“We are continually faced with great opportunities which are brilliantly disguised as unsolvable problems.” – Margaret Mead

In almost every developed country in the world, healthcare systems have adopted the World Health Organization’s International Classification of Functioning, Disability, and Health (WHO-ICF) to label the challenges experienced by people with impairments and disabilities. The WHO-ICF was created over many years by experts around the world. The only developed country still fumbling with a variety of classification tools is the United States, and, I believe, the rehabilitation industry is remiss in not making a positive contribution to our country’s enlightenment. The paradigm of rehabilitation has eroded since the 1990s, from one of treatment of the whole person to a mechanical definition, which has been reduced to FIM scores, lists of comorbidities and vital signs.

Too often, we accept the definitions of rehabilitation that others, not experts in rehabilitation, foist on us. There’s the “rehabilitation ready” assertion by Medicare that a patient must be able to tolerate three hours of rehabilitation from day one in the rehabilitation hospital or unit. One doesn’t join a health club and perform three hours of exercise in the first visit. You build stamina over time to achieve that. Physiologically, a person who has spent the last five days lying in bed cannot be expected to undertake a schedule of demanding physical and cognitive expectations on the first day in rehabilitation. Consequently, if this hurdle cannot be overcome, the discharge direction is to a nursing home. How many of those patients are transferred to a rehabilitation hospital when they have increased stamina sufficient to withstand the requisite three hours of therapy? My guess is that very few do, thus assuring that they never have access to the expertise they need to resume their lives.

“Too often, we accept the definitions of rehabilitation that others, not experts in rehabilitation, foist on us.”

We are conducting a campaign to educate an insurance company in our region that expressly prohibits payment for cognitive retraining. What possible definition of rehabilitation could they have adopted? As a rehabilitation provider, it is difficult to understand how cognitive retraining could not be considered imperative in the rehabilitation program for someone who has sustained a brain injury or stroke. This type of payment denial is based on the assumption that what it means to be human is to walk, without regard for the person’s capacity to regain their speech, comprehension, personality and life role. We even had one insurance company disallow coverage for a patient with a spinal cord injury because he would never learn to walk.

I could go on indefinitely with antidotes like this, but all rehabilitation providers have experienced them. My point is that we need to use the concepts, the language, the knowledge of rehabilitation to educate the uninformed in every conversation, in every exchange with Medicare and with all other payers. We need to talk about life roles and goals and what is required to regain them. We need to talk about environmental and social challenges and factors associated with resumption of activities. We need to use the WHO-ICF language of biopsychosocial rehabilitation rather than the outdated medical model.

In this issue, we have provided a synopsis of the WHO-ICF. It is more than a classification system. It is a structure and concept fundamental to our work in rehabilitation. And it needs to become a greater part of our dialogue with insurers, CMS, every physician and every discharge planner. Most of all, it needs to be a central theme in our lobbying efforts to redefine rehabilitation as it should be.

Published in the AMRPA Magazine May 2012

By: Marsha Lommel, MA, MBA, FACHE
President and CEO, Madonna Rehabilitation Hospital