Inpatient rehabilitation services at hospitals and freestanding facilities in Georgia are facing two crucial Medicare rule changes that could directly impact patient care.

The rule changes proposed by the Centers for Medicare and Medicaid Services (CMS), the federal organization that administers Medicare, would limit the type of Medicare patients who could be accepted in these facilities. The rules would be implemented by Blue Cross/Blue Shield, the company that contracts with the Medicare program in Georgia, Alabama, Tennessee, New Jersey, North Carolina and Pennsylvania.

To further complicate matters, the rule changes are occurring as CMS tries to modify its existing patient critieria, known as the "75 percent rule," which restricts the types of patients who can be admitted into rehab facilities.

Currently, patients with conditions such as hip fractures, amputations, stroke, brain injury, spinal cord injury and other neurological problems are moved to a rehab unit with a physician's order. There, these patients are usually cared for by a multi-disciplinary team, consisting of a rehab nurse, occupational therapist, physical therapist, speech and language pathologist, neuropsychologist and a physician specializing in physical medicine and rehabilitation.

Current Medicare rules require at least three hours of therapy a day, and patients will usually spend between two and four weeks with this regimen. The rehab team works with the patient to set goals to restore function, return them to the community and improve their quality of life.

That would change under both revised rules. Called the Local Medical Review Policy (LMRP), the new rule would send these same patients either directly to a nursing home or to their own homes for care. The new rules would impact all 50 of Georgia's rehab facilities, as well as those in other states.

At Kennestone Hospital, for example, almost all Medicare patients use the inpatient rehab facilities - and nearly 80 percent would be excluded under the revised rules.

"When we determine who comes into rehab, we have been following a Medicare section 211 hospital manual [for 20 years] to see if [patients] meet the critieria," said Dr. Vimala Nair, medical director for rehabilitation services at Kennestone Hospital. "What they are proposing is that 80 percent of the patients that we now accept do not meet the [new] critieria."

Tabitha Rautenstrauch, program director for The Center For Rehabilitation Medicine at Piedmont Hospital (CRM) has been lobbying against the changes, working with various professional organizations, including the American Hospital Association.

Advances in medicine and best practices in the past 20 years have significantly improved patient outcome, she explained. And often it's not a single diagnosis that qualifies a patient for rehab, but several factors.

"Specific criteria using section 211 criteria," are already being used to assure that patients who are admitted benefit from their rehab stay, she said. Results are documented, she added.

"We have found that 89 percent of our patients at CRM return to the community," Rautenstrauch said.

Updating the 75 percent rule - and the LMRP - makes sense, said Karen Waters of the Georgia Hospital Association. The GHA is another organization that has been actively lobbying Congress to take another look at the changes before they are enacted.

The GHA is working with Blue Cross/Blue Shield to revise the new regulations, so they more accurately reflect best practices in rehab medicine.

"We would like to send the whole issue to the Institute of Medicine," said Waters, vice president of professional services for the organization.

"We need to be able to evaluate those people who definitely have the ability to improve and function and return home, and put them in an intensive therapy program, so when they finish, they're home - and don't have to go back to an acute-care setting," Waters said.

"Many of these patients aren't sick enough to stay in the acute-care hospital, but need the services of the rehab facility to function in daily life," Kennestone's Nair said.

"If they remain in the hospital, the patients will get some therapy - an occupational therapist or physical therapist may be able to spend about 15 to 30 minutes with them at the bedside. But most of these patients benefit from at least three hours of therapy a day for several weeks in order to gain functional abilities."

Medical literature suggests that patients who are discharged without participating in a rehab program often fall prey to a variety of complications that can lead to hospital readmission.

"Most of these patients are very medically complex and 24-hour rehab nursing is important here, because they aren't well enough to go home yet," Nair said.

For information, contact Rautenstrauch at tabitha.rautenstrauch@piedmont.org.