Greg Vigna, MD, JD: Rehab Options For The Spinal Cord Injured

03/27/2013 // Concord, CA, USA // LifeCare123 // Greg A. Vigna M.D., J.D. // (press release)

Medical Perspective:

A Model Spinal Cord Injury Systems Program, Inpatient Rehabilitation Facilities, Long-Term Acute Hospitals, and Skill Nursing Facilities are all potential discharge destinations for the acutely injured spinal cord patient. The benefits and draw backs of each will be discussed from the perspective of physiatrist who is a certified life care planner and attorney who trained at a Model Spinal Cord Injury Program (Texas Institute of Rehabilitation and Research), and has 15 years experience practicing in an acute inpatient rehabilitation hospital, long-term acute hospitals, and skill nursing facilities.

The Model Spinal Cord Injury System program, are government sponsored programs across the United States that have displayed a history of excellence in the field, providing educational activities to physicians, and dedicated research in the field of spinal cord injury. They are ‘innovative programs for the delivery of care and comprehensive medical, vocational, and other rehabilitation services to meet the needs of individuals with spinal cord injury.’ The Model System Centers work together to improve care and participate in research dedicated to improving the medical outcomes, decrease complications, and improve the functional outcomes of patients with spinal cord injury. These centers are truly multidisciplinary in scope in that the patient’s care is under the primary care of a physiatrist who oversees both the medical and the rehabilitation services provided to the patient. The physiatrist in these centers are generally leaders in the field who will be able to consult other medical specialists to meet the unique medical problems associated with spinal cord injuries which may include neuro-urology, plastic surgery, general surgery, orthopedic surgery, neurosurgery, pulmonary, and infectious disease specialists. From a rehabilitation services standpoint each patient will have rehabilitation nursing, rehabilitation case managers, physical and occupational therapy, recreational therapy, neuropsychology, vocational counselors, and clinical and counseling psychologists. A patient’s care plan will involve input from all of these disciplines and will allow both short term and long term goals to be outlined. A patient and their family will be trained and educated regarding all of the medical and rehabilitation aspects concerning the unique aspects of the patient’s spinal cord injury. After goals have been attained transition to home will be planned, equipment needs determined, outpatient rehabilitation recommendations will be made, and future educational and vocational assessments will be planned, and home renovation recommendations will be determined.

It is the author’s opinion that an acutely spinal cord injured patient will have significant advantages at a Model Spinal Cord Injury System program. From my experience at Texas Institute of Rehabilitation and Research, the benefits are apparent. At TIRR there is a floor that is dedicated to the care of spinal cord patients. The benefit of this is that there are both acutely and chronically injured spinal cord patients in the facility. Patients will see and meet other patients in various stages in their recovery as they battle for their own independence. This can be a great source of strength and motivation. Also, these patients will be under the care of physical and occupational therapists who have extensive experience in the treatment of spinal cord patients which will improve strength and mobility, and independence in self care. These therapists will be up to date in terms of the most appropriate equipment and assistive technologies available that can maximize independence. The facilities have drivers evaluation programs to enhance community independence and provide extensive education that is invaluable for families and patients. It is also of great benefit to the acutely spinal cord injured patient to be on a floor with patients who have spinal cord related problems that are avoidable with adequate self care such as decubitus ulcers and renal related problems. This experience should motivate a patient to be compliant in terms of managing their self care to prevent horrific preventable complications.

Inpatient Rehabilitation Facilities (IRF) are classified as acute hospitals that are either free standing or housed in an acute medical surgical hospital. They operate similarly to the Model Spinal Cord Injury System in that the care they provide is multidisciplinary under the direct supervision of a rehabilitation physician and individualized to the needs of the patient. Spinal cord injury is an approved diagnosis for admission as dictated by Medicare. Patients generally must be able to participate in three hours of therapy a day and must receive therapy from at least two disciplines such as physical and occupational therapy.

It is this author’s opinion that a spinal cord injured patient must be a knowledgeable consumer when it comes to being referred to such a facility because not all IRFs are created equal. Over the past ten years there has been increasing stress because of economic cuts by Medicare which has restricted access of Medicare beneficiaries to receive care at these facilities and decreased payments by Medicare for services provided. Increasingly these facilities have been forced to cut services such as psychological treatments, recreational therapy, and been forced to provide group therapy as opposed to individual therapy. Another disturbing trend is that physician care over the past decade has shifted from independent doctors to hospital employment doctors who are under ‘inherent pressure’ to refer a patient to a hospital owned in-house rehabilitation unit as opposed to other IRFs or Model Systems that provide superior care. Most IRFs will not have inpatient access to uroneurologist, plastic surgeons, and may not have support of orthopedic and neurosurgeons to meet the unique needs of a spinal cord injured patient. Also, clearly not all rehabilitation physicians are created equally, and without training in a Model System they may not have the experience to provide education and required care for a spinal cord injury. Finally, acute medical surgical hospitals discharge planning are increasingly being controlled by hospital employed case managers who are scrutinized regarding discharges that do not utilized hospital services.

Long-Term Acute Hospitals (LTAH) are acute hospitals that generally receive patients from medical surgical acute care hospitals with multiple medical problems requiring ongoing medical care for an extended period of time. The patients accepted to these facilities have a variety of problems including wound care, ventilator management, infectious disease problems that require prolonged IV antibiotics, and chronic cardiac and pulmonary conditions. These facilities generally have staffing that may or may not include a physiatrist.

It is this author’s opinion that LTAHs are not appropriate for the management of the acute spinal cord injured patient for several reasons. These facilities will generally lack the expertise to handle the unique medical needs, unique rehabilitation needs, and the education and psychologic need of an acutely injured spinal cord patient. They, however, do have advantages to IRFs in handling chronic medical problems that require lengthy hospitals such as decubitus ulcers and infections disease issues that require prolonged IV antibiotics, and chronic ventilator care in the spinal cord patient.

‘Skilled Nursing Facilities (SNF) are nursing homes which provides 24-hour skilled medical care for both acute and chronic conditions’ with services which include nursing care, physical and occupational therapy, and speech therapy. There are over 16,000 SNFs in the United States with and average age of admission at 79 years of age. Physician visits can be up to three times per week. There is generally physician over site, but patients care conference generally are not overseen by a physician.

It is the author’s opinion that a SNF is not an appropriate discharge disposition for an acute spinal cord patient. For an acutely injured spinal cord patient a SNF will more likely breed dependence on care givers rather than independence. Three physician visits a week is not adequate coverage for the multiple problems presented by a spinal cord injured patient and there will not be the therapy expertise to foster the attainment of functional goes that should be attainable based on the level of injury.

Life Care Planner Perspective:

A properly constructed life care plan will serve as a guide to future medical, rehabilitation, and day to day needs of a catastrophically injured patient. A life care planner’s primary role is an educator or the public and that role requires him to be objective in the evaluation of the needs of the patient, not looking at insurance issues, and provide a guide that is medically necessary and appropriate for the patient. The earlier that a life care planner is involved in a spinal cord patient the better. Generally, a spinal cord injured patient will only get one chance with acute rehabilitation and inadequate rehabilitation in terms of length of stay and quality of care can make a big difference in outcomes and decreasing complications in the future. A life care planner can evaluate the available scope of services, medical expertise, and outcomes available at community based IRF and educate the patient and the public regarding the value of referral to a Model Spinal Cord Injury Systems Program. Early involvement of a life care planner the greater chance that inappropriate referral to an ill equipped rehabilitation center can be avoided.

Lawyer Perspective:

A serious injury lawyer has an ethical obligation to provide diligent and competent representation to his client. Part of providing competent representation is ensuring that their client receives the benefit of the best available physicians and rehabilitation to optimize medical and functional outcomes. Of equal importance is to provide a medical foundation for the court of all future medical and rehabilitation, equipment needs, home renovations, vocational rehabilitation, need for aid and attendant care in the future, and future costs associated with aging with a spinal cord injury. These costs will likely be challenged by the defendant and the greater the expertise of the medical providers of the patient, the greater the weight the jurors will give it allowing for maximum money judgment. It should be remembered that in a catastrophic case that involves millions the defense will have their own experts. Treating physicians from a TBI Model System Program will likely be given greater weight by the jury because of their experience and research in the field of TBI compared to a ‘hired gun’ expert from the defense who likely has not examined or provided care to the client.

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