Getting Started in Acute Inpatient Rehabilitation

In acute inpatient rehabilitation, an interdisciplinary treatment team works closely together to assist individuals in reaching their goals for achieving the highest possible quality of life, whether it be in work, school, recreational, or daily living activities. Speech-language pathologists in this setting have expertise in evaluating and treating individuals with communication and swallowing problems resulting from stroke, brain injury and other neurologic conditions. Because of the intensive nature of the rehabilitation, patients frequently receive group treatment in addition to daily individual treatment. Many hospitals also provide rehabilitation services on the weekend.

Patient Demographics

The following information comes from the National Outcomes Measurement System (NOMS) data collected by ASHA members across the country.

Age range of rehabilitation patients

30-49 years: 12%
50-59 years: 13%
60-69 years: 19%
70-79 years: 28%
80 years and older: 23%

Top 5 primary medical diagnoses of rehab patients

CVA: 50%
Head injury: 10%
Hemorrhage/injury: 7%
Respiratory diseases: 6%
CNS diseases: 3%

Top 5 Functional Communication Measures scored by SLPs working in rehabilitation hospitals

Memory: 51%
Swallowing: 46%
Spoken Language Comprehension: 38%
Spoken Language Expression: 36%
Attention: 32%

Average length of stay for rehab patients

20 days

Reimbursement mechanism

Generally, a third party payer covers the cost of acute rehabilitation services, although coverage varies widely from policy to policy. Inpatient rehabilitation facilities (IRFs) are under a prospective payment system (PPS) which applies to patients who have Medicare as a primary payer. There are 4 other types of reimbursements common in IRFs: Medicaid, fee-for-service, managed care and workers compensation.

Medicare Prospective Payment Systems: A Summary

Impact of reimbursement system on clinician

After an individual is admitted to an acute rehabilitation setting, the length of time that they stay in that setting is determined by their ability to benefit from at least 3 hours per day of rehabilitation therapy (including physical therapy, occupational therapy, and speech-language pathology). Speech-language pathologists participate with the treatment team in this decision-making by conducting functional communication and swallowing evaluations and setting measurable, functional long and short-term goals.

Referral process

Individuals are referred for communication or swallowing evaluation by their attending physicians. In most settings, a physician's order is required for continued treatment.

Collaboration with other disciplines

Speech-language pathologists work in conjunction with the entire interdisciplinary rehabilitation team. This team consists of the patient, family, physicians, nurses, physical therapists, occupational therapists, psychologists, dietitians, recreation therapists, music therapists, vocational rehabilitation counselors, and social workers/case managers.

Rehabilitation professionals work collaboratively, formulating goals that can be supported by other members of the treatment team. They often coordinate the team treatment plan through weekly team meetings. In addition, two disciplines may co-treat a patient. This involves addressing different yet complementary goals in the same treatment session, often resulting in an outcome that surpasses single-discipline treatment.

Documentation Requirements

Speech-language pathologists working in acute rehabilitation settings are required to document services in a medical record. Initial evaluations are conducted over a period of days, with subsequent progress documentation on at least a weekly basis. A discharge summary assists with continued care/continuity of patient care as the patient transitions to the next level of care (e.g., outpatient treatment, home health services).

Acute rehabilitation hospitals treating patients under Medicare are required to complete the IRF PAI (Inpatient Rehabilitation Facility Patient Assessment Instrument). Although speech-language pathologists do not complete this instrument, they may be asked to provide ratings for communication and swallowing items. The rating scales come from the Functional Independence Measure (FIM) scales, which are used to track functional outcomes. ASHA's Functional Communication Measures are scales that track SLP treatment outcomes in greater detail than FIM, but are not required.