Access to Inpatient Rehab for People with Disorders of Consciousness

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How do patients with disorders of consciousness qualify for inpatient rehab?
With Joseph Giacino, PhD

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Joseph Giacino, PhD
Project Director
Spaulding-Harvard Traumatic Brain Injury Model System

In the United States, if we look at the issue of access to care for people with brain injury — and much of these data are around people who have sustained traumatic brain injury, but I believe they apply to people who have sustained non-traumatic brain injury like stroke and anoxia as well — the fact is that less than 15% of individuals in the U.S. who sustain moderate to severe traumatic brain injury receive inpatient rehabilitation … are admitted to an inpatient rehabilitation hospital. That is driven by a number of different factors. But one key factor is that there is the so-called three hour rule in the U.S., which says that in order for a patient with brain injury to be authorized for inpatient rehabilitation, they have to be able to actively participate in three hours a day of therapy.

So that typically is speech therapy, occupational therapy, physical therapy, a few other things go into that. But the operative word is actively participate. So a person who has a disturbance in consciousness is not going to be able to actively participate. They simply are incapable of doing that because of the nature of the injury. So when it's time for the patient to leave the ICU, go to the next step, the providers in the acute hospital have to make the case that this person's appropriate for inpatient rehabilitation.

So if we follow those policy guidelines that say, can this person actively participate in three hours a day of therapy, the answer is going to be no for the vast majority of people coming out of the acute center, despite the fact that these individuals have huge potential for recovery. And the timeframe that we're asking that question has nothing to do with the likelihood that they're going to improve further. But in large part because of that policy language, individuals just simply don't have access to care and then are going to be referred to typically ill-equipped long-term care facilities that don't have the specialized knowledge and techniques to be able to provide appropriate care to promote their recovery.