Consider the situation of a typical patient on a post-acute rehabilitation unit. Prior to his or her arrival, the patient has almost always experienced a recent trauma—a stroke, heart attack, amputation, or other major medical affront.
Second, they’ve likely had surgery and/or other major significant interventions that bring physical pain, fatigue, and other challenges. Finally, they’ve had to endure a hospitalization, which disrupts their normal routine, sleep schedule, diet, and other habits that help keep people emotionally grounded.
In this context, it’s easy to see why patients arriving at a post-acute care center may struggle in the beginning. Given the circumstances, a first reaction to the challenge of rehab might be something like, “You must be joking! Just let me relax and recuperate for a few days.”
But clinicians know that every day of missed rehab decreases the chances of a successful discharge, and, fortunately, most patients find the inner strength to rise to the occasion and get to the gym.
Who doesn’t? Those patients with mental health issues, which, if untreated, can become insurmountable barriers to a successful rehabilitation and discharge back to the community.

High Stakes

The stakes are always extremely high on a post-acute care unit. First and foremost, a post-acute care stay is usually a life-altering event for the patient, as the outcome often means the difference between a return to one’s normal life in the community and admission to a long term care center. From the center’s standpoint, excellent outcomes are critical, too.

When patients achieve a successful outcome, they return to the community, essentially serving as positive emissaries for the treating center. Conversely, the friends and family members of a patient who does not do well may share negative perceptions of the center in their communities.

Referral sources such as hospitals and insurance companies also closely scrutinize centers’ post-acute rehab outcomes and incorporate these data into their decision making about where to steer their referrals. These entities look at the percentage of successful discharges back to the community, length of stay, and the number of post-acute patients that require rehospitalization. A center’s success in meeting these benchmarks determines its ability to survive in the ever-changing health care landscape.

Identifying Psychological Issues

One of the best ways for centers to improve their post-acute outcomes is to aggressively identify and treat the psychological issues that might otherwise serve as barriers to patients putting forth their best efforts in the gym. As a side effect of this approach, physical and occupational therapists will have more time to spend in the gym—relieved of the need to address the nonphysical issues that interfere with patients’ participation in treatment. Invariably, these professionals will appreciate the lowered prevalence of noncompliant patients so they can focus on their primary responsibilities.

Unfortunately, most post-acute care centers lack a proactive approach to mental health issues, especially on the rehab unit. It’s not uncommon for centers to wait much too long to bring behavioral health services into play, often not until the patient is already failing in rehab and it’s too late to help them achieve a successful outcome and discharge.

Costs, Warning Signs

The cost of poorly treated or untreated behavioral health issues is enormous. The best case scenario is that these patients create increased time demands on center and rehabilitation staff but somehow manage to return to the community, albeit not at their highest possible level of recovery.

More typically, such patients do poorly, with premature discharge from rehab and an increased risk of rehospitalization and permanent disability. For centers, the result is lost revenue and other negative outcomes visible to the community and referral sources.

The most common manifestations of psychological distress in the post-acute population are depression and anxiety. While many post-acute rehab patients will express some of these issues, those for whom the following verbalizations and behaviors are more persistent should be evaluated immediately:
  • Overtly depressed, sad, tearful, withdrawn, passive;
  • Combative, irritable, frustrated, noncompliant, angry;
  • Pessimistic, negative, resigned, hopeless; and
  • Low pain tolerance.
Most patients with significantly deleterious levels of depression and/or anxiety will manifest several of these symptoms and behaviors. There are other patients whose presentation does not fit this mold but who may nevertheless be at significant risk for a poor rehab outcome.

Patients who do not present as depressed or anxious but are pessimistic about their prospects for returning to the community, self-predict a poor outcome, or are consistently self-deprecating may also fail to do the difficult work that is required of them in the gym. Those with cognitive limitations, who have a poor understanding of the rehabilitation process or an unrealistic expectation of their chances for success, are also at risk.

Identifying Those Most at Risk

To identify these individuals, the post-acute unit manager must ask: “Whose mood, motivation, or attitude is likely to interfere with a good rehabilitation outcome?” Put another way: “Which of my patients may be too depressed, too anxious, too unmotivated, too overwhelmed, etc., to put forth their best effort in the gym?”

An additional and often overlooked barrier to successful rehabilitation resides not in the patient’s psychological matrix, but in the dynamics of their extended family. A hospitalization and subsequent post-acute rehabilitation are often occasions for an influx of family members. Particularly if it’s the patient’s first significant life-altering medical challenge, all kinds of questions are presented by the family, the most prominent being, “Will Mom be able to return to her home, or will she need extended nursing center care?”

The answer to this question will often lead to a variety of others that have enormous impacts on the family’s emotional and financial situation. While it is often very helpful for patients to receive support from the family, if family systems are dysfunctional, the intended support can be perceived as intrusive and disruptive to the patient’s plan of care.

When psychological issues reside within a patient or in the extended family, neither the size of the gym nor the expertise of the rehabilitation staff will determine the patient’s outcome. The critical factor is how well the center helps the individual and/or family manage the ferocious emotional challenges of rehabilitation.

Those centers that become adept at identifying the warning signs of psychological issues and provide a pro-active, evidence-based response will see an improvement in post-acute outcomes. Aggressive treatment of behavioral distress, routinely employed, often proves the difference between a successful discharge back to the community and an unsuccessful post-acute episode.

A Path Toward Success

Behavioral health providers can address the mood, motivation, and other issues that stand in the way of a patient’s progress, as well as work with those challenging families whose involvement may interfere with the patient’s progress.

Beyond these interventions, however, the robust deployment of behavioral health care in the post-acute arena can have a broader impact in creating a center culture that improves patient and family investment in rehabilitation outcomes, helps the organization demonstrate consistent messaging pertaining to patients’ progress, and facilitates a widespread improvement in a center’s skill in managing the full range of biopsychosocial issues that impact the patient’s ability to return to the community.

Post-acute programs that aggressively deploy professional behavioral health interventions will realize greater efficiency on their rehab units, increased patient attendance, and improvements in their percentage of successful post-acute outcomes.
Richard Juman, PsyD, is national director of psychological services at TeamHealth. He can be reached at or (212) 661-4642.