This past week I have been interning at Health South, a rehabilitation hospital here in town. Health South not only operates in West Virginia; it also has rehabilitation hospitals, outpatient rehabilitation satellite clinics, and home care in 27 states as well as Puerto Rico.
What makes a rehabilitation hospital different from a “normal” hospital? Rehab hospitals provide care for patients who are ready to be discharged from the hospital, but are not yet able to function safely at home. Many patients leave their stay at the hospital to return to a skilled nursing facility or nursing home, but rehab hospitals are for those that have the goal of returning to a certain level of independence at home. Rehab hospitals assist in bridging that gap.
A patient’s progress at a rehab hospital is measured by a FIM (Functional Independence Measure) which is a scale that measures physical and cognitive disability. The scale is made up of 18 components which are ranked from a scale of 1 to 7. A score of 1 means that the patient contributes to <25% of the task or is unable to contribute (total dependence), and a score of 7 represents total independence. Scores can then range from 18 to 126, with the higher number denoting a higher level of physical and cognitive independence. The FIM scale includes assessing self-care (eating, grooming, bathing/showering, dressing upper body, dressing lower body, and using the toilet) as well as mobility (transfers from bed to chair/wheelchair/toilet, stairs, walking/using a wheelchair), sphincters (bowel and bladder management), communication (expression and comprehension), and cognition (problem-solving and memory).
Who would be a good patient for a rehab facility? According to Health South’s website, “Anyone who is limited functionally from an injury or illness can benefit from rehabilitation. As a next step in the continuity of care, rehabilitation hospitals restore function and strength so patients can return to their highest level of independence.” This could be someone who has a traumatic brain injury from a motor vehicle accident, recovering from a stroke/CVA (cerebrovascular accident), a recent amputation, spinal cord injury, pulmonary issue (COPD – chronic obstructive pulmonary disease), or someone recovering from an accident such as a bad fall.
What I’ve noticed in the past week is that you see a lot less tube feedings and parenteral nutrition in rehab hospitals. That is not to say that patients have no troubles with eating, however! Many patients have chewing and swallowing difficulties due to esophageal strictures, dysphagia from a recent stroke, and may have no teeth or use full/partial dentures. I was able to be in the room and witness 2 barium swallow tests that assessed the patients’ level of swallowing and chewing function in front of an x-ray. Thin liquids, nectar-thickened, and other foods were tested to see what patients are able to safely swallow. The National Dysphagia Diets (NDD) have three levels, all of which I have seen on diet orders at the rehab facility:
- NDD Level 1: Dysphagia-Pureed (homogenous, very cohesive, pudding-like, requiring very little chewing ability).
- NDD Level 2: Dysphagia-Mechanical Altered (cohesive, moist, semisolid foods, requiring some chewing).
- NDD Level 3: Dysphagia-Advanced (soft foods that require more chewing ability).
- Regular (all foods allowed).
A dietitian at a rehabilitation hospital will assess and evaluate patients when a physician orders a diet consult, or when the patient triggers for another reason. General questions to ask the patient during the assessment include questions about the patient’s appetite, bowel function, any chewing/swallowing difficulties, changes in weight and other questions that apply to the individual patient. There may be recommendations for a diet change, the addition of an evening snack, or the addition of a nutrition supplement such as Glucerna or Ensure to promote weight gain, weight maintenance, or protein intake.
In addition to dietitians, rehab hospitals also employ a multitude of different health professionals, including physical therapists, occupational therapists, speech language pathologists, x-ray technicians, doctors, nurses, case managers, and pharmacists. There really is a multitude of different professions working together to help patients regain their strength, endurance, and independence.