Acute inpatient rehab (IRF)
- Needs multiple disciplines; one must be PT or OT
- Intensive therapy: about 3 hours a day, 5 days a week
- Able to participate and expected to make measurable gains
- Rehab physician visits at least 3 days a week
Design proposal · Clinical communication
Speak MD
How to frame a rehab discharge recommendation in the language hospitalists use, so the physician backs it and the therapy note gives the payer what it needs to approve it.
- Audience
- Acute care OTs and PTs
- Setting
- Interdisciplinary rounds, therapy notes
- Format
- Training guide + pocket card
- Pairs with
- MNCR rounds, IRF vs. SNF card
The problem
Good recommendations get lost in translation
Therapists see things on the unit that physicians don't: how a patient stands, how far they walk before their oxygen drops, whether they can dress themselves. That makes our discharge recommendation one of the most useful inputs on rounds.
But we often report it the way we document it, in assist levels, FIM-style detail and treatment narrative. A hospitalist with fifteen patients is listening for something else: where is this patient going, why, what's in the way, and what do you need from me?
When the recommendation doesn't answer those questions, it gets skipped or overridden, and the IRF referral starts late or never starts. When the note behind it is vague, the payer denies it.
The project · Speak MD
The approach
Lead with the decision, then earn it
Physicians present cases bottom line first. Speak MD gives therapists the same four-part order, in about 20 seconds.
1 · Bottom line
Where they should go
Say the recommendation first: IRF, SNF, home health or home with outpatient.
"Recommend acute inpatient rehab."
2 · Because
Why, in their terms
Diagnosis, current function vs. prior level, and tolerance for therapy.
"L CVA, mod assist ADLs, was independent and driving 2 weeks ago, tolerating 2+ hrs."
3 · Barriers
What's in the way
The one or two things blocking discharge or progress, medical or functional.
"Orthostatic on standing; spouse can't provide physical assist."
4 · The ask
What you need from them
A specific order, consult or clearance, so the next step has an owner.
"Can we get a PM&R consult and IRF referral today?"
Phrasebook
Therapy language, physician language
The clinical content stays the same. What changes is what it means for the medical plan and the discharge.
| How we often say it | What the hospitalist hears clearly |
|---|---|
| "Patient is mod A x1 for sit-to-stand and min A for toilet transfers." | Not safe to go home alone yet. Needs hands-on help of one person to stand and use the toilet. |
| "Patient tolerated treatment well." | Tolerated 45 minutes of active therapy with two seated rests; SpO2 stayed above 92% on 2 L. |
| "Pt is progressing toward goals." | Went from max to mod assist for lower-body dressing in 3 days. On track for IRF-level gains. |
| "Patient would benefit from continued skilled therapy." | Recommend IRF. Needs PT, OT and speech daily, and can do 3 hours a day. |
| "HR increased to 138 during ambulation, session terminated." | Tachycardic to 138 walking 20 feet. That's limiting mobility. Is this expected, or do you want to work it up before we push? |
| "Patient lives in a 2-story home with 12 STE, B rails." | Bedroom is upstairs, 12 steps. Can't do stairs yet, which rules out going straight home. |
Example at rounds
The same patient, said two ways
Before
"So I saw her yesterday, she was mod A for bed mobility, max A for lower body dressing, she did sit-to-stand with mod A and a rolling walker, she was a little impulsive, we worked on sitting balance, and I think she'd benefit from rehab."
After · Speak MD
"Recommend IRF. Left MCA stroke, mod to max assist for ADLs and transfers, but she was independent and still working two weeks ago, and she tolerated over two hours of therapy yesterday. Barrier is impulsivity, so she can't be alone. Can we get a PM&R consult and start the referral today?"
The second version is shorter and gives the physician everything needed to agree: the setting, the reason it qualifies, the safety issue and a concrete next step.
Backed by the payer, too
What the note has to show for IRF approval
A physician who agrees still needs a therapy note that supports the referral. Medicare Advantage and commercial plans usually require prior authorization, and the decision often rests on what we wrote.
Every IRF-bound note should show
- PT and OT needs, plus a third discipline such as speech where it applies
- Tolerance for about 3 hours of therapy a day, with what you observed
- Measurable progress or clear potential: assist levels, trends and timed goals
- A high prior level of function and a realistic plan to return home
- Medical needs that call for close rehab physician oversight
Weak vs. strong wording
Patient tolerated treatment well.Completed 50 min of active therapy with 2 rest breaks; vitals stable.
Making progress.Toilet transfers improved from max to min assist over 4 sessions.
Would benefit from rehab.Requires daily PT, OT and SLP; goal of supervision for ADLs in 2 weeks to return home with spouse.
Subacute rehab (SNF)
- Traditional Medicare: 3 inpatient days first; observation days don't count
- Daily skilled nursing or therapy 5 days a week
- Improvement isn't required; maintaining function can be covered
- Often the right fit when 3 hours a day isn't realistic yet
Criteria summarized for traditional Medicare from CMS IRF guidance (42 CFR 412.622) and SNF coverage rules. Check current CMS guidance and each payer's criteria before using in practice.
Deliverable
Pocket card for rounds
A badge-sized card therapists can glance at before speaking. It fits behind an ID badge.
Speak MDRounds · 20 sec
- 1Bottom line. IRF, SNF, HH or home.
- 2Because. Dx, function now vs. PLOF, therapy tolerance.
- 3Barriers. One or two. Medical or functional.
- 4The ask. Consult, order, clearance, referral.
"Recommend IRF. L CVA, mod A ADLs, indep 2 wks ago, tolerating 2+ hrs. Barrier: impulsivity. Need PM&R consult + referral today."
Result
How a pilot would be measured
These are the measures planned for a one-unit pilot.
- Recommendation followedShare of rehab recommendations the physician acts on
- Time to referralHours from therapy evaluation to IRF referral sent
- Authorization denialsIRF denials citing insufficient documentation
- Rounds timeSeconds per patient for the rehab update