of this talk today. Prepare them for success. Again, in the interest of time, I'll just say work on that sleep as much as you can. There are medications, again, that can help with sleep. Using them is a bit of an art, and everybody has their own style. There was a paper a few years ago about really getting the diagnosis right on sleep issues. You can do this in your care hospital with tools you already have. You don't need a polysomnography. Please let me know if you want this citation. But just this in the course of the day can really help you optimize the patient's sleep again. Because if you're just throwing melatonin at everything and someone has an obstructed sleep apnea, you're not going to see much success. So you do have to work through the diagnosis. Again, hopefully, this will set the patient up to give you some of the tools you need to address criteria for CMF. And then I'm going to give you a few caveats. Dr. Shafir talked just a little bit on this, but I'm going to drive this home. Number one, until at least January, by all accounts, we're going to have the COVID waiver program in place at most hospitals. You can bring the patient to your rehab unit, even if they're not ready for rehab, if you're freeing up an acute care bed that's needed. Number two, one favorite of mine is to adjust the therapies to what I would call less physically strenuous therapies, like OT and speech. If they're that sick, they probably have OT and speech needs. You can front load those in the beginning of the rehab stay transition to PT as you get that endurance built up. That's a favorite trick of mine. And then for specific criteria, you can stretch out the therapy. And here's the list on that. Dialysis, chemotherapy, which probably only really affects jeggies, because I don't think anybody else can afford to provide chemotherapy or radiation during the rehab. Wound care, which I think we all do, and oxygen desaturation. So three of those, dialysis, wound care, and oxygen desaturation, are pretty easy for us to grab, even in a community rehab like mine. Chemotherapy and radiation are usually cost prohibitive. So just to drive this home, and I'll make it super quick, because I know we're out of time, but you can get this done with extreme cases. And one example of that, again, I'm going back to the disorders of consciousness. So when that was looked at, 400 patients with the OT in the model system, they did phenomenally well when they got to rehab, despite supposedly to participate or being too low level. At five years, that same group of patients was evaluated. And the ones who had a good recovery were doing even better, oftentimes independent for everything from problem solving to ambulation in a wheelchair. And even the ones who didn't do well during rehab ended up great five years later, independent on something on the stem at the time. Of course, now we see. And then the same group of patients that did 10 years later, now almost 80% of them are walking. 72% are bathing independently. 80% have bowel management at an independent level. So there's something about rehab more than just what we do and the outcomes we see. We're setting these patients up for success five and 10 years later. And I think you have to keep that in mind when you're looking at these really complex patients. And hopefully, that will help you give them a chance. So maybe we need to challenge a little bit who meets criteria for inpatient rehab. And maybe we need to challenge what are the benefits of rehab. Because I think we have some data that shows that the things that we're doing in inpatient rehab, even for the sickest patients, even for the ones who don't seem to make the kind of progress, really does seem to pay off five and 10 years later. All right, just a few announcements. One, US Society, we have UST University, which is live. If you see the kind of work that I do or making your practice better, please let me know. We're also launching a UST podcast. Number two, I have two talks at the assembly if you'd consider joining. If you like what I talk today, one is on practice consideration for early career society. The other one is making transitions better for you and your patients. And then ACRM, I am teaching the DOC hands-on course on Sunday. And we're doing spasticity management for DOC patients on Thursday. And it's my daughter's sixth birthday today. So thank you all for celebrating with me. If there's noise in the background, I apologize. And I'm done. Thank you so much for a great talk. And happy birthday to your daughter. Apologize to her for me, please. So we've now finished the formal presentations. I see a great question from Genevieve Jacobs that I'd like to throw to the panel. Can you comment on complex medical patients who don't progress as expected and might need to go from IRF to SNF? So I see some great responses there. But if anyone has anything they'd like to say, chime in. And for anyone else who has any questions, you can raise your hand, use the Q&A, use the chat. We have the ability to stay on longer. And happy to engage with other questions, concerns. So can anyone want to tackle Dr. Jacobs' question? I think I just would comment that the data is pretty clear. And the guidelines are also clear that stroke rehabilitation outcomes, in particular, are improved through inpatient rehabilitation. And CMS does indicate that practical progress towards reasonable goals is important, including potentially discharge to community. But a lot of medical directors and programs misread that CMS guidance as meaning that patients must have the potential for discharge to the community as a prerequisite for coming to rehab. When, in fact, that's not the case. And if you can make the case that a patient coming to rehab would benefit in multiple levels by coming to the rehab unit, even if they do need to go to a SNF afterwards, I've always thought to do the right thing for each individual patient. And I've certainly seen that in patients that I've cared for and others. That by setting them up for success by coming to the rehab unit to begin with will lead to long-term better outcomes for those patients. And avoid readmissions, avoid complications like severe spasticity, and UTIs, and pressure ulcers, and pneumonia, et cetera, et cetera, DVTs. So I've always favored, if possible, if a patient can make significant improvements, even if it's not discharge to the community, it's still worthwhile coming to the rehab unit. Yeah, I would certainly echo that. And then I would say one of the nice practices I do around the SNF. And sometimes the patients do have to ping pong back and forth a few times before they're able to get home. But if you have a decent SNF, if they're willing to do some rehab, you can do that and keep the progress going and extend their function. And maybe it's two, maybe it's three rehab admissions, two, three SNF admissions before they get home, but they got home and then they're independent. Then they usually do great. And it's unfortunate that our system is so closed that if you don't kind of fit in that 14 to 21 day box and it doesn't work for you, because some of them need 30, 40, 60, 80 days of rehab and you got to kind of stitch it together to make it work for them. I agree as well. I will say I am a little more cautious depending on the payer source. So we do have some local payers who make it nearly impossible to get SNF after IRF. And those are the ones usually for which NaviHealth is the overseeing vendor. So I am particularly cautious in those cases, but far more lenient in others. And I see some laughs because I think that's a pretty uniform experience across the country. Dr. Tennyson, anything to add? Yeah, I was gonna say, I agree with what you guys are saying. I think I have seen instances where maybe the case manager might've mentioned why bring the patient to the inpatient rehab floor when I have to do the work again to now to try to find a SNF outside after inpatient rehabs. I have heard of those kinds of arguments too. And sometimes those come back to us in faculty meetings as to why did you bring this patient when you know that this patient will eventually need a SNF also. But I agree that if a patient can benefit from short stay of inpatient rehab and they're kind of medically complicated, they would do better at our facility as opposed to SNFs. And I think a lot of the consultants and oncologists at our hospital, they much, much prefer that the patients stay in-house because they can closely monitor the patient's progress too. And a lot of services closely monitor labs also, which is helpful for us. So I think that it helps for the patients to do inpatient rehab as long as they can tolerate and make some improvement before going on to the SNF. So while waiting to see if there are any other questions, just given recent events, thought it was important to remind everyone that some of these medically complex patients have special emergency preparedness needs. So if you're discharging a patient on electrically powered devices that are necessary for life or function, I do advise registering with the utility companies for medically essential service. There's usually a certificate that you need to complete for priority turn-on service in the event of a widespread outage. They should also consider purchasing a generator or portable power station and consider registering for medical shelters and or evacuation assistance in advance of an approaching storm. Also, just quick reminders, some other upcoming events of interest. The geriatric member community has their event tomorrow and they will also be talking about some post-acute care issues, particularly among older adults, and they invited our group to join them. That's between 10 and 1 p.m. Eastern. And if you're coming to Baltimore, I will be running a session on rehab considerations for patients with advanced heart failure with Drs. Ponte, Rydberg, and Eichmeyer. We're not gonna do the basic cardiac rehab talk. I don't think we're gonna even mention METS, but we will be talking about LVADs, life vests, heart transplants, remote cardiac monitoring, and milrinones, so things that we're increasingly being asked to manage in rehab settings. So I think it will be a good talk for this group. And again, if you're coming to Baltimore, please stop by our in-person networking event between 10 and 11. I hope to see you there and also in our FYS forum on the website.

transition of care

medically complex patients

healthcare setting

coordination of care

outcome measures

readmission rates

patient satisfaction

discharge planning

clear communication

inpatient rehab

skilled nursing facility

emergency preparedness

geriatric member community event