EnduraCare Acute Care Services

The public health emergency (PHE) created by the COVID-19 virus has had a significant impact on healthcare systems and has made evident the important role that post-acute care providers have in the continuum of patient care. Many acute care hospitals have been overwhelmed with patient volumes and the need to care for medically complex patients during various pandemic stages. Moving patients to an appropriate post-acute care provider has been critical to acute care hospitals in managing the patient volume surges and for the continued care of survivors of acute COVID infection. Many of these survivors have continued neurological, cardiovascular, pulmonary, and psychosocial issues that require a multidisciplinary management approach in a post-acute care setting. Inpatient rehabilitation facilities/units (IRFs/U’s) are well-positioned to provide this level of care.

Historically, skilled nursing facilities have comprised approximately 21 per cent of acute hospital patient discharges to post-acute care. During the pandemic, these referral patterns have shifted with acute care discharges to skilled nursing facilities having a decrease of more than 6 per cent. Many factors have contributed to this shift in referral patterns including the fear among patients to discharge to a skilled nursing facility. During the pandemic, many skilled nursing facilities were the epicentre of the COVID-19 outbreak with more than 200,000 deaths in nursing homes being contributed to COVID-19 in the first year of the PHE.

Residents of skilled nursing facilities are often frail elderly adults with multiple comorbidities which make them susceptible to the COVID-19 virus and because of this many skilled nursing facilities have been reluctant to admit survivors of acute COVID-19 infection for concern that these patients would transmit the infection to other residents in their facilities. This shift in acute care discharge referral patterns away from skilled nursing facilities and the need for the continued care of medically complex post-COVID-19 patients presented an opportunity for Inpatient rehabilitation facilities/units (IRFs/U) to increase their post-acute market share.

While skilled nursing facilities and IRF/U’s provide post-acute care to patients who have therapy needs there are some significant differences. An IRF/U level of care is in a hospital setting and patients admitted require an interdisciplinary care approach led by a physician. Patients admitted to an IRF/U also have intensive therapy needs which the Center for Medicare and Medicaid Services (CMS) has defined as three hours of therapy a day, five days out of a week (known as the 3-hour rule). Additional requirements by CMS to be classified as an IRF/U includes that 60 per cent (known as the 60 per cent rule) of all patients admitted must have a diagnosis or co-morbidity that falls within 13 diagnostic categories. In contrast, skilled nursing facilities do not have a requirement for the intensity of therapy or requirements to have certain diagnoses for admission.

During the PHE, IRF/U’s were granted waivers that allowed flexibility for patient admissions. Many managed care providers removed the prior authorization process for admission to IRF/U’s. This process has typically delayed admissions to IRF/U’s from acute care hospitals. The elimination of this process allowed acute care hospitals to admit patients to IRF/U’s without delays. This assisted the acute care hospitals in managing patient surges brought on by the PHE. There were three Federal waivers that assisted IRF/U’s in facilitating admissions. These included the relaxation of the 60 per cent rule, the allowance of acute care and rehab patients to be commingled in IRF/U’s, and the relaxation of the 3-hour rule. The first two waivers allowed acute care hospitals to move acute care patients to the IRF/U’s and accept patients that did not fall within the 60 per cent rule. The relaxation of the 3-hour rule allowed therapists to base the amount of therapy a patient receives in an IRF/U on patient need and not on a required amount of time.

The waivers granted for IRF/U’s created the need for these facilities to adapt their admission practices and assess their ability to care for medically acute care patients. Those facilities that were able to make these adjustments had an increase in admissions and were seen as a value-add service in providing capacity for acute care hospitals during patient surges. While many IRF/U’s admitted patients who were still deemed as having acute care need the per cent of admitted patients to IRF/U’s who were discharged to the community did not decrease. This suggests that IRF/U’s are capable of caring for patients earlier in their recovery process with a positive outcome of a discharge back to the community.

As we learn from the PHE, we should reassess the placement of patients within the post-acute care continuum. IRF/U’s have demonstrated their ability to care for patients with increasingly complex medical needs and have demonstrated their value in the post-acute care continuum.