What are the key differences between Skilled Nursing Facility (SNF) and Inpatient Rehabilitation Facility (IRF) in terms of patient suitability and rehabilitation goals?

Key Differences Between SNF and IRF for Patient Rehabilitation

Inpatient Rehabilitation Facilities (IRFs) provide more intensive rehabilitation services and achieve better functional outcomes than Skilled Nursing Facilities (SNFs), making IRFs the preferred option for patients who can tolerate intensive therapy and have potential for significant functional improvement.

Patient Suitability Criteria

IRF Suitability

• Patients who require and can tolerate intensive rehabilitation therapy (at least 3 hours per day for at least 5 days per week) 1
• Patients with medical comorbidities requiring 24-hour physician availability and close supervision by a registered nurse with specialized rehabilitation training 1
• Patients for whom significant functional improvement is expected within a reasonable timeframe 1
• Patients who are likely to return to a community setting after discharge rather than requiring transfer to another inpatient facility 1
• Patients who require a coordinated interdisciplinary team approach including rehabilitation physicians, therapists, nurses, case managers, and social workers 1

SNF Suitability

• Patients who may not reach full or partial recovery but require skilled nursing services to maintain function or prevent deterioration 1
• Patients who cannot tolerate intensive rehabilitation (3 hours daily) due to frailty or comorbidities 1
• Patients with less rehabilitation potential who still require daily skilled nursing or rehabilitation services 1
• Patients with more complex medical needs and higher levels of disability 2
• Patients who are older (particularly 85+ years) and have more comorbidities 2

Staffing and Supervision Differences

IRF Staffing Requirements

• Direct physician supervision with daily physician visits typically required 1
• Physicians are expected to have training or experience in rehabilitation 1
• Registered nurses present continuously, often with specialty certification in rehabilitation nursing 1
• Interdisciplinary team conferences required at least every 2 weeks 1
• Documentation of patient progress, problems impeding progress, and solutions required 1

SNF Staffing Requirements

• Rehabilitation nursing required on site for minimum of 8 hours per day 1
• Care must follow a physician's plan, but no requirement for direct daily physician supervision 1
• Less intensive medical oversight compared to IRFs 1

Rehabilitation Intensity and Duration

IRF Intensity

• Minimum of 3 hours of rehabilitation therapy per day (PT, OT, SLT) for at least 5 days per week 1
• More intensive therapy regimen with higher frequency of treatment 1
• Shorter average length of stay (median of 15 days) 1

SNF Intensity

• No minimum requirement for therapy hours 1
• Generally less intensive therapy than IRFs 1
• Longer length of stay, dependent on individual stroke severity 1
• Medicare provides coverage for up to 100 days 1

Outcomes and Effectiveness

IRF Outcomes

• Substantially better improvements in physical mobility and self-care function compared to SNFs 3
• Higher mean scores for mobility and self-care at both admission and discharge 3
• Larger improvements in mobility score (11.6 points vs 3.5 points) and self-care score (13.6 points vs 3.2 points) compared to SNFs 3
• More LOS efficient (shorter stays with better outcomes) 4

SNF Outcomes

• Smaller functional improvements compared to IRFs 3
• More payment efficient (lower cost per case) 4
• Can still be effective when used in conjunction with IRF care for patients requiring extended rehabilitation 5

Facility Characteristics and Access Issues

• Significant unexplained variation exists among hospitals in their use of IRF versus SNF post-stroke, even after accounting for clinical characteristics and geographic availability 6
• Medium-volume facilities among both SNFs and IRFs tend to be most efficient 4
• Patients who are older, non-Hispanic Black, Hispanic, or have Medicaid/Medicare are less likely to be discharged to IRFs than SNFs 2
• Patients at larger hospitals (200+ beds) and hospitals with dedicated stroke units are more likely to be discharged to IRFs 2

Clinical Decision-Making Algorithm

1. Assess patient's rehabilitation potential:

   • Can the patient tolerate 3 hours of therapy daily? 1
   • Is significant functional improvement expected? 1
   • Is return to community setting likely? 1

2. Evaluate medical needs:

   • Does the patient require daily physician supervision? 1
   • Are there complex medical needs requiring 24-hour specialized nursing? 1

3. Consider functional status:

   • Patients with moderate disability who can actively participate in therapy are better suited for IRF 2
   • Patients with severe disability who cannot participate in intensive therapy may be better suited for SNF 1

4. If the patient meets IRF criteria and has access to an IRF, this should be the preferred option due to better functional outcomes 3, 1

5. If the patient cannot tolerate intensive therapy or does not have access to an IRF, SNF placement is appropriate 1

Common Pitfalls and Caveats

• IRF admission should not be limited by age alone, as even older adults can benefit from intensive rehabilitation 2
• Early rehabilitation is consistently predictive of efficient treatment in both settings 4
• Some SNFs provide rehabilitation care at a level that overlaps with what may be available in IRFs, so individual facility assessment is important 1
• Sociodemographic factors should not determine rehabilitation setting, though disparities exist in access to IRF care 2
• For patients requiring extended rehabilitation beyond what can be provided in an IRF, a combined approach of IRF followed by SNF may be effective 5