Success from the Front Lines:  How One IRF Stepped to the Plate for a COVID Win

We rarely mention a specific client by name in our reports, however, we feel that the model represented here is one that IRFs should consider in dealing with the current Public Health Emergency and those that we may face in the future.  The information presented here is provided with the consent of Martin Beaulac, the Regional Director of Neurosciences & Rehabilitation Services at Henry Ford Macomb Hospital in Michigan. 

Faced with rising numbers of COVID cases within the hospital system, the hospital struggled to find adequate medical/surgical beds due to the challenges it had with discharging COVID patients.  With a strong desire to address the need for surge capacity and to meet patient needs for inpatient rehabilitation, Mr. Beaulac and his leadership and care team evaluated ways to keep the IRF open and provide much needed rehabilitation services while assisting the organization in meeting the needs of an influx of COVID patients and managing throughput to open acute beds as needed.  

While inpatient rehabilitation facilities (IRFs) across the nation have responded in varying ways – The IRF at Henry Ford Macomb Hospital created a model that resulted in wins across the board for patients, staff and the health system — a true “Grand Slam” for the team.

The model included some key components:  

• Isolated Space
• Reasonable Expectations for Staff
• Infection Control and Cleaning Practices
• Allowance for “Telephonic” Team Meetings

Isolated Space and Infection Control Practices
Initially, the organization identified a 9-bed wing on the IRF distinct-part unit that would be dedicated to patients with functional deficits recovering from COVID.  The program was so successful that a second 8-bed wing was added, allowing for treatment of 17 recovering COVID patients. 

Infection Control was instrumental in setting up the units, which were a combination of mostly private and some semi-private rooms.  Because all patients already were COVID positive, it was determined that the patients did not pose a risk to each other which allowed them to share a room.  The COVID wings were blocked off from regular traffic through closure of hallway doors, signage, restricted elevator access and physical barriers.  Patient room doors were kept closed at all times, except when the patient came out for therapy. 

A patient room was converted to allow for creation of a gym space so that patients could practice important activities of daily living including transfers, stair climbing and longer distance ambulation while limiting exposure to patients in rehabilitation for other diagnoses.  Unlike when the COVID patient was on the acute floor, when they came to the rehab unit, they were allowed to ambulate for short distances in the hallways, with staff ensuring that they did not stray beyond the space limited for this group.

Staff Expectations
The rehab staff participating in the early stages of the program were volunteers.  The key to staff feeling comfortable treating this population, according to Mr. Beaulac, was N-95 masks.  Due to their severely debilitated condition, the activities that these patients would do would often mobilize lung secretions and would result in frequent coughing by the patient.  With the proximity of the staff, it was imperative to provide them with the appropriate equipment to provide maximum protection of the staff.  In addition to the N-95 mask, all staff wore a face shield, gloves and gowns.  Once staff knew they would have the appropriate level of protection along with the flexibility to maintain a reasonable productivity, the team was on board. 

One side effect of wearing all the PPE was staff fatigue.  The heat generated by wearing the PPE made it difficult for staff to provide continual care, which required more frequent respites.  Since many of the patients needed rests as well, productivity expectations were reduced to allow for staff and patients to take breaks.  Staff were provided with appropriate PPE along with reduced productivity expectations due to the increased effort to don and doff protective equipment and to allow “staff recovery time” from the stress of dealing with critically ill patients. 

Staff worked in teams and were assigned only four patients per therapist per day with a goal of each patient receiving a minimum of two hours of intense therapy.  As the program progressed, not only did staff reach well beyond that expectation but, by dividing treatment times into smaller blocks and providing weekend therapy, patients received very close to the expected intensity of therapy in an IRF program. 

Cleaning
Dedicated cleaning staff worked throughout the day to assure all surfaces touched in the rehabilitation process were frequently cleaned following current infection control guidelines, reassuring patients and staff that safety was a critical concern for everyone.

A planned benefit of reducing productivity was it allowed time for staff to maintain the required cleanliness of the equipment that the patients touched.  All staff were responsible for cleaning any equipment that the patient touched to ensure safety for the patient.  When a patient vacated a room, Environmental Services did a deep cleaning of the room, which included the use of UV light to ensure the elimination of any virus.

Team Meetings
Initially, with a thought of preserving PPE, staff reported out to colleagues who attended the conferences in their place and discussed patient status and goals.  Ultimately, many of the staff doing COVID rehab opted to attend the conferences in person to ensure the best communication. 

PMR Visits
A focus of this program from the outset was maximal safety for patients and staff.  While nurses and therapist activities required close contact with the COVID patients, attempts were made to limit exposure of others.  The PMR physicians used a variety of methods to check on the patients, including in person and tele-visits.  Many physicians opted to visit the patient in the room, but during times of unusual concern, the physicians did patient visits from the doorway and augmented their visit with consults with the care team.  Social work staff were asked to communicate with the patients from the doorway or via a tele-visit.  Patient visitors were not allowed.

Evaluating the Model
Now, more than six weeks into operating the program, leadership has been able to identify key data that measures success:

• 100 percent of patients discharged from the program have returned home.
• The average LOS has been only 11.6 days.
• There have been no falls in this population.
• Case Mix Index (CMI) has averaged 1.3, with the most common diagnosis of Critical Illness Myopathy which is a CMS-13 Qualifying Diagnosis.
• Patient satisfaction is high

As these have been recent patients, Press Ganey surveys measuring patient satisfaction have not yet been received and tabulated.    Anecdotally, however, the response has been overwhelmingly positive.  As you might expect, many of the patients were concerned about their outcomes when they were admitted to the hospital for COVID, so they were grateful to have the opportunity to rehab.  Overall, as the patient improves, their enthusiasm often increases, to a point where the rehab team had to limit the patient efforts when they saw lower O2 Sats or increased heart rates. 

As we noted earlier, we see the success of this model as a “Grand Slam” for the system:

• Patients had an opportunity to receive essential rehabilitation services to allow them to regain function and return home.
• The organization was able to transition patients from acute beds to post-acute beds allowing acute beds to remain open to address surge needs.
• Employees who might have been furloughed remained on the job and
• The organization maintained a post-acute revenue stream to help address loss of revenue from volume across other areas of the system.

The Impact of Waivers
While the organization had the opportunity to utilize the COVID-19 waivers in their program planning related to intensity of service and the CMS-13 60 percent rule, the actual need for these was less than anticipated.  Still, the flexibility allowed by the waivers provided an opportunity to design and implement an excellent rehabilitation program for this critical patient population.

EDITOR’S NOTE: If you would like more information about this model program, please contact the author.  Ms. Phillips will assist you or make an introduction to the program leadership.