Afternoon Consults
Following the team conference, Dr. Reinstein spends most of the afternoon on consults. Today, he has been asked to see a number of patients in order to determine if admission to the rehab unit is appropriate for each one. Patients’ attending physicians make these referrals, and Dr. Reinstein works with them to make a final decision. In a typical day, he sees five to six new consults—most of them the day after surgery. At the same time, he follows up with four to five patients a few days after he first saw them to check progress, finalize decisions, and—when appropriate—prepare them to transfer to the rehab unit.
“I try to see the patients first who will be admitted to our unit today. We want to do the admits earlier. There are staff onsite to help them settle in, and it frees a bed for the hospital,” explains Dr. Reinstein.
Each consult starts with the patient’s chart, which he reviews carefully. In addition to medical issues, he looks at relevant social information, such as whether the patient lives in an apartment or a two-story house. This can affect goals and how much rehab the patient will need to function post-discharge. Dr. Reinstein checks medication regimens, vital signs, lab data, and other information on a nearby COW (or computer on wheels). These are located throughout the facility for easy access by clinicians.
After pulling and reviewing the chart, Dr. Reinstein goes to the patient’s room armed with a special form he uses to record his assessments and final recommendation. Following a greeting, he conducts a brief physical exam and asks the patient about pain and other relevant issues. He also considers weight-bearing status, a big issue in rehab.
The consults, which can take several hours, usually result in some new admissions to the rehab unit and the need for some follow-up visits that he will have to conduct in two or three days.
Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.
Dr. Reinstein consults with family member Sylvia Schechter. He sees five to six new patients each day in addition to following up with four to five patients to check their progress and prepare them for discharge.
System Challenges
Preparing patients for discharge can be like playing “Beat the Clock” for Dr. Reinstein and his team. “Insurance companies will only approve a certain number of days, and there have to be strong medical reasons for an extended stay before they will pay,” he says. He emphasizes that his decisions are based on several factors that have to do with the patient’s well being and health rather than on an insurance company’s criteria. He also stresses that the patient is part of this decision making.
In particular, he mentions one individual who was waiting for an assistive device and expressed concern about going home before she had it and could get used to it. “I’m not going to push someone like this out the door,” he says. “We have to weigh the pros and cons and—ultimately—do what is best for each individual patient.”
Most of Dr. Reinstein’s patients—the majority of whom are 65 and older—want to get back to their homes and communities, and the team works hard to make that happen. In fact, 80% of patients are discharged to the community, with 20% going to a nursing facility or subacute unit.
Private insurance companies require prior authorization before patients can be admitted to the rehab unit following surgery or a fracture. “The main problem here arises when the insurance company decides that the patient doesn’t need this level of rehab,” says Dr. Reinstein. “At this point, we have to sit down with patients and families [and discuss] the options—including self-pay or transfer to a less expensive subacute facility.”