Choosing a High-Quality Medical Rehabilitation Program

Choosing a High-Quality Medical Rehabilitation Program:

AN NRH FIELD GUIDE FOR PEOPLE WITH DISABILITIES Choosing a High-Quality Medical Rehabilitation Program: AN NRH FIELD GUIDE FOR PEOPLE WITH DISABILITIES

TO DOWNLOAD A PDF VERSION OF THIS GUIDEBOOK, GO TO WWW.NRHRESEARCH.ORG/CHDR/REHABGUIDE OR WWW.BU.EDU/HDR/CONSUMERGUIDE.PDF FOR ADDITIONAL COPIES OR FOR COPIES IN ALTERNATIVE FORMATS, CALL 1-866-380-4344.

ACKNOWLEDGEMENTS

This guidebook was developed with a grant awarded to the Health & Disability Research Institute at Boston University from the National Institute on Disability and Rehabilitation Research (NIDRR): Rehabilitation Research and Training Center for Measuring Rehabilitation Outcomes, Grant No. H133B990005.

The creators of this guidebook acknowledge and thank Paul Rao, PhD, and Michelle Rives, MPH, who were the authors of the National Rehabilitation Hospital’s publication, A Consumer Guide for People with Stroke: Choosing a Rehabilitation Program, on which this guidebook is largely based.

We would also like to thank the following individuals for their time and efforts in reviewing this guidebook and providing valuable consumer feedback: Marcus Bell, Bertha Joachin, and Robert Sevigny, in addition to all of the other reviewers for their insightful comments, time, and energy.

This guidebook was prepared by Melinda T. Neri at the National Rehabilitation Hospital Center for Health and Disability Research in Washington, DC and designed by Flannery Studios in Montgomery Village, MD. CHOOSING A HIGH-QUALITY MEDICAL REHABILITATION PROGRAM

Contents

INTRODUCTION ...... 1

PART 1: MEDICAL REHABILITATION ...... 3 What is medical rehabilitation and how can it help me? ...... 3 Who will I work with during rehabilitation? ...... 5

PART 2: HEALTH INSURANCE PLANS ...... 7 What rehabilitation programs and services will my health insurance cover? ...... 7 What are some different types of health insurance plans? ...... 7 What’s the difference between private and public health insurance plan payers? . . . .8 What does Medicare cover? ...... 9 What does Medicaid cover? ...... 10

PART 3: CHOOSING A REHABILITATION PROGRAM ...... 11 How do rehabilitation programs differ? ...... 11 Will I need more than one kind of program? ...... 16

PART 4: QUALITY AND REHABILITATION ...... 17 What is meant by ‘quality?’ ...... 17 What are rehabilitation outcomes? ...... 17 What are some ways quality is measured at the individual level? ...... 19 What are some ways quality is measured at the organizational level? ...... 21

TERMS ...... 25

QUALITY CHECKLISTS ...... 31

RESOURCES ...... 35

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CHOOSING A HIGH-QUALITY MEDICAL REHABILITATION PROGRAM

STEPS FOR CHOOSING A HIGH-QUALITY REHABILITATION PROGRAM

iv NRH Center for Health and Disability Research CHOOSING A HIGH-QUALITY MEDICAL REHABILITATION PROGRAM

Introduction electing a high-quality medical rehabilitation program after you experi- Sence an injury or illness can be hard to do. You want a rehabilitation program that will give you the best possible care choose a high-quality rehabilitation pro- and that takes into account your own cir- gram. It includes four major parts. Part 1 cumstances. For instance, you will want a describes medical rehabilitation—what it program that considers how well you get is, how it can help you, and the different around, the type of transportation you use, rehabilitation professionals who will work where you live, your level of family sup- with you. Part 2 discusses health insurance port, and your insurance coverage. You plans so that you can understand what also want a program that will help you to your plan will and will not cover. Part 3 become as independent as you can be in talks about the different types of rehabili- your daily living. tation programs available to you, and Part 4 looks at ways that can help you find a When it comes time to choose a rehabilita- high-quality rehabilitation program to suit tion program, where do you start? How your needs. can you tell which rehabilitation programs offer high-quality services that will meet At the back of this guidebook, you will find your needs, and which programs will not? a glossary of terms. When you are reading through this guidebook and see a word in Unfortunately, people often must decide boldface type, you can find out its mean- where to go for rehabilitation when they ing in the terms section. You can also look do not have the time to gather details through the terms section first, to familiar- about all available programs. Typically, ize yourself with some of the words. You decisions about which rehabilitation pro- will see that next to each word is a page gram to use are made when a person is number where it appears in the text, if you already in an acute care hospital. If some- need further descriptions. one has not talked with you or a family member within the first few days after In addition, you will also find checklists to being admitted to a hospital, ask to see a help you choose a high-quality rehabilita- hospital social worker. The social worker tion program, as well as a listing of can help you begin the process of choosing resources including organizations, Web a rehabilitation program. sites, and phone numbers that might be useful. The goal of this guidebook is to help you to

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After reading this guidebook, you should will be better prepared to choose a pro- have a better understanding of how to find gram that meets your health care needs a good quality medical rehabilitation pro- and helps you to be as independent as gram. By becoming more informed, you possible.

MARTIN’S STORY: THE ROAD TO RECOVERY In the summer of 1999, For Martin and others, the his rehabilitation and Martin was an active 42- changes that come with recovery. “Rehabilitation is year-old who rode his bike disability can create about believing in yourself, 20 miles roundtrip to work lifestyle challenges. Medical knowing that you can get each day. One weekend, as rehabilitation helps to better with determination,” he was gearing up for a identify each person’s abili- he reflected. “It’s not easy, long ride and putting on ties and finds ways to use but my family and thera- his cycling shoes, he sud- those abilities and new pists were very supportive.” denly lost all feeling in his skills in daily life. After rehabilitation, Martin right arm and leg. There One of Martin’s biggest joined a stroke support was no pain, no sickness, challenges after his stroke group. This group of stroke no blurred vision—just no was learning how to do survivors and family mem- feeling. things with his left hand, bers met each month to Martin was taken right even though he was right- talk about their experi- away to an acute care handed. “I had to learn ences. Personal achieve- hospital where he learned how to brush my teeth ments were also shared as he had a mild stroke. Two with my left hand. That a way to inspire others to weeks later, he transferred seems simple enough, but reach their own personal to a rehabilitation hospital it’s been a long, difficult goals. where he could rebuild his process. In the end, it’s Years later and almost fully strength and relearn skills been worth it to still be recovered, Martin is still an needed for independent able to do many things for active member of the living. After his intensive myself.” stroke support group. In inpatient rehabilitation, Martin found that confi- fact, he now bikes to and he continued with weekly dence, self-esteem, and from the meetings each outpatient therapy. support from family and month. friends played a big part in

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PART 1: AL R EHABILIT

Medical A Rehabilitation TION

CHOOSING A HIGH-QUALITY MEDICAL REHABILITATION PROGRAM

PART 1: Medical Rehabilitation t’s important to try to understand some to walk on a flat, indoor surface where of the basic concepts about disability. there are no curbs or steps. To begin with, how well you function I Performance is one’s ability to do a cer- depends on your health, where and how tain task in a real-world setting that may you live, and other individual factors. have barriers, such as steps, uneven Living with a disability means that your ground, or bad weather. Although you body might not be able to function fully. It might have the capacity to walk, the envi- also means that you might be limited in ronment affects your real walking per- doing some tasks or taking part in some formance. It makes it harder for you to activities. function and plays a part in your disability. Capacity and performance are two terms that can help you understand how your WHAT IS MEDICAL REHABILITATION AND functional ability relates to the concept HOWCANITHELPME? of disability. Capacity refers to one’s abil- Treatment for disability or illness most ity to do an activity in a barrier-free place. often begins with acute medical care. For example, you might have the capacity This medical care usually is provided in an

KERRY’S STORY: THE ENVIRONMENT AND DISABILITY Kerry was 19 and working since the injury. He is able bad weather. For example, as a summer house painter to function and walk inde- rains hinders his walking when he fell from a ladder pendently with his braces performance because the and sustained an incom- and uses public transporta- sidewalks get slick. When plete spinal cord injury. tion to get to and from the sidewalks get slick, it is After his injury and rehabil- work. However, the physi- harder for him to walk iation, he had a reduced cal environment sometimes safely from the subway to capacity for walking and makes walking difficult. his office building. When needed to wear braces to it’s not raining and the The environment plays a help him get around. sidewalks aren’t slick, Kerry role in Kerry’s disability doesn’t have to worry as Kerry has been living a because his walking per- much about falling. productive and full life formance is more limited in

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acute care hospital before you begin Medical rehabilitation can help you to live rehabilitation. Acute medical care seeks to as independently as possible with your dis- stabilize your condition and lessen any ability. It helps to reduce the effects of any further complications. Rehabilitation problems you may experience after your begins after you are stable and your injury or illness. Rehabilitation uses a care- doctors think you will have no more fully planned program to help you regain complications. your ability to function on your own at

MEDICAL REHABILITATION IS DIFFERENT FOR EVERYONE The rehabilitation process good progress while there. was looking for. Within is different for everyone. It months, she was making Looking back, Elvira now depends on many different the progress that she knew knows that in rural Costa things, including how you she was capable of. Being Rica she wasn’t getting the are injured or become ill, near supportive family and rehabilitation services and how old you are when this friends, Elvira also received professional and emotional happens, where you live, the encouragement and support that she needed to and the resources and serv- support that she needed make progress. After 6 ices that are available to to help her. She was months recovering in Costa you. Most importantly, it now highly motivated Rica, Elvira decided to also depends on YOU. to improve both her move back to the United functional ability and her Meet Elvira. Elvira was 40 States so that she could capacity to live and work years old and living in rural get the rehabilitaiton serv- independently again. Costa Rica when she cies she needed. She would awoke one night with an also be closer to family and Today, nine years after her upset stomach and stinging friends to get the emotion- stroke in another county, pain shooting down her al support that she was Elvira is able to receive left arm, coupled with arm lacking in her recovery. weekly therapy. She has cramps. When she tried been working full-time as Once back in the states, to get up, she found that an Administrative Assistant Elvira’s first doctor told her she couldn’t stand. She for over a year, and com- that she was never going to immediately called for mutes to and from work walk again. She knew that an ambulance, and after via public transportation. he was wrong and was arriving at the hospital, the As she says, “You would be determined to prove it. doctors told her she had a surprised at how fast you Elvira believed she would stroke. Elvira was kept in can recover after finding indeed, walk again. She that hospital for 6 months, the right treatment and found a rehabilitation team receiving very little rehabili- believing in youself that that provided her with the tation and not making very you can improve.” services and treatment she

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home, at work, and in the community. can make in your home to increase your independence. These changes might The rehabilitation process takes time and include putting in ramps, changing door- requires patience, motivation, and hard knobs, widening doorways, and work. To have a successful rehabilitation moving furniture and rugs. experience, you will need to relearn some old skills, such as how to get around, While you are in a rehabilitation and you will need to learn some program, you might feel limited new skills as well. because you can’t do everything you did The primary aim of before your injury or ill- medical rehabilitation is ness. With persistence for you to be able to do and the help of family, activities of daily liv- friends, doctors, ther- ing, such as eating, dress- apists, nurses, and ing, and bathing, so that you other rehabilitation can live as independently as experts, you will be able to possible. Rehabilitation works to regain some of the functional reduce the limitations you may experi- ability you had before. You will also learn ence with certain activities. For example, if new ways to do tasks and take part in you cannot walk on your own, physical activities on your own. therapy will help improve your balance and muscle strength. WHO WILL I WORK WITH You might also be given assistive equip- DURING REHABILITATION? ment. This would include items such as a During rehabilitation, you will most likely cane, walker, brace, or wheelchair. All of work with several different rehabilitation these will help to increase your independ- professionals. These professionals make up ence. This equipment will also help you to your rehabilitation team. The members of function better, get around on your own, your team will depend on your needs, your and make your life easier. current insurance coverage, and the type of Rehabilitation will also help you find ways rehabilitation program you choose. to cope with the barriers of your physical Following is a list of some of the people that environment. For example, you may learn you might work with; some of them might how to go up and down ramps, get through be familiar to you. Regardless, full defini- doors, and use public transportation. tions and descriptions of all of these professionals are included in the ‘Terms’ section You might also learn about changes you at the back of this guidebook.

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Audiologist Prosthetist

Chaplain Rehabilitation case manager

Clinical neuropsychologist Rehabilitation engineer

Clinical psychologist Rehabilitation nurse

Dietician Respiratory therapist

Occupational therapist Social worker

Orthotist Speech-language therapist

Physiatrist Therapeutic recreation specialist

Physical therapist Vocational rehabilitation specialist

POINTS TO REMEMBER FROM THIS SECTION • Rehabilitation will help you regain your functional ability. This may involve relearning old skills and learning some new skills. • During rehabilitation, you will work with many different rehabilitation professionals. The members of your rehabilitation team will depend on your needs, your insurance coverage, and the type of program you have chosen.

8 NRH Center for Health and Disability Research PART 2: Health Insurance Plans H EAL TH I NSURANCE P L ANS CHOOSING A HIGH-QUALITY MEDICAL REHABILITATION PROGRAM

PART 2: Health Insurance Plans he rehabilitation programs that you will also depend on whether you currently can choose from will depend on, in have a private insurance plan or a public Tpart, what services your current insurance plan. Following, the differences health insurance plan will cover. It is are described. important to know and understand the type of insurance coverage you have so WHAT ARE SOME DIFFERENT TYPES you’ll know what type and amount of OF HEALTH INSURANCE PLANS? rehabilitation services you can receive. For There are two general types of private example, if you are a veteran, you might be health insurance plans, traditional insur- eligible for rehabilitation services through ance plans and managed care plans, and the Department of Veterans Affairs. two types of public plans, Medicare and Medicaid. Over time, the differences WHAT REHABILITATION PROGRAMS between these two types of plans have AND SERVICES WILL MY HEALTH become less and less clear. Today, many INSURANCE COVER? traditional plans have managed care fea- When selecting a health insurance plan, tures. Many managed care plans also have make sure to select a plan that covers features of traditional plans. rehabilitation services, for the type of reha- Traditional health insurance plans are bilitation services you can choose will sometimes referred to as fee-for-service depend largely on the type of health insur- plans. Usually, such plans only pay a por- ance coverage you have. Your health tion of your yearly health care expenses insurance coverage can limit your choice after you have paid a set amount of money of rehabilitation services, providers, and toward all the health care services you facilities. It is important to understand receive. This set amount of money (such your health plan so you can make as $250) is called the yearly deductible, informed decisions about your care. and you pay for this amount out of your Keep in mind that all health insurance own pocket. plans are not alike. They vary from state to For example, your traditional health insur- state and from person to person. Your ance plan might pay for 80% of all your plan’s coverage for rehabilitation services health care expenses after you have paid

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your yearly $250 deductible. After you type of managed care plan. have paid the $250 “out of pocket,” you With managed care plans, most of the fees would only pay 20% of the cost of your that you would pay for services you next service. Your health plan would then receive are fully covered. But each time pay for the remaining 80% of the cost. you use a service, you must pay a small Traditional health plans generally offer co-payment amount instead, as opposed more flexibility than managed care plans. to the actual “fee” for the health care serv- With a traditional plan, you likely will have ice. This co-payment can range from $5 to more choices in terms of where to go for $50 or more, depending on the service. rehabilitation, how much care you can With managed care plans, you generally receive, and which doctors you can don’t have to pay a yearly deductible see. Some traditional plans don’t amount before the health insurance starts limit the number of rehabilitation to pay a percentage of your cost. services Instead, all of the cost of the you service is covered after receive. you pay the small This is dif- co-payment ferent than amount at each managed visit. care plans, which usually limit The downside of man- the number of rehabilita- aged care plans is that your tion visits that will be covered. choice of doctors and health care facilities is limited. You often must choose from Managed care plans are the other com- only doctors who participate in the plan. mon type of health insurance plans. With Also, the plan may limit the amount of cer- this type of plan, all health care services tain health care services, such as rehabili- are delivered at a reduced price to plan tation services, you can receive. members who agree to only get their health care from certain doctors at certain Remember that not all health care plans locations. With managed care plans, a are alike. Be sure to check with your health doctor known as a primary care doctor plan provider before making any decisions manages your care. You usually have to about your rehabilitation program. No see your primary care doctor first, and matter what type of health insurance plan then he or she can refer you to other you have, find out which services will be providers you might need to see. A health covered and how many services you can maintenance organization (HMO) is a receive.

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What’s the difference between What does Medicare cover? private and public health If you are 65 or older, or under 65 and have insurance payers? a disability, and if you meet certain require- There are two types of health insurance ments, part of your health care likely is paid payers—private and public payers. Private for by the federal Medicare program. payers typically are employers. If you Medicare is made up of Parts A, B, C have health coverage through your (Medicare Managed Care) and D. Medicare employer, then your health care services Part A covers: are covered by a private payer. • All inpatient hospital expenses, Public payers are the government Medicare and Medicaid programs. They • Certain services provided in a hospice cover your health and rehabilitation service or skilled nursing facility, and needs if you meet certain requirements. • Certain services provided through home The Medicare program is run by the federal health care services. government and provides health care cov- Medicare Part B is optional coverage that erage mainly for people with disabilities can be purchased and paid for each and those who are over the age of 65. The month. This insurance covers: Medicaid program is run by state governments and provides coverage mainly for • Doctors’ and outpatient hospital services, people with low incomes and those with • Physical and occupational therapy, certain disabilities. Because the Medicaid program is run by the individual states, cov- • Certain medical equipment, and erage varies from state to state. Each state • Some home health services. sets its own rules for who is eligible for coverage and what services are covered. Medicare can have features of both tradi-

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tional and managed care insurance plans. health insurance coverage for low-income For example, Medicare Part C, as it is com- people of any age. It also covers persons monly referred to, includes Medicare with certain kinds of disabilities. In gener- Managed Care plans (Medicare + Choice). al, Medicaid covers: Introduced in 1997, Medicare Managed • Hospital care, Care plans offer expanded benefits, for a fee, through HMO’s that contract with • Doctors’ services, Medicare. In 2004, Medicare + Choice was • Nursing home care, replaced by Medicare Advantage. • Home health care, Mecicare Part D is the new prescription drug coverage, which becomes fully effec- • Outpatient services, and tive in 2006. This prescription drug benefit • Prescription drugs. is optional and coverage, deductibles, co- payments, and out-of-pocket costs will vary In some cases and depending on your depending on both your personal income income, Medicaid can also help to pay for and total prescription drug expenses. some of the Medicare expenses (such as deductibles and co-payments) mentioned Make sure to find out about coverage limi- above. tations under your Medicare plan, because Medicare has rules about the services and Medicaid rules, eligibility, and coverage treatments covered. For example, depend- differ from state to state. Make sure to ing on your Medicare coverage, you may check with your state Medicaid office to have to pay for a portion of the health care find out your state’s eligibility require- services you receive. You also may have to ments and what rehabilitation services are pay either a yearly deductible or co-pay- covered. ments for certain services. To learn more about Medicare and Medicaid, visit the federal Centers for What does Medicaid cover? Medicare and Medicaid Services’ Web site The state-run Medicaid program provides at: http://www.cms.gov.

POINTS TO REMEMBER FROM THIS SECTION: • Know your health insurance plan when making choices about rehabilitation services. • There are two kinds of private health insurance plans: traditional (fee-for-service) and managed care. Each type of plan has different characteristics. • Private payers of health insurance are typically your employer. Public payers are the federal and state governments (Medicare and Medicaid).

14 NRH Center for Health and Disability Research PART 3: Choosing a Rehabilitation Program C HOOSING A R EHABILIT A TION P R OGRAM CHOOSING A HIGH-QUALITY MEDICAL REHABILITATION PROGRAM

PART 3: Choosing a Rehabilitation Program Now that you know what rehabilitation is, • Subacute rehabilitation, what it can do for you, and what your cur- • Day rehabilitation, rent insurance plan may cover, the next step is to understand the different types of • Home care, rehabilitation programs available. • Outpatient rehabilitation, and

HOW DO REHABILITATION • Nursing home rehabilitation. PROGRAMS DIFFER? Acute rehabilitation programs provide Programs differ from one another in terms both medical care and a full range of reha- of: bilitation services. These services include physical therapy (PT), occupational thera- • The types of rehabilitation services py (OT), rehabilitation nursing, speech- they provide, language therapy (SLT), vocational reha- • How often the services are provided, bilitation (VR), and therapeutic recreation

• The physical setting where these (TR). Other services may also be offered. services are provided, and In an acute rehabilitation program, a team

• Who provides the services. designs a personalized, interdisciplinary rehabilitation program to meet your needs. When choosing a program, find out if the Doctors are in direct contact with you services you need will be offered often (usually daily, but no less than 3 times a enough and whether your treatment will week) to monitor your medical condition be supervised by a rehabilitation doctor or and progress. In an acute rehabilitation other rehabilitation professional. Also find facility, you would also receive 24-hour out if the program’s services are covered nursing care. by your health insurance plan. If you have complex medical needs and Several different kinds of rehabilitation could develop complications if your medical programs are available. They include: treatment is not continued, an acute reha- • Acute rehabilitation, bilitation program is best for you. To take

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TYPES OF REHABILITATION PROGRAMS

Amount of Program Where Services Rehabilitation Nursing Rehabilitation Type are Provided Services Offered Care Offered Therapy Provided

Acute At an acute Medical care, physical 24-hour At least 3 hours rehabilitation rehabilitation therapy, occupational nursing care of therapy a day, facility located in therapy, speech-language at least 5 days a freestanding therapy, vocational a week rehabilitation rehabilitation, therapeutic hospital, or a recreation, psychological rehabilitation unit services, and other in an acute care services as needed hospital Subacute At a subacute Medical care, physical 24-hour 1 to 3 hours rehabilitation rehabilitation therapy, occupational nursing care of therapy a day, facility or unit, or therapy, speech-language 1 to 6 days in a skilled therapy, therapeutic a week nursing unit recreation, psychological services and other services as needed Home care At home Physical therapy, As needed, 1 to 2 hours occupational therapy, and 1 to 7 days of therapy a day, speech-language therapy a week 1 to 3 days a week Day At hospital-based Physical therapy, Depending on 3 to 5 hours rehabilitation outpatient clinics occupational therapy, program and of therapy a day, or free-standing speech-language therapy, individual 3 to 5 days a week outpatient clinics therapeutic recreation, needs and psychological services Outpatient At an outpatient Physical therapy, None 1to 3 hours rehabilitation facility, such as occupational therapy, of therapy a day, hospital-based speech-language therapy, 2 to 3 days a week outpatient clinics vocational rehabilitation, or free-standing and psychological services outpatient clinics Nursing home At a nursing Depending on the 24-hour 1 to 3 days a week, rehabilitation home nursing home, various nursing care depending on the rehabilitation services individual’s needs may or may not be provided

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part in such a program, you must be able to therapy given in an acute rehabilitation tolerate at least 3 hours of rehabilitation program. Subacute rehabilita- therapy per day, at least 5 days a week. tion also requires that you are in stable medical condition Acute rehabilitation and need continued medical programs can be care to avoid possible com- found in freestand- plications. For subacute ing rehabilitation rehabilitation, you must hospitals. These be able to tolerate 1 to 3 hospitals are dedi- hours of therapy per day, 1 cated solely to to 6 days per week. rehabilitation. You will also find acute Subacute rehabilitation is rehabilitation pro- offered in many different grams in acute settings, including: care hospitals that have specialized reha- • Freestanding, subacute rehabilitation bilitation units. facilities that provide medical rehabilita- Subacute rehabilitation programs often tion only; provide therapy needed before or after you • Subacute rehabilitation units that are a complete acute rehabilitation but before part of general, acute care hospitals; you go home. A fairly wide range of rehabilitation services, including PT, OT, SLT, • Skilled nursing units that are a part of and TR, is provided. Subacute rehabilita- general, acute care hospitals; and tion is less intensive and generally lasts • Skilled nursing beds that are located in longer than acute rehabilitation. nursing homes. A subacute rehabilitation program A skilled nursing facility (SNF) is one includes 24-hour nursing care, and your place you might receive subacute rehabili- treatment plan is supervised by a rehabilitation. SNFs meet certain industry stan- tation doctor. The rehabilitation doctor dards and offer a higher level of nursing also provides additional health care as care than that offered by nursing homes. needed. However, you will see the rehabilitation doctor less often than you would in Day rehabilitation, or day treatment, an acute rehabilitation program. programs are like acute rehabilitation programs except that patients do not stay Subacute rehabilitation is best for you if overnight in a hospital. You can live at you have a high level of disability but can- home or in another community setting. not tolerate the amount or intensity of

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These programs offer many rehabilitation therapy). Additional nursing care is not services, which are supervised by rehabili- provided. Typically, you receive outpatient tation doctors. Nursing care and general rehabilitation therapy services 2 to 3 days medical care are also offered as needed. per week.

If you are medically stable and don’t need If you are in a medically stable condition intensive nursing care or constant monitor- and are able to live in your own home ing by a doctor, a day rehabilitation pro- without the risk of developing complica- gram is best for you. These programs pro- tions, outpatient rehabilitation is best for vide 3 to 5 hours of therapy per day, 3 to 5 you. Outpatient rehabilitation therapy days per week. Day rehabilitation programs services are often given to continue treat- can be independent freestanding programs, ment after more intensive acute or suba- or part of rehabilitation hospitals. cute rehabilitation.

Home health care services allow you to Outpatient rehabilitation therapy services receive rehabilitation treatment in your are provided in many different settings, own home. Home health care would be including doctors’ offices, hospital-based right for you if you are able to live at home outpatient units, hospital-owned outpa- but are not able to travel to an outpatient tient centers, and other outpatient centers facility if your health does not allow it, you that are not a part of hospitals. live too far away, or you do not have trans- A nursing home is another setting where portation. you might receive rehabilitation services. With home health care services, rehabilita- Nursing homes are different from skilled tion professionals travel to your home to nursing facilities because not all nursing provide rehabilitation services and nursing homes provide rehabilitation services for care. Services and care are provided as their residents. often as your doctor prescribes them and The kinds of rehabilitation services offered your insurance allows. You typically and the intensity of the rehabilitation treat- receive 1 to 2 hours of therapy per day, 1 to ment vary from one nursing home to 3 days per week. another. Some nursing homes provide Outpatient rehabilitation is provided if rehabilitation treatment 1 to 3 days per you live at home and can travel to an out- week. Treatment can be a single rehabili- patient facility. Outpatient rehabilitation tation therapy service, such as physical can include a full range of therapy services therapy. It can also be offered as a coordi- that make up a coordinated program of nated program of care that includes sever- care. It can also include only one or two al different services. services (such as physical or occupational

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If you are medically stable but have special nently or for a period of time. needs that require 24-hour nursing care, a Nursing homes differ greatly in the care nursing home is a good choice. You might they provide, so it is very important to ask want to consider a nursing home if you many questions when you are choosing need ongoing nursing care and cannot be this type of care. Make sure to ask about cared for safely at home, either perma-

LOLA’S STORY: FINDING A QUALITY REHABILITATION PROGRAM FOR YOUR NEEDS Lola was 32 when she was grams. They then gathered Having all of this informa- hit by a car as she was information to help decide tion helped Lola and her crossing the street. Her which of the remaining husband choose a high- left leg was shattered and programs would offer the quality rehabilitation her left hip broken. After best quality of care to meet program. They felt that many surgeries and weeks Lola’s needs. the program they chose in an acute care hospital, would best help Lola To begin, they looked on Lola went to an acute reach her goal of living as the CARF website to find rehabilitation facility, independently as possible out which nearby rehabili- where she was an inpatient in her own home. tation programs were for a short time. accredited. They called After going home from the She and her husband had those programs to ask acute rehabilitation facility, to start thinking about about the FIM scores of Lola continued to work which rehabilitation pro- discharged patients. toward her recovery goals. grams would best meet her With months of home and In addition, they asked long-term recovery needs outpatient therapy, she what percentage of previ- after she was discharged noticed a gradual, yet ous patients went home, from the acute rehabilita- marked improvement in rather than to nursing tion facility. This involved her walking ability. homes or assisted living learning about the different centers when discharged. By the time she finished outpatient programs They also wanted to know outpatient therapy, she offered in their area. how satisfied other felt that she had made Lola had a private health patients were with the the right decisions when insurance plan offered program and facility. To choosing her therapy through her employer. find out, they asked about programs. Despite her Because of the plan’s cov- the results of any of the disability, she was well on erage limits, she and her programs’ patient and her way back to her active, husband had to rule out family satisfaction surveys. independent lifestyle. certain rehabilitation pro-

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the kinds of rehabilitation services that are skills, you could then get to the rehabilita- offered, how often the services are provid- tion facility for outpatient care. ed, and what types of rehabilitation profes- Subacute rehabilitation can also be a sionals provide care in the nursing home. bridge between your discharge from an acute care hospital and the beginning of Will I need more than one another rehabilitation program. Subacute kind of program? care might be helpful if you need time to During the course of your rehabilitation, increase your endurance and tolerance for you may need and receive care in more rehabilitation before starting another pro- than one program or setting. Depending gram. on how your medical condition and reha- Moving from one treatment program or bilitation needs change, you might be setting to another is common. Doing so moved to a different program or treatment helps make sure that you receive the kind setting. One program may serve as a and amount of rehabilitation services you “bridge” to another. need, when you need them. For example, home health care can be Keep in mind that there is no “right” way to used as a bridge between the acute care progress through rehabilitation. Each per- hospital and an outpatient rehabilitation son has different needs that are met by dif- program. During home care, you might ferent kinds of rehabilitation at various learn certain skills, such as how to man- points in time. age stairs in front of your home and how to get in and out of a car. After learning those

POINTS TO REMEMBER FROM THIS SECTION: • There are many different types of rehabilitation programs offered in different rehabilitation settings. • The type of program you choose should depend on both your rehabilitation needs and your health insurance coverage. • You may progress through more than one type of rehabilitation program during your recovery.

22 NRH Center for Health and Disability Research PART 4: Quality and Rehabilitation Q U ALIT Y AND R EHABILIT A TION CHOOSING A HIGH-QUALITY MEDICAL REHABILITATION PROGRAM

PART 4: Reports to compare the cost, reliability, and special features of different models. You can then choose a high-quality, affordable Quality and TV that has the features you want.

Rehabilitation In the same way, when you are looking for It’s also a good idea to try to find out about a rehabilitation program, you can compare the quality of rehabilitation services when the quality and services of different pro- you choose where to go for rehabilitation. grams to help you decide how well they The following section will help you to fig- meet your own needs. One way to do this ure out what to look for in a high-quality is to compare different rehabilitation hos- rehabilitation program. It also describes pitals. For example, U.S. News & World some of the ways to measure quality. With Report magazine publishes yearly ratings this information, you will be able to com- of America’s best pare the rehabilitation programs and hospitals, services that you are choosing from. including rehabilita- WHAT IS MEANT BY ‘QUALITY?’ tion hospitals.

In health care, quality refers to You can also contact how well health care services different rehabilitation meet an individual’s programs to ask questions needs. Some pro- and make your own compar- grams and facil- isons about their services and quality of ities do a bet- care. The checklists at the back of this ter job of this guidebook suggest some questions to ask than others. when looking for a high-quality rehabilita- When choos- tion program. In addition, the information ing health care below should help you understand what to services, you can compare the quality of think about and look for when comparing services provided by different programs to the quality of rehabilitation programs. help you decide which one will best meet your needs. WHAT ARE REHABILITATION ‘OUTCOMES?’

In some ways, comparing health care One way to find out about the quality of providers is like comparing products you rehabilitation services is to look at rehabil- can buy. For instance, if you want to buy a itation outcomes. In general, the outcome new television set, you can read Consumer of an event is the end result of that event. For example, the outcome of an event

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such as a football game would be the final rehabilitation outcomes such as these, you score. The score reflects the fact that one can compare services and programs and team did better than the other. decide which one is best for you.

In the rehabilitation setting, outcomes Information about rehabilitation outcomes refer to certain “scores,” or pieces of infor- is collected in many different ways and mation that tell you how good a certain about many different topics. Information service, treatment, or rehabilitation pro- can be collected about just one person, or gram is. For example, after treatment, can it can be collected about the rehabilitation you walk without help? Do you have less organization or program as a whole. All of pain? Walking without help and having this information will help you to figure out less pain are possible positive outcomes of how good the services are and if the pro- rehabilitation treatment. By looking at gram is of high quality.

MORE ABOUT When measured at patients and families, based OUTCOMES admission and discharge, on any available survey a patient’s FIM score can results? “OUTCOMES” may be a range from 18 to 126. A The higher the satisfaction term that you have not higher average change in levels of patients and fami- heard of before. Outcomes FIM score at discharge is lies, the better. Ask to see are the impact of the better. For example, an any results from the pro- rehabilitation care and overall change of 20 points gram’s patient and family treatment provided to at discharge is better than satisfaction surveys, includ- a patient. an overall change of 10 ing results for your specific points. When you’re choosing condition. a rehabilitation program, ASK: What percentage of be sure to ask about the ASK: What percentage of the the program’s inpatients are program’s outcomes. program’s inpatients go back discharged to the community, Below are some examples to a hospital or other inpatient rather than to nursing homes? of questions for you to ask, health care facility within 15 and what to look for in the The higher the percentage days of discharge from the answers you may receive: of patients who return to rehabilitation program? their community, the better. The lower the percentage ASK: What is the average For example, 85% of of people readmitted to a change in FIM scores for inpatients returning to hospital or other inpatient patients discharged from their community is better facility, the better. For your program? than 65%. example, 5% of a pro- FIM scores measure ASK: How satisfied with the gram’s patients going back patients’ changes in func- program were previous to inpatient care is better tion during rehabilitation. than 25%.

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WHAT ARE SOME WAYS QUALITY IS home and to their communities when MEASURED AT THE INDIVIDUAL LEVEL? they leave the program, and

In an acute, inpatient rehabilitation • Patients’ and family members’ satisfac- setting, the quality of services can be tion with the program. measured by looking at certain individual Changes in functional ability. A change outcomes. For instance, most rehabilita- in functional ability is one way to look at tion providers collect information about how effective the services are in restoring the functional ability of their inpatients, as and improving function and meeting reha- well as their ability to meet key, functional bilitation goals. goals. This information often is collected twice-once at admission and again at dis- When you are first admitted to an acute, charge. Any changes in functional ability inpatient rehabilitation facility, your reha- can then be measured, recorded, and com- bilitation team will collect information on pared with other programs' outcomes. how well you are functioning. For example, the team may measure your ability to When choosing a rehabilitation program, walk or groom yourself independently. The you can look at some of the program’s team will then compare this information individual outcome measures and then with how well you are functioning when compare them with those of other pro- you leave the facility. The ideal outcome, grams. Following are three individual out- or end result, would be that your level of comes that you can look at: functioning and independence increased • Patients’ changes in functional ability, after your stay in the rehabilitation setting.

• The percentage of patients who return Your level of functioning will probably be

MORE ABOUT discharge shows how much interactions, problem THE FIM patients’ function has solving, and memory. improved overall during The FIM, or Functional Each of the 18 items can their stay. Independence Measure, is be scored from one to the most widely used func- The FIM tool includes seven. The overall FIM tional measurement tool in 18 items about self-care score for the entire medical rehabilitation. The (grooming, eating, bathing, questionnaire can therefore functioning of inpatients is and dressing), sphincter range from 18 to 126. A usually measured at admis- (bowel and bladder) con- higher overall score means sion to a rehabilitation set- trol, and mobility and that the person is more ting, and then again at dis- walking. Other items ask independent. A lower over- charge. The change found about comprehension, all score means that the between admission and understanding, social person is more dependent.

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measured through what is called the FIM, home and community, and patient satis- or Functional Independence Measure. The faction, you can get an idea of how good a FIM is a measurement tool with 18 items rehabilitation program’s services are (See that look at how well you do certain activ- “More About Outcomes” box). ities while in acute inpatient rehabilitation. (See “More about the FIM” box). WHATARESOMEWAYS QUALITY IS MEASURED AT THE Return to community. Another outcome to ORGANIZATIONAL LEVEL? consider is the percentage of individuals The measures described above will help who return to their communities (rather than you learn about the quality of care provid- to nursing homes, for example) after inpa- ed to individuals who have been in a reha- tient rehabilitation. This would mean that bilitation program. They will help to they are functioning well enough on their answer questions such as: Do inpatients own to not need assistance with daily living. have functional improvements? Are they Satisfaction. Patients’ and their family able to go home after rehabilitation? Are members’ satisfaction is another outcome they satisfied with their care? to think about. Many rehabilitation facili- All of those are important questions to ask. ties and programs ask inpatients to fill out But there are also many other ways to look a satisfaction survey and to rate their care. at quality on a broader, more general level By asking about FIM scores, return to as well. For example, you can ask about:

MEASURING OUTCOMES

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• The qualifications of the rehabilitation and certified in a specialty such as physical team members, medicine and rehabilitation or neurology.

• The rehabilitation team’s experience A program’s other rehabilitation team and success with your condition, and members should also be trained and skilled in their fields. For instance, team • The organization’s or program’s accred- members should have degrees and cre- itation status. dentials in physical therapy, occupational Qualifications of the team. Rehabilitation therapy, or speech-language pathology. team members who are qualified to treat Experience and success with your you should have rehabilitation training and condition. The rehabilitation program you experience in their fields. For example, the choose should have a good record of treat- team should include a doctor who is trained ing patients with your disability or condi-

MORE ABOUT certain performance stan- CARF, the Rehabilitation JCAHO AND CARF dards. JCAHO reviews and Accreditation Commission, ACCREDITATION accredits different kinds of accredits only medical health care organizations rehabilitation services and Accrediting bodies make and programs, including programs in the Health sure that health care rehabilitation programs. Care Division. organizations are of high quality and standards. JCAHO has three levels of If a rehabilitation program Accreditation refers to a accreditation scores. These or facility is accredited by status given to hospitals levels are “Not Accredited”, CARF, its rehabilitation and other health care facil- “Conditional Accreditation,” services are of the highest ities that meet certain and “Full Accreditation.” standards and quality. standards of excellence Fewer JCAHO recommenda- CARF may also recommend and quality. Hospital, facil- tions to improve the quality “Non-Accreditation,” ity, and program quality is of their care reflect better “Conditional Accreditation,” assessed by a panel of outcomes. or a 1 or 3 year accreditation period. experts who follow an JCAHO accreditation approved review process. results, or the “status” of To find CARF-accredited JCAHO and CARF are two health care organizations, rehabilitation programs for major accrediting bodies. can be obtained and com- your condition in a partic- JCAHO is the Joint Com- pared using the JCAHO ular state, visit the CARF mission on Accreditation of website: website and search under the link “Search for a Healthcare Organizations. http://www.jcaho.org/ Provider:” This group looks at how qualitycheck/directry/ well health care organiza- directry.asp http://www.carf.org tions and programs meet

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tion. Some facilities provide a wide range JCAHO is the Joint Commission on of rehabilitation services for conditions, Accreditation of Healthcare Organizations. such as stroke rehabilitation, brain injury, It is an independent, non-profit organiza- multiple sclerosis, and hip replacement. tion that looks at how well health care Others programs may offer expert care in providers meet quality and performance only one area, such as hand or spinal cord standards. JCAHO looks at the quality of injury rehabilitation. the staff and equipment, as well as the organization’s success in treating patients. It is important to find out which rehabilita- An organization, hospital, or program is tion programs provide the specialized care accredited only if these standards are met. you need. If one is not available in your area, you might want to consider going to CARF, the Rehabilitation Accreditation another area or state for rehabilitation. Commission, is another independent, non- profit group that helps to ensure high-quality Accreditation status. Another way to find care and the best possible outcomes. CARF’s out about the general quality of a rehabili- Health Care Division only reviews and tation program, organization, or facility is accredits medical rehabilitation services and to look at its accreditation status. programs. These services and programs may Accreditation is like a “seal of approval” be offered in an inpatient hospital, an outpa- given to hospitals and both health care tient clinic, or in a workplace or other com- facilities. Accredited organizations and munity setting. CARF accreditation means programs meet high standards of excel- that the services that a program provides lence in service and quality. meet high standards of quality. Two accrediting groups you may hear of If you know how to look at quality and out- are JCAHO and CARF. If a rehabilitation comes at both the individual and organiza- facility, program, or health care organizational levels, you will be better prepared to tion is accredited by both of these organi- choose a high-quality rehabilitation facility zations, you can feel confident that it will or program that will best meet your needs. provide high-quality care. (See “More about Part 3 of this guidebook offers more advice JCAHO and CARF Accreditation” box). for choosing a rehabilitation program.

POINTS TO REMEMBER FROM THIS SECTION: • One way to know about rehabilitation quality is to look at a program’s outcomes. • Individual outcomes you can look at include FIM scores, where patients are discharged to, and patients’ and families’ satisfaction with the program. • Organizational outcomes you can look at include a rehabilitation programs’ accreditation status given by JCAHO and CARF.

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STEPS FOR CHOOSING A HIGH-QUALITY REHABILITATION PROGRAM

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32 NRH Center for Health and Disability Research T ERMS Terms

CHOOSING A HIGH-QUALITY MEDICAL REHABILITATION PROGRAM

or she will make recommendations Terms about the need for hearing aids or other Accreditation (p.22): An objective assistive hearing devices. evaluation process that determines Capacity (p.3): A person’s ability to if hospitals and other health care do a task or activity in a controlled organizations meet certain high environment or place, free of any standards of excellence, service, external barriers. and quality in their field. Think of accreditation as a “seal of approval.” Chaplain: A hospital chaplain is available in the hospital 24 hours a day, and is Activities of daily living (ADL) (p.5): able to provide crisis intervention and Routine activities a person does every spiritual support for you and your family. day, such as standing, sitting, walking, eating, bathing, and grooming. Clinical neuropsychologist: A psychologist who specializes in studying brain Acute care hospital (p.3): A hospital behavior relationships. Neuropsycholo- that provides acute medical care. gists treat people who may have some- Acute medical care (p.3): Medical care thing wrong with the way that their that is meant to stabilize one’s short- nervous system (the brain and spine) term medical condition and minimize functions. complications; usually received before Clinical psychologist: A mental health rehabilitation. professional who can help people Acute rehabilitation (p.11): Medical understand and adjust to disability. He services that include both medical or she will teach coping skills, such as care and other rehabilitation services, stress management and pain control, such as physical therapy, occupational and will offer individual, family, or therapy, and speech-language therapy. group counseling.

Assistive equipment (p.5): Any equip- CARF, the Rehabilitation ment or device, such as a wheelchair, Accreditation Commission (p.22): An brace, walker, or speech aid, that helps independent, non-profit body that helps a person become more independent, to ensure high-quality and the best pos- function better, and perform activities sible outcomes in rehabilitation services of daily living. and programs. A rehabilitation program accredited by CARF means that the Audiologist: A health care professional services provided are of the highest who uses advanced equipment to evalu- standards and quality. ate and diagnose hearing problems. He

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Co-payment (p.8): In a managed care inpatient rehabilitation. The FIM meas- plan, a small, fixed dollar amount that ures a person’s ability to perform the you must pay before you receive a following independently: self-care, health care service. Depending on the sphincter (bowel and bladder) control, plan and the health care service you are transfers, locomotion, communication, receiving, a co-payment can range from and social cognition. $5 to $50 or more. Health maintenance organization Day rehabilitation (day treatment) (HMO) (p.8): A type of managed (p.13): Rehabilitation care that provides care plan in which people can only see a full range of intensive rehabilitation doctors who are a part of their HMO services, but allows patients to stay at network of providers. Referrals from a home overnight. primary care doctor are needed in order to see specialists or to get other health Deductible (p.7): A yearly dollar amount care services within the network. that the patient must pay before an insurance company begins paying for Home health care (p.14): Health care any services. This amount varies services provided in your home by a vis- by insurance plan. iting health care professional, such as a nurse or therapist. Dietician: A professional who designs a dietary plan that meets your personal Inpatient rehabilitation (p.19): nutritional needs. The dietician will take Rehabilitation services received as an into account your food preferences, inpatient in a rehabilitation unit or a free- your physical abilities, and any dietary standing rehabilitation hospital setting. recommendations from your doctor. Joint Commission on Accreditation of Disability (p.3): An impairment, Healthcare Organizations (JCAHO) limitation in activities, or restriction (p.22): An independent, non-profit in participation. organization that evaluates how well health care organizations and programs Functional ability (p.3): How well a (including rehabilitation programs) person is able to perform daily activities meet rigorous quality and performance (such as eating, bathing, dressing, and standards. communicating) without help from someone else. Managed care (p.8): Health insurance plans that deliver comprehensive health Functional Independence Measure care services at a reduced price for (FIM) (p.19): A measurement tool that members who agree to use certain uses 18 items to assess progress during providers and facilities.

36 NRH Center for Health and Disability Research CHOOSING A HIGH-QUALITY MEDICAL REHABILITATION PROGRAM

Medicaid (p.9): A state government-run Outcomes (p.17): The impact of care program that provides health insurance and treatment provided to a patient. mainly for low-income families and In the rehabilitation setting, one way people with significant disabilities. to measure this impact is to collect information about the patient regarding Medical rehabilitation (see rehabilita- functional abilities at admission and tion) (p.3). then again at discharge. The services Medicare (p.9): A health insurance delivered can be compared as to their program administered by the federal effectiveness in restoring and improving government that provides health function. Patient satisfaction measures insurance for people age 65 or older, are also considered an “outcome.” some people with disabilities, and Outpatient rehabilitation (p.14): others who qualify. Rehabilitation services provided to a Nursing home (p.14): A facility where person who lives at home. Outpatient patients stay to receive rehabilitation rehabilitation may be a comprehensive, services, long-term care, or skilled daily program of multiple services or nursing care. only one or two services once or twice a week. Occupational therapy: Therapy that teaches skills and adaptations to Performance (p.3): A person’s ability to improve one’s ability to do tasks at do a certain task in his or her present home, at work, and in the community. environment, which may include certain The occupational therapist (OT) or barriers, such as steps or bad weather. occupational therapy assistant will Physiatrist: A physiatrist is a doctor teach you skills and adaptations needed who specializes in physical medicine to improve your ability to do tasks at and rehabilitation (see next term). home, at work, and in the community. Physiatrists are trained to assess your Your OT practitioner will focus on pre- level of functioning, diagnose your venting, reducing, or adjusting to dis- disability, and treat any medical ability so that you can do a wide range complications related to your disability. of activities, from bathing to managing Their goal is to maximize your function- personal finances. al ability, independence, and quality Orthotist: A professional who helps of life. Your physiatrist will manage make, fit, and repair adaptive devices, your rehabilitation team and will be such as orthopedic braces (orthoses). responsible for medical decisions about your care.

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Physical medicine and rehabilitation states are the public payers of health (PM&R): A medical specialty dedicated insurance programs such as Medicare to diagnosing, treating, and preventing and Medicaid. disability, and to improving patients’ Quality (p.17): How well health care functional ability, quality of life, and services meet the unique needs of each independence. individual patient. Quality can be deter- Physical therapy (p.5): Therapy that mined by asking, for example: Is the restores and maximizes movement and patient satisfied with the health care function. A physical therapist (PT) services? Is the health care organization will evaluate how well you control responsive to each patient’s needs? Are movement and your physical function- staff members qualified in their fields? ing. He or she will do tests to see how Is the organization accredited? much mobility, strength, and range of Rehabilitation (also see medical rehabil- motion you have. Your PT will then itation) (p.3): Treatment received as part design a treatment program to restore of a program to enhance functional abil- and maximize your movement and ity following disease, illness, or injury. function based on the test results. Rehabilitation services can include, but Primary care doctor (p.8): In a man- are not limited to, medical care, nursing aged care plan, this is the doctor that care, physical therapy, occupational manages your care. He or she can also therapy, speech-language therapy, refer you to medical specialists or other therapeutic recreation, vocational providers for additional health care that rehabilitation, counseling, and other you may need. activities prescribed to increase a patient’s independence and functional Private payer (p.9): A non-governmental abilities. entity that pays for your health insurance plan. Private payers typically Rehabilitation case manager: A health are employers. care professional who makes sure that a person receives needed services after a Prothetist: A professional who helps rehabilitation stay. A rehabilitation case make, fit, and repair adaptive devices, manager coordinates care across health such as artificial limbs (prostheses). care providers and facilities, and also Public payer (p.9): The federal makes sure that all aspects of your government or state that pays for treatment comply with the rules of your a person’s health insurance plan. insurance coverage. The federal government and individual

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Rehabilitation engineer: A specially community. A social worker will work trained engineer who helps select, with you, your family, and community modify, and design assistive equipment agencies to make arrangements for for mobility, communication, work, support services that may be needed recreation, and therapy needs. during and after rehabilitation. This might include making referrals to Rehabilitation nurse: The rehabilitation community agencies; arranging for nurse will work with other rehabilitation continuing care; and offering counseling professionals to personalize your care. to you, your partner, and your family. He or she will assist you with activities of daily living and will help make your Speech-language pathology (some- rehabilitation services a part of your times referred to as speech-language daily hospital routine. The rehabilitation therapy): Therapy to restore and devel- nurse will also teach you and your op communication skills and abilities. A family about your disability, medica- speech-language pathologist (SLP) tions, and treatment. will work with you to enhance your communication skills if they have been Rehabilitation team (p.5): A group of affected by your illness or injury. This health care professionals from different may involve helping you to improve your fields who work with the patient and voice, speech, language, or conversa- family to plan and provide rehabilitative tional skills. It may also involve teaching care. you how to use gestures, computers, or Respiratory therapist: A health care other devices to communicate. In addi- professional who tests one’s ability to tion, your SLP will help you to adapt to breathe and designs a personalized any problems with swallowing or eating. breathing program. Subacute rehabilitation (p.13): Skilled nursing facility (SNF) (p.13): Rehabilitation services that include A facility that provides patients with a daily nursing services, supervision by a high level of nursing care and meets rehabilitation doctor, and medical care certain industry accreditation standards. as needed. Subacute rehabilitation is less intensive and generally lasts longer Social worker: A professional who pro- than acute rehabilitation. vides services to help with the transition from an acute care setting to rehabilitation, and then back to the family and

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Therapeutic recreation: Therapy to Vocational rehabilitation: Services that regain as much independence as possi- help to figure out a person’s job ble in one’s leisure activities, pastimes, strengths, and provide guidance for and hobbies. A therapeutic recreation employment or education planning. A specialist will help you to evaluate vocational rehabilitation counselor your leisure needs, abilities, and inter- will help to determine your job strengths ests, and work with you to develop a and will provide guidance for employ- treatment program. Therapeutic recre- ment or education planning. He or she ation activities take place in both the will work with your current employer or rehabilitation facility and the communi- school and will help to make sure that ty. These activities are designed to help needed accommodations are made. you regain as much independence as A vocational rehabilitation counselor possible in your leisure pursuits. might also help you to look for new employment and may talk with specific Traditional health insurance (also employers about your employment. known as fee-for-service) (p.7): A type In addition, he or she will coordinate of health insurance plan in which a fee referrals to community-based job is charged for each health care service service and vocational rehabilitation received. The patient can freely choose programs. where to receive health care and rehabilitation services. The insurance plan covers a part of the cost of services after a set deductible amount is paid.

40 NRH Center for Health and Disability Research Quality Checklists Q U ALIT Y C HEC KLIS T S

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Quality Checklists

QUALITY CHECKLIST: MEETING YOUR PERSONAL NEEDS Following are more examples of questions for you to ask as you look for a high-quality rehabilitation program. These questions relate to what you personally want in a rehabilitation program. These questions should be considered carefully, depending on your personal needs.

Yes No

Is the location of the rehabilitation program convenient to family members and friends who will visit you?

Are the visiting hours convenient for your family and friends?

Does the program ask patients and family members how satisfied they are with the services and care they received?

If so, are the satisfaction data available?

Is the feedback positive?

Is the program covered by your health insurance plan?

If the program isn’t covered by your health insurance plan, will your plan cover any of the costs of the program?

OTHER QUESTIONS TO CONSIDER:

What is the program’s average length of stay for people with your condition? ______days

What percentage of people with your condition return to their homes after being discharged (as opposed to being discharged to a nursing home)? ______%

What is the overall patient satisfaction rating? ______%

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QUALITY CHECKLIST: MEETING INDUSTRY STANDARDS Below are some examples of questions for you to ask as you look for a high-quality rehabilitation program that best meets your needs. These questions are based on quality standards within the rehabilitation industry.

Yes No

Is the program or hospital accredited by CARF?

Is the program or hospital accredited by JCAHO?

Is the program certified by Medicare? (Programs certified by Medicare must meet minimum health and safety standards)

Has the program been in operation for at least 1 year?

Does the program have experience with your particular condition(s)?

Does the program have a system for checking both the clinical progress of its patients and its own internal quality?

FOR ACUTE REHABILITATION AND DAY TREATMENT PROGRAMS:

Does the program offer at least 3 hours of therapy per day, 5 days a week?

Does the program offer services such as physical therapy, occupational therapy, speech-language therapy, and psychology, depending on your individual needs?

FOR SUBACUTE PROGRAMS:

Does the program offer at least 1 hour of therapy per day, 1 to 6 days a week?

Does the program offer services such as physical therapy, occupational therapy, speech-language therapy, and psychology, depending on your individual needs?

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QUALITY CHECKLIST: MEETING STANDARDS OF EXCELLENCE Following are more examples of questions for you to ask as you look for a high-quality rehabilitation program. These questions are based on what makes an excellent rehabilitation program.

Yes No

Does the program have a relationship with other programs that offer rehabilitation services you may need at a later point in time (such as subacute care, day treatment, outpatient treatment, or home care)?

Do the physicians who provide care in the program have a background in rehabilitation medicine or a rehabilitation-related specialty, such as neurology?

Does the program have a full-time physiatrist or rehabilitation specialist available for patients?

Is your personal physician or primary care provider permitted to visit you at this facility?

Does the program use a “team approach,” where the doctor, therapists, and other rehabilitation professionals work together and meet at regular intervals to talk about your progress?

Does the program hold “family conferences” to keep families involved and informed of your progress?

Does the program conduct home visits to make recommendations before discharging people who are returning home?

Does the program look at the progress of each patient by measuring his or her functional ability and level of independence in doing daily activities?

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46 NRH Center for Health and Disability Research Resources R ESOUR CES CHOOSING A HIGH-QUALITY MEDICAL REHABILITATION PROGRAM

American Academy of Physical Resources Medicine and Rehabilitation Following is a list of resources. You may (AAPM&R) find some of these to be useful as you http://www.aapmr.org/ gather information to help you to choose a 312-464-9700 quality rehabilitation program for your AAPM&R is a professional organization for specific needs. physiatrists. Its Web site includes a search- ABLEDATA able database that helps users to find http://www.abledata.com/ physical medicine and rehabilitation spe- 800-227-0216 cialists who are members of AAPM&R. TTY: 301-608-8912 American Congress of Rehabilitation ABLEDATA is a federally funded project Medicine (ACRM) that provides assistive technology infor- http://www.acrm.org mation, including product descriptions, an 317-915-2250 online library, other disability-related ACRM is a professional organization for resources, and a consumer forum. professionals who work in rehabilitation Administration on Aging (AoA) fields. Its mission is to promote the art, sci- U.S. Department of Health ence, and practice of rehabilitation care for and Human Services people with disabilities. The ACRM Web http://www.aoa.gov/ site includes resources and links to other 202-619-0724 organizations.

AoA is the federal focal point and advocate American Occupational Therapy agency for older persons and their con- Association (AOTA) cerns. It supports state and local commu- http://www.aota.org/ nity-based services, including home-deliv- 301-652-2682 ered meals, in-home assistance for elderly TTY: 800-377-8555 persons, transportation services, and AOTA is a professional organization for employment help. occupational therapy professionals. Its Web site provides consumers with general information about occupational therapy; tip sheets about health and disability issues, conditions, and daily living; resource listings; and a searchable directory of occupational therapy specialists.

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American Physical Therapy Arthritis Foundation Association (APTA) http://www.arthritis.org/ http://www.apta.org/ 800-283-7800 800-999-2782 The Arthritis Foundation is a national, TTY: 703-683-6748 non-profit organization that provides APTA offers consumers information about advocacy, programs, services, and physical therapy, including research, fit- research for the more than 100 types of ness guides, and an online directory of cer- arthritis and related conditions. tified therapists that is searchable by state Centers for Medicare and Medicaid and specialty. Services (CMS) American Speech-Language-Hearing U.S. Department of Health and Association (ASHA) Human Services http://www.asha.org/default.htm http://www.cms.gov 800-638-8255 (voice and TTY); 877-267-2323 8:30 a.m. to 5 p.m., Eastern Time TTY: 866-226-1819

ASHA provides callers with referrals to CMS is the federal government agency certified speech-language pathologists responsible for the Medicare and Medicaid and audiologists throughout the country. health insurance programs. CMS offers The association also helps consumers to information about Medicare and Medicaid find therapists who are bilingual or have coverage. special skills. CARF, the Rehabilitation American Therapeutic Recreation Accreditation Commission Association (ATRA) http://www.carf.org http://www.atra-tr.org/atra.htm 520-325-1044, voice and TTY 703-683-9420 CARF is an independent, not-for-profit The American Therapeutic Recreation organization that reviews and accredits Association (ATRA) is the largest, national rehabilitation facilities to help ensure high- membership organization representing quality care and the best possible out- the interests and needs of recreational comes. CARF’s Web site includes a list of therapists. accredited rehabilitation programs that can be searched by state and program type. Click on the “Search for a Provider” link from the home page.

50 NRH Center for Health and Disability Research CHOOSING A HIGH-QUALITY MEDICAL REHABILITATION PROGRAM

DisabilityInfo.gov Joint Commission on Accreditation of http://www.disabilityinfo.gov Healthcare Organizations (JCAHO) http://www.jcaho.org/qualitycheck/ DisabilityInfo.gov is a comprehensive fed- directry/directry.asp eral Web site of disability-related govern- 630-792-5000, 8 a.m. to 5 p.m., ment resources. It offers information about Central Time employment, housing, transportation, technology, and other topics. JCAHO looks at how well health care programs, including rehabilitation programs, Disability Resources meet standards of quality in care. JCAHO’s http://www.disabilityresources.org Web site includes the accreditation scores, Disability Resources is a nonprofit group or “status,” of rehabilitation and other that seeks to promote and improve aware- health care organizations. ness, availability, and accessibility of infor- Medical Rehabilitation Education mation to help people with disabilities live Foundation independently. Its Web site includes infor- 800-GET-REHAB (800-438-7342), mation about government agencies and 8 a.m. to 8 p.m. Eastern Time non-profit organizations, publications, TTY: 800-688-6167 databases, and online guides. The Medical Rehabilitation Education Independent Living Research Foundation provides information about Utilization (ILRU) the benefits of medical rehabilitation and http://www.ilru.org refers callers to rehabilitation providers 713-520-0232 nationwide. TTY: 713-520-5136 National Clearinghouse of ILRU is a national center for information, Rehabilitation Training Materials training, research, and technical assistance (NCRTM) in the area of independent living. Its Web http://www.nchrtm.okstate.edu site offers a national directory of independ- 800-223-5219 ent living centers and information about TTY: 405-744-2002 living independently with a disability. NCRTM is a federally funded clearinghouse that provides a variety of educational and training materials to the rehabilitation community. Its Web site offers links to other disability and rehabilitation-related sites.

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CHOOSING A HIGH-QUALITY MEDICAL REHABILITATION PROGRAM

National Institute on Disability and National Spinal Cord Injury Rehabilitation Research (NIDRR) Association (NSCIA) U.S. Department of Education http://www.spinalcord.org http://www.ed.gov/about/offices/list/ Toll-free helpline: 800-962-9629 osers/nidrr/index.html?src=mr The National Spinal Cord Injury 202-205-8134 Association is dedicated to improving the TTY: 202-205-4475 quality of life for individuals living with NIDRR provides leadership and support for spinal cord injury and disease and their research related to the rehabilitation of families. They strive to educate and people with disabilities. empower individuals with spinal cord injury and disease to maintain independ- National Multiple Sclerosis Society ence, health, and personal fulfillment. (NMSS) http://www.nmss.org National Stroke Association 1-800 FIGHT MS (1-800-344-4867) http://199.239.30.192/NationalStroke/ Default.htm The mission of the National Multiple 1-800-STROKES (1-800-787-6537) Sclerosis Society is to end the devastating effects of MS. The Society promotes The leading resource for stroke, the mis- research, education, and advocacy for the sion of the National Stroke Association is newley diagnosed and those living with to reduce the incidence and impact of MS over time. stroke, improve quality of care, and increase patient outcomes. They provide National Rehabilitation Information education, services and community-based Center (NARIC) activities in prevention, treatment, rehabil- http://www.naric.com itation and recovery. 800-346-2742 TTY: 301-495-5626 National Therapeutic Recreation Society NARIC is a federally funded library and http://www.nrpa.org information center concerned with disabil- 703-858-0784 ity and rehabilitation. It offers disability- related information, resources, and access The National Therapeutic Recreation to research findings. Society (NTRS) is an organization for those interested in the provision of therapeutic recreation services for people with disabilities. NTRS is a branch of the National Recreation and Park Association (NRPA).

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Nursing Home Compare mation on funded studies and research http://www.medicare.gov/nhcom- statistics. pare/home.asp Social Security Administration (SSA) 800-MEDICARE (800-633-4227) http://www.ssa.gov This Web site was created by the federal 800-772-1213, 7 a.m. to 7 p.m., Centers for Medicare and Medicaid onday - Friday Services (CMS), which runs the Medicare TTY: 1-800-325-0778, 7 a.m. to 7 p.m., and Medicaid programs. It helps con- Monday - Friday sumers to find nursing homes in specific SSA offers information about Social geographic areas. Security Disability Insurance (SSDI) and Office of Disability Employment other benefits that persons with disabilities Policy (ODEP) may be eligible for. SSA’s Web site includes U.S. Department of Labor contact information and Web sites for http://www.dol.gov/odep/ state rehabilitation services departments 866-633-7365 or vocational rehabilitation offices at TTY: 877-889-5627 http://www.ssa.gov/disability

ODEP works to increase employment State Vocational Rehabilitation opportunities for adults and youth with Services Departments disabilities. Its Web site includes facts These individual state departments will sheets and other publications about have helpful information on state pro- employment of persons with disabilities, grams for people with disabilities, as well links to employers that wish to hire per- as job and rehabilitation information. Each sons with disabilities, and information state will offer different services and about employment-related programs. resources. Following is a list of the contact Rehabilitative Services information for each of the 50 states and Administration (RSA) the District of Columbia: U.S. Department of Education Alabama http://www.ed.gov/about/offices/list/ http://www.rehab.state.al.us osers/rsa/index.html 800-441-7607 202-205-5482 Alaska RSA oversees programs that help people http://www.labor.state.ak.us/dvr/ with disabilities live independently by pro- home.htm viding counseling, job training, and other 800-478-2815 services. The RSA Web site includes infor-

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Arizona Georgia http://www.de.state.az.us/rsa/ http://www.vocrehabga.org/ default.asp 404-232-3910 602-542-3332 TTY: 404-232-3911 TTY: 602-542-6049 Hawaii Arkansas http://www.state.hi.us/dhs/ http://www.arsinfo.net/index.html 808-692-7722 501-296-1600 Idaho TTY: 501-296-1669 http://www2.state.id.us/idvr/ California 208-334-3390 http://www.rehab.cahwnet.gov/ Illinois 916-263-8981 http://www.dhs.state.il.us/ors/ TTY: 916-263-7477 800-843-6154 Colorado TTY: 800-447-6404 http://www.cdhs.state.co.us/ods/dvr/ Indiana ods_dvr1.html http://www.state.in.us/fssa/ 303-866-4150 servicedisabl/ Connecticut 317-232-1252 http://www.brs.state.ct.us/index.html Iowa 800-537-2549 http://www.dvrs.state.ia.us/ TTY: 860-424-4839 515-281-4211 (voice and TTY) Delaware Kansas http://www.delawareworks.com/ http://www.srskansas.org/rehab/ divisions/dvr/welcome.htm index.htm 302-761-8275 888-369-4777 TTY: 302-761-6611 Relay: 800-766-3777 District of Columbia Kentucky http://dhs.dc.gov/info/rehabservices. http://www.glasgowbarren.com/ shtm glas_acc/vrehab/pages/reachus.htm 202-442-8400 502-651-5147 TTY: 202-442-8600 Louisiana Florida http://www.dss.state.la.us/offlrs/index. http://www.rehabworks.org/ htm 800-451-4327 (voice and TTY) 800-737-2958

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Maine Nebraska http://www.state.me.us/rehab/ http://www.vocrehab.state.ne.us/ 800-698-4440 402-471-3644 TTY: 888-755-0023 Nevada Maryland http://detr.state.nv.us/rehab/index.htm http://www.dors.state.md.us/ 775-684-4040 888-554-0334 TTY: 775-684-8400

Massachusetts New Hampshire http://www.state.ma.us/mrc/ http://www.ed.state.nh.us/VR/ 800-245-6543 (voice and TTY) 800-299-1647 TTY: 603-271-3471 Michigan http://www.michigan.gov/mdcd/0, New Jersey 1607,7-122-25392—-,00.html http://www.state.nj.us/ 866-MY-GOALS humanservices/disable/index.html 888-285-3036 Minnesota http://www.mnwfc.org/programs/ New Mexico vorehab.htm http://www.dvrgetsjobs.com/Public/ 800-328-9095 Index.asp TTY: 800-657-3973 877-475-8226 (voice and TTY)

Mississippi New York http://www.mdrs.state.ms.us http://www.vesid.nysed.gov/ 800-962-2230 800-222-JOBS(5627)

Missouri North Carolina http://www.vr.dese.state.mo.us/vr/co/ http://dvr.dhhs.state.nc.us/ VRWeb site.nsf 919-855-3500 877-222-8963 North Dakota TTY: 573-751-0881 http://lnotes.state.nd.us/dhs/dhsweb. Montana nsf/ServicePages/DisabilityServices http://www.dphhs.state.mt.us/dsd/ 800-755-8529 govt_programs/vrp/ TTY: 701-328-8968 877-296-1197 Ohio TTY: 406-444-2590 http://www.state.oh.us/rsc/ 614-438-1200 (voice and TTY)

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Oklahoma Vermont http://www.okrehab.org/ http://www.vocrehabvermont.org/ 800-845-8476 866-VRWORKS (866-879-6757) (voice and TTY) Oregon http://www.dhs.state.or.us/disabilities/ Virginia 503-945-5944 http://www.vadrs.org/ TTY: 503-947-5330 800-552-5019 (voice and TTY)

Pennsylvania Washington 800-442-6351 http://www1.dshs.wa.gov/dvr/ http://www.dli.state.pa.us/landi/cwp/ 800-637-5627 (voice and TTY) view.asp?a=195&Q=68442&landiRNav West Virginia radC6865=|&landiRNavradC1381=| http://www.wvdrs.org/ TTY: 800-233-3008 800-642-8207 Rhode Island Wisconsin http://www.ors.state.ri.us/ http://www.dwd.state.wi.us/dvr/ 401-421-7005 800-442-3477 TTY: 401-421-7016 TTY: 888-877-5939 South Carolina Wyoming http://www.scvrd.net/scvrinfo.htm http://dwsweb.state.wy.us/vr.asp 803-896-6500 307-777-7389 South Dakota http://www.state.sd.us/dhs/drs/ United Cerebral Palsy (UCP) 605-773-3195 http://www.ucp.org/ Tennessee 800-872-5827 http://www.state.tn.us/humanserv/ TTY: 202-973-7197 VRServices.html The United Cerebral Palsy is the leading 615-313-4714 (voice and TTY) source of information for individuals with Texas cerebral palsy. They advocate for the http://www.rehab.state.tx.us/index.html rights of persons with disabilities and 800-628-5115 strive to advance the independence and productivity of people with disabilities. Utah http://www.usor.utah.gov 800-473-7530

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Center for Health & Disability Research 102 Irving Street, NW Washington, DC 20010-2949 www.nrhchdr.org