Mr. Jones is a 78-year-old man admitted for short-term rehabilitation following a broken hip and surgery. He also presents with several chronic medical conditions, but they have been well controlled in the community by his primary care physician.
When the physical therapist enters his skilled nursing facility (SNF) room on the first day to discuss the work they’ll be doing, Mr. Jones sits up a bit straighter in his bed and says, “I’ve been expecting you. I’ve heard there’s a great rehab gym here—just show me the way.”

Mr. Smith is a 78-year-old man admitted for short-term rehabilitation following a broken hip and surgery. He also has several chronic medical conditions, but his primary care physician has helped keep them under control.

When the physical therapist enters his SNF room on the first day to discuss the work they’ll be doing, Mr. Smith pulls his blanket up a little higher and says, “Young man, you must be joking. Do you know what’s happened to me? I broke a hip, had surgery, and spent three days being poked and prodded in the hospital. I haven’t been sleeping well, and I’m in pain. Give me a few days to get my bearings, then let’s talk.”

Same facility, same gym, same physical therapist. But if asked to predict which patient’s rehab episode would lead to the following issues and outcomes, which patient would it be?
  • Increased time demands on staff during stay
  • Premature, unsuccessful discharge from rehab
  • Increased risk of rehospitalization
  • Increased chance of permanent disability
  • Poor functional capabilities
  • Resident and family dissatisfaction
  • Lost revenue for program and facility
  • Problematic discharge from the facility
  • Possible admission to long term care facility.

Treating Emotional Issues

Successful rehabilitation has to start with the individual patient experience. In Mr. Smith’s case, one hopes the physical therapist’s explanation that missing even one day of therapy can reduce his chances of returning to the community will get him out of bed and into the gym. But perhaps not—if Mr. Smith is too depressed, too anxious, too unmotivated, or too confused. 

Almost every admission to short-term rehab is preceded by some degree of emotional trauma, and many failed rehab episodes can be traced to the failure to recognize and treat emotional distress early enough in the rehab stay to allow the patient to complete his or her regimen and return home.

Reflection Matters

There is no more important reflection of a SNF’s quality than its short-term rehabilitation outcomes, which have well-established financial ramifications and impacts on facility census. When post-acute patients return to the community after a successful rehabilitation episode in a facility, they send a clear message to the community that the facility and staff have what’s needed to quickly set patients on the road to stable recovery.

In contrast to a facility’s reputation as a long term care provider, where quality-of-life outcomes are complex and more subjective, there is nothing subjective about rehab outcomes, and they are much more binary.

From the family perspective, it could be, “My husband broke his hip, but after two weeks at that fantastic ABC Nursing and Rehab he is back home and getting back to his normal activities.” Or it might be, “My husband broke his hip, but after two weeks at that miserable XYZ Nursing and Rehab they told us he needed long term care. We took him right out of there.”

Obviously, hospitals, insurance companies, and other potential referral sources are coming to their own conclusions about a facility’s rehab results and the role they see the provider playing in their care network. With reimbursement and penalties increasingly tied to outcomes, the SNFs that will thrive in the changing health care landscape are those that reliably produce good rehab outcomes.

Where to Start

In the author’s experience, the best way for facilities to improve their short-term rehab outcomes is by starting at the level of the individual patient. Obviously, nobody is more interested in outcomes than the patients themselves, who are being confronted by the possibility of a life-altering loss of functional ability that could lead to a long term care admission. But at the same time, many of these patients are so overwhelmed by their recent turn of events that they are not in an optimal frame of mind to exert the requisite effort in the gym. Failure to address this fact is why many rehab episodes fail.

A SNF administrator should ask the unit manager: “Who are you worried about? Do we have any new patients who seem too depressed to do the work that is going to be required of them? Too anxious? Too unmotivated, confused, paranoid?” In all the times the author has asked these questions, he hasn’t had a single unit manager tell him that everyone was motivated, working hard, and on track for on-time discharge. There are always patients who are struggling with emotional, cognitive, and motivational issues.

The administrator’s next question should be, “What is our plan for helping those patients overcome these barriers to successful rehabilitation and discharge?” How the facility answers this question is a major factor in determining how successful its short-term rehab program will be.

Identify and Evaluate

Early identification of emotional distress that can lead to failed rehabilitation episodes is critical. Nothing bothers a behavioral health clinician more than receiving a referral for evaluation on a rehab patient in the middle of their second week on the rehab unit who has been doing poorly since their first day. If the patient’s PHQ-9 score, or depression module, was scary, and they’ve refused therapy four out of the first seven days, why wasn’t the patient referred on day two, when it was still possible to turn things around?

The key is to quickly evaluate the patient for signs and symptoms that are highly correlated with unsuccessful short-term rehabilitation. These include:
  • Depressed, withdrawn, tearful, passive, pessimistic
  • Combative, irritable, frustrated, noncompliant, angry
  • Unrealistic expectations or recognition of disability
  • Cognitive impairments
  • Maladaptive personality issues
  • Chaotic family dynamics
  • Low frustration tolerance
  • Poor tolerance of pain
  • Hopelessness, low motivation.
Failure to respond immediately and aggressively to these “red flags” of potential rehab failure will keep a facility’s rehabilitation outcomes below where they should be. In contrast, when behavioral, mood, and attitudinal warning signs are identified and addressed immediately, the psychiatry and psychology team, in concert with facility staff and members of the rehabilitation department, can focus on the issues that so frequently derail the therapy process and prevent a successful discharge back to the community.
Richard Juman, PsyD, is national director of psychological services at TeamHealth. He can be reached at or (212) 661-4642.