| Discipline | Focus | Key Interventions |
|---|
| Physical Therapy (PT) | Mobility, strength, balance, gait, transfers, wheelchair skills | Therapeutic exercise, gait training, NDT, FES, locomotor training, assistive device fitting |
| Occupational Therapy (OT) | ADLs, IADLs, upper extremity function, cognition, vision, home/work reintegration | Task-specific training, adaptive equipment, home assessment, work hardening, cognitive rehab |
| Speech-Language Pathology (SLP) | Communication, cognition, swallowing (dysphagia) | Aphasia therapy, AAC, cognitive-communication, VFSS/FEES, diet modification, respiratory-swallow coordination |
| Neuropsychology / Cognitive Therapy | Executive function, memory, attention, behavior, emotional regulation | Computerized training, strategy coaching, compensatory systems, family education |
Medical and Nursing Management
- Physiatrist-led: Board-certified PM&R physician directs plan of care.
- Rehab nursing (CRRN): 24/7 care; bowel/bladder training, skin integrity, medication management, reinforcement of therapy gains.
- Medical complexity: Tracheostomy/vent weaning, complex wound care, spasticity management (botox, ITB), heterotopic ossification monitoring.
Support Services
- Case Management / Social Work: Discharge planning, insurance coordination, community resources, caregiver training, psychosocial support.
- Nutritional Services: RDNs for malnutrition, dysphagia diets, tube feeding management, metabolic demands of recovery.
- Pain Management: Multimodal (medications, blocks, TENS, CBT, meditation); minimize opioids.
- Recreational Therapy: Community reintegration, adaptive sports, leisure skill development.
- Spiritual Care: Chaplaincy for existential distress, meaning-making.
- Vocational Rehabilitation: Job analysis, workplace accommodations, return-to-work coordination.
- Driver Rehabilitation: Clinical + on-road assessment, adaptive equipment.
Admission Criteria (CMS IRF Requirements)
- Require intensive interdisciplinary rehab (≥3 hrs therapy/day, 5 days/week).
- Require 24/7 rehab nursing and physician supervision.
- Reasonable expectation of measurable functional improvement.
- Qualifying conditions: stroke, SCI, TBI, major trauma, burns, amputation, neurological disorders, post-surgical deconditioning.
Outcome Measurement
- Functional Independence Measure (FIM) or CARE Tool—admission/discharge.
- Discharge to community rate; readmission rate; length of stay efficiency.
- Patient-reported outcomes (PROMIS, satisfaction).
Rehabilitation hospitals provide coordinated, high-intensity, goal-directed care that bridges acute hospitalization and community living—maximizing independence and quality of life after disabling illness or injury.
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