Chip Kahn (00:11):
Hello, and welcome to another episode of Hospitals in Focus. I’m your host, Chip Kahn. Today we’ll be exploring the right dose of rehabilitation services, and what happens after someone leaves an acute care hospital setting. We have the perfect guest for this topic, Dr. Richard Senelick of Encompass Health.

Encompass Health has rehabilitation hospitals across the country. The patients that have gone to rehab know all too well the wonderful services they provide, bur for most, there probably isn’t a clear understanding of the role of these facilities versus other settings in that period of rehabilitation after a person has left the acute care hospital setting. We will dive into this subject today. Let’s get started by welcoming our guest, Dr. Richard Senelick.

Dr. Richard Senelick (01:00):
Thank you very much for having me. It’s always a pleasure.

Chip Kahn (01:03):
Great to have you, Richard, and I look forward to our conversation. To get started here, let’s talk about yourself a bit before we dig into Encompass Health and rehabilitation. What’s your background? How did you get to play the role that you do at Encompass Health in this organization?

Dr. Richard Senelick (01:26):
Well, asking a physician to speak about themselves is always dangerous there, Chip. I’m a neurologist who does neuro rehabilitation. So, I was doing general neurology here in San Antonio, Texas when I was approached to be medical director of a new rehabilitation hospital being built here. It’s 108 beds, particular in 1988, one of the largest rehabilitation hospitals around. Then what was Encompass Health previously had been Health South. So, they bought the hospital in 1993, and I’ve been medical director here since I’d say 1986.

Then we started a publishing company, which was Health [inaudible 00:02:10] Press, now Encompass Health Press, which I’ve been the editor. I always like to prove that paper doesn’t refuse ink. So, I’ve written many books for families, for the patients to try and educate them. That’s, aside from taking care of patients, which I’ve done for many years, my role has been to create educational material for therapists, for patients, for families, which has evolved over time from paper and pencil to internet webinars and that sort of thing.

Chip Kahn (02:41):
Great. That gives us a sense for you. I’ve at least given some introduction to Encompass Health itself, but can you give us a sense when we say rehab, and talk about rehabilitation hospitals, about the role that you play for patients? Obviously, when we talk about rehab, people think about injured athletes recovering from knee surgery or arm surgery or baseball players recovering from a sore elbow. But frankly for seniors and those who receive surgeries or other kinds of care. I think there’s a lot more to rehab than most people think.

Dr. Richard Senelick (03:24):
I think we fall in that category of things that you think are never going to happen to you, strokes, brain injuries, spinal cord injuries, amputees. If I’m lecturing to a large group of people, I can ask the women, raise your hand if you worry or think you might get breast cancer, and everybody’s going to raise their hand. If you ask, do you think you’re going to get a stroke, do you think you’re going to need physical rehabilitation, virtually nobody raise their hands. It’s a black box to people.

One of the things about rehabilitation, the thing we had to overcome for, I mean I’ve been doing this for a long time, for decades, is people think drug and alcohol, not just sports rehabilitation. So when you say, “Rehab, I’m going to rehab,” they think you’re going to Betty Ford for that. It’s a black box and it’s a problem because what goes on in the acute care hospital, somebody has a stroke or a brain injury and spinal cord injury, the doctors and the nurses there and the case managers really don’t know what goes on in a rehabilitation hospital. Don’t understand its complexity and may not even have a relationship directly with the physicians there, like you do. I did acute neurology for many years. You knew all the people you were working with. So, it’s a different environment. This is a great opportunity because we’re trying to educate people as to what actually does go on and does it make a difference where you send your patient.

Chip Kahn (04:52):
In this idea of the difference where you send your patient, particularly with seniors on Medicare, they may not have a clear notion of the difference between the rehab facility, the skilled nursing facility, and the home health. And each for rehab services represents a different level of service. Can you give us some sense as to the differentiation and how you begin to help work through with patients and their hospital providers what kind of settings them should be in post hospital care?

Dr. Richard Senelick (05:29):
One of the things I ask people to do, I don’t know how many, it was a decade ago or two decades ago, almost seemed like overnight every nursing home changed its sign to ABC Rehabilitation Center, so that if you drive around your community, you won’t see the ABC Center for the Ager or the ABC Nursing Home. They’re all changed to rehabilitation facilities, but what actually takes place between a rehabilitation hospital and skilled nursing facility is dramatic. One of the things

I think we all recognize as physicians, people working in hospitals, is that the patients coming to us to rehabilitation, or at least let’s put it discharged from the acute care hospital are being discharged sooner. The plan is how fast can I get you out of the hospital. And as a result, those patients are sicker and in need of more care. So if anything, it amplifies the difference between an in-patient rehabilitation hospital and a skilled nursing facility because now you have a patient who has left the acute care hospital much sicker, needing a higher level of physician care and a higher level of nursing care.

Chip Kahn (06:43):
Can you illustrate for us how we can visualize the difference between being in a rehabilitation hospital like those that Encompass Health have across the country or being in one of these skilled nursing facilities, whatever their labeled, whether it’s rehabilitation center or a nursing home, and then a home health in terms of having therapists come out to the home?

What’s the experience for a patient that’s really different that will help our audience understand and visualize the difference?

Dr. Richard Senelick (07:19):
Well, I think one of the best ways, let’s take a specific patient. Assume you are the family member, and you have your loved one had a stroke. What would be the difference? They are sick, still need their diabetes, their hypertension managed. They may need a lot of assistance. Well, rehabilitation uses the word hospital because it is indeed a hospital. It is staffed round the clock 24/7 by registered nurses, many of whom are certified in rehabilitation, as opposed to a skilled nursing facility that only needs to have an RN on eight hours a day, and the rest is LVNs and a much lower staffing ratio. In a rehabilitation hospital, just like an acute care hospital, you’ll have the requirement of seeing a physician on a regular basis with that whole armamentarium or team of specialists, as opposed to a skilled nursing facility, where there is no specific requirement that the physician visit personally on any given number of times. It could be as little as once every 30 days, maybe twice a week. So, the differences there are great.

The other would be as when you think about dose. When we take an antibiotic or a medicine for hypertension, there’s a specific dose. So, think as something as simple as strep throat. You take penicillin for 10 days so you don’t get rheumatic fever. Now assume that we know in a rehabilitation hospital, you must get at least three hours of therapy a day. In a skilled nursing facility, you may get 30 minutes, an hour, if you’re lucky an hour and a half. So, if you had a problem and you had hospital A and hospital B, would you go to the one that gives you the full dose of medicine or would you go to the one that only gives you the half of a dose or a third of a dose? I think put in that setting, it’s
pretty clear cut.

Chip Kahn (09:21):
Richard, I’m sure in your experience that there were patients that would come to the rehabilitation hospital who you said, “Gee, they can’t possibly get better, but we’ll try.” Can you give us some examples or an example of when you experienced that and what was the outcome?

Dr. Richard Senelick (09:41)
I think one of the … This just exemplifies one of the dangers of pre-authorization in rehabilitation and trying to make that judgment at a very early stage in the acute care setting. One of the examples I like to use is when I first started doing rehabilitation and neuro rehab, and my neurologist partners who would make rounds on the weekend when I wasn’t on call, and one time my partner Mike, he hadn’t seen this patient in about three weeks. He came and he called me up and he says, “Richard, I didn’t know these people got better.” It was, this is what happens. They’re seen in the acute care, so as general neurologists we would see a stroke patient, a brain injured patient, Guillain-Barre, take your choice. You say, “Oh they’re terrible. I mean, they’re not going to get better.” Then lo and behold with rehabilitation, I mean it’s like watching grandchildren grow. If you see them every day, they don’t grow. If you see them once every six months, it’s like, “Oh my god, how did you get so big?” This is what happens in rehabilitation.

To try and make that decision upfront and make that prediction that someone isn’t going to get better isn’t fair to the patient because lo and behold, every day we see people get better, return home to their families, and give those grandkids a big hug.

Chip Kahn (11:05):
So clearly from our discussion, this issue of intensity is defining for the various levels of rehab and setting. One of the recent studies that we saw from the Health and Human Services’ office of inspector general said that we were sending too many patients to rehab hospitals, and called for some kind of system where acute care hospitals would have to get prior authorization on patients who were on Medicare to go to a rehab hospital. My concern with this, and I guess my question is, the care that you get in rehab hospital obviously is partly defined by intensity. The other aspect of it is how important is it in terms of speed that we get a patient who is stable, either from a stroke of from concluding some surgery, and get them into rehab in terms of their overall recovery time, and also for us to anticipate that their recovery will be a more full one? How important is that time factor?

Dr. Richard Senelick (12:22):
Well I think the time factor is important, and particularly depending on where that patient goes because I’ve been doing this for a very long time, and I have always been told, let’s say the decision is made to send the patient to a skilled nursing facility with the idea that, oh you know when they get better we’ll send them to you for rehab. It really doesn’t happen. Once a person gets sent down a path, that path continues. So, it becomes a self-fulfilling prophecy, or a glass ceiling. If you decide, I don’t think this patient really needs this level of care, we’re going to give them a lower level of care. If they get the lower level of care, they’re not going to reach that point. They’re going to reach a glass ceiling. The studies have clearly been done that those patients that go directly to rehabilitation hospitals have better outcomes, they’re less likely to be readmitted to an acute care hospital, and they’re more likely to return home to the community, to their family, and to their loved ones.

So, the problem with pre-authorization is you have somebody on paper trying to make a decision which is already a very complex system. We already carefully screen patients. A physician is involved. A rehabilitation physician has to sign off that that patient is an appropriate candidate for rehabilitation. And it’s already a cumbersome process that with pre- authorization would really, I mean it would deny many patients who need this service. You can look backwards and say, “You know what, see. That patient didn’t get better. I told you they weren’t going to get better.” And it’s a self-fulfilling prophecy. If you don’t deliver the care, they’re not going to get better.

Chip Kahn (14:08):
Let’s do a deeper dive here on the physician and the discharge planner in an acute care hospital that’s going to sign off on a patient, what are the kinds of criteria, let’s say for a stroke patient or for someone with an orthopedic procedure, that are going to help determine whether they should go from their best judgment of these professionals to a rehabilitation hospital versus one of these other settings?

Dr. Richard Senelick (14:35):
There are clear cut medical necessity criteria that have to be met. One of them is that you need to see a rehabilitation physician at least three times a week. There’s a medical necessity that you need a multidisciplinary team. That you’re in need of these therapists, PT, OT, speech. That you can tolerate three hours of therapy a day. But we can spread it out over seven days. We have to have 15 hours, but you can spread it out over seven days until a patient can tolerate it. What has concerned me as the years have gone on is that these decisions are made upstream so that a case manager in an acute care hospital, a therapist in an acute care hospital makes the decision that they don’t think the patient can tolerate it, as opposed to rehabilitation physicians and those of us looking at the patient and saying, “You know, we think they can.”

So the question is, if you put in pre-authorization and now somebody else makes a decision that they don’t think they can tolerate it, you’ve really denied the patient that care.

Chip Kahn (15:44):
Can we visualize the day for a patient, particularly in terms of let’s take one of these intense days where they’re going to do therapy? For our audience, could you describe what the patient will go through? They get up in the morning and it’s time for therapy. What happens that’s unique in some ways too in Encompass Health kind of setting?

Dr. Richard Senelick (16:07):
I’m going to do an introduction of that with just a real little preface. That’s when somebody looks at a patient in the acute care hospital and they’re in a hospital gown or their pajamas and they’ve had a gazillion tests and they’re exhausted and they’re tired, they may look like they’re not motivated or they won’t tolerate this intensity of services, but you have to remember the environment they’re in. When we transfer them to the acute care setting, the first thing we do, and I’ve had many physicians say to me over the years, they say, “Richard, when I come see my patient at your hospitals, they look so much better.” I said, “Well yes, we put clothes on them.”

One of the things is that patients get up in the morning. They have an occupational therapist usually working with them on what are called activities of daily living, learning how to dress. If you have a paralyzed arm, you’re going to act that differently. How do you do one-handed shoe tying? Eating. How to use a rocker knife. How to use utensils. You may be in a feeding group with people with like problems or impairments, being supervised by an OT or a speech and language pathologist. A dietician will meet with you to decide on the consistencies of your food and the type of food. This is all taking place early in the morning, before maybe the first so-called official therapy session in a gym.

If a patient is brain injured and can’t tolerate a lot of stimulation, they may have bedside therapy or a satellite gym, a smaller gym with less noise and distraction. Then therapy can be broken up. Rather then thinking, “Oh we have three hours of continuous therapy. This is like going to the gym. I’m going to be exhausted.” Let’s break this up. Let’s have our 45 minutes of physical therapy. We’ll get back to the room. We’ll have a rest period. One of the things people forget is who’s spending 24/7 with that patient? It’s nursing. So, as opposed to an acute care hospital where nursing may be totally separated and segregated from the other players of the team, here it truly is a team process. So, the nurse carries over what you’re doing in therapy, so if the patient has to transfer a certain way from bed to chair.

So, it’s a model we use in rehabilitation. That’s help do, rather than do for. Think about it. Everybody’s in a hurry in the acute care hospital. Okay, we’ll get you out of bed. Come on, we’ve got to get you off the gurney. We’re going to move you to X-ray. Whereas there’s, I mean I look at our therapists and nurses, they’re the most patient people in the world. They help you do, trying to teach you how to either compensate for your deficit. I always say going to rehab’s like going to school. You re-learn old things you’ve forgotten or new ways of doing thing.

Chip Kahn (18:59):
Richard, how long with patients, how long for a stroke patient let’s say are we generally, and I know it’s hard to take all cases, but how long are we talking about in a length of stay? And when do you know in that process usually that you can break through with a patient in terms of their improvement?

Dr. Richard Senelick (19:24):
That’s an interesting question because that has changed drastically over the years. The amount of time that we can keep a patient has been reduced drastically during my career where we could keep a patient let’s say a month. Now your average length of stay may be 14 days. So you’re trying to get a lot done. It’s why it’s important that it continues as an outpatient, and home health has a very important role in continuing the therapy. So, it’s unfortunate that we can’t keep patients longer. A lot of studies have showed particularly older patients, patients with severe deficits benefit by staying longer. And it’s not unusual to have what’s called a team conference. Once a week, all the therapists and the nurse and the doctor get together to discuss the patient, and you’ll realize that, you know if I keep this patient three, four extra days, I can probably get them home because one of the things that takes place in a rehabilitation hospital, whether it’s a stroke patient, which is really common, or bladder and bowel programs where the highest correlations of self-esteem is being continent.

And these are things that don’t take place in a SNF or in an acute care hospital.

Chip Kahn (20:39):
We’ve covered a lot of territory here in terms of the uniqueness of the services provided by rehabilitation hospitals. As we close out, are there any other thoughts you think are important for our audience to understand in terms of what we have described I think in this discussion as the unique role of the rehabilitation hospital in the continuum of care for certain levels of patients?

Dr. Richard Senelick (21:06):
I mean a really important message particularly is that you have a choice. I think in today’s healthcare world, patients, families believe they don’t have a choice. We just go to the point where we don’t think we have to accept that, no this is where you’re going. It’s hard to become an informed consumer. You didn’t expect to have a stroke. Where do you go? What do you do? And now you’re told you’re going to a certain place. I think the key is to try and educate people. Physicians have become less involved. I think physicians are somewhat beaten down. We used to be strong advocates and get on the phone, talk to the insurance companies and say, “This patient really needs this.” I think that role has changed.

I mean, the message I would give physicians, you are one of the last lines of advocacy for your patient. You need to do that for them. And for patients and families, you have a choice. Get educated. It will make a difference.

Chip Kahn (22:09):
This has really been a great conversation, and one I know our listeners will find interesting. But if you want to hear more from Dr. Senelick, the good news is you can. He has a website, RichardSenelick.com. What will people find there, Richard, if they go to your website?

Dr. Richard Senelick (22:28):
Well, I would lead them to two websites. There’s my website, which will have the books I’ve written. They’re in audio book form free because we think that’s an important message to be given out. Lectures, webinars. But also at EncompassHealth.com, there’s Encompass Health Press. That’s our publishing company that I’m the editor of. There you will find a whole series of educational lectures. Also access to books for families and educational materials. So, our whole hope and role is to educate people about their disability so that they’re better able to handle it.

Chip Kahn (23:10):
Well, that sounds great. Thanks again, Richard, for joining us today. I hope that members of our audience will go to those sites and learn more about the role that rehabilitation plays in the critical rehab of patients in the United States. Thank you so much.

Dr. Richard Senelick (23:29):
Thank you for the opportunity.

Chip Kahn (23:31):
Thanks so much for listening to our podcast today. We hope you found this conversation interesting and will join us every other week as we talk with leaders on a broad spectrum of healthcare issues. Don’t forget to subscribe to Hospitals in Focus. We can be found on Apple podcasts, Google Play, and now Spotify. Be sure to rate and review us and tell a friend. Thanks for listening.

Dr. Richard Senelick, Encompass Health

Dr. Richard C. Senelick is a neurologist, author, speaker and teacher.

As the Editor in Chief of Encompass Health Press, the publishing arm of one of the nation’s largest hospital systems and the author of more than 15 nonfiction books, Dr. Senelick is one of the leading experts on neurorehabilitation.

His career has spanned over 40 years, taking him from his native Chicago, to Arizona, Utah and finally to Texas. He was raised in Chicago and received his medical degree from the University of Illinois College Of Medicine. After meeting his wife of 48 years, Anne, who was a forest ranger’s daughter, it was off to the Wasatch Front and the University of Utah for his residency in neurology and a bit of fly fishing training from his new bride.

His career then led him to the Air Force, where he served as a Major and staff neurologist at Wilford Hall Medical Center in San Antonio, TX.  Initially, there were no plans to settle so far from the mountains, but those clear Texas skies, friendly people and Mexican food won them over. They have been there ever since, living and working in San Antonio.

Although initially working in the field of neuro-ophthalmology, Dr. Senelick became dedicated to the lives of the disabled and the need to educate patients, families and lay people about their needs. He was the Medical Director of HealthSouth RIOSA, a 108-bed inpatient and outpatient rehabilitation hospital in San Antonio from its inception in 1986 until 2016.

Since taking on the role of Editor in Chief of Encompass Health Press, Dr. Senelick has been on a journey of advocacy and education for people with disabilities, which has led him to write numerous books, publish articles and speak on an international scale about the need to provide treatment, resources and respect to the disabled and their families.

Whether writing in San Antonio or in the peace of the Targhee National Forest in Idaho, Dr. Senelick’s focus is on educating patients, their families and lay people through his blogs, books and educational DVDs.