VA Hospital Guidelines for PAs and NPs


Rehabilitation occurs across a continuum at various levels of intensity and in different care settings. Veterans may have their rehabilitation provided in a variety of environments from acute inpatient hospitalization through a spectrum of inpatient and outpatient rehabilitation care settings, including CLCs and within the home, if medically appropriate. Regardless of the location, any designated inpatient rehabilitation unit must earn and maintain CARF Accreditation. NOTE: There is a waiver for smaller bed units, if approved by the National PM&RS Program Director.

The continuum of rehabilitation services is determined by the Veteran’s rehabilitative needs and not by the program’s location or designation. After a patient or CLC resident is identified as needing rehabilitation services, a designated and qualified rehabilitation specialist screens the patient or CLC resident. This person is called the Rehabilitation Point of Contact (RPOC).

Core Levels of Care. Core levels of care in the rehabilitation continuum include:

Acute Medical Rehabilitation Consultative Services. Hospitalized patients experiencing the onset of illness or injury may benefit from one or more rehabilitation therapies to assist in regaining physical and functional abilities. This is typically initiated by a consult to PM&RS.

An appropriate credentialed and privileged provider may initiate this consult to a physical medicine physician for a comprehensive medical assessment or to manage a specific condition, such as Polytrauma, TBI or amputation care, or to perform or recommend various modalities and therapy treatments. In most VA medical facilities, Licensed Independent Providers (LIP), Nurse Practitioners (NP) and Physician Assistants (PA) are able to initiate consults and make referrals for specific therapies such as OT, PT, KT, and RT specialists, if their approved Scope of Practice at the medical facility permits.

Specifically, PAs and NPs may provide and coordinate comprehensive PM&RS patient care services when authorized by an approved Scope of Practice. The Scope of Practice ensures that PAs practice medicine as agents of their supervising physicians with defined levels of autonomy.

PAs and NPs may order PM&RS consults and other specialty consults for assigned patients as the Scope of Practice permits.

These services are provided in central therapy clinics, satellite clinics, and at the bedside or in another environment (home, group home, assisted living facility, etc.) depending upon the needs of the patient.

Comprehensive Integrated Inpatient Rehabilitation Program (CIIRP) i.e., Inpatient Rehabilitation Bed Services.

CIIRP provides a patient-centered, coordinated, intensive program of multiple services delivered by an IDT that may include, but is not limited to: a rehabilitation physician, rehabilitation nursing, rehabilitation case management, OT, PT, SPT, KT, RT, social work, and May 2, 2014 VHA HANDBOOK 1170.03 19 psychology. The IDT supports and reinforces each patient’s individual plan of care 24 hours a day, 7 days a week (see VHA Handbook 1170.01, Accreditation of Veterans Health Administration Rehabilitation Programs).

CIIRP must meet high standards of care and earn accreditation from CARF. Regardless of the location, if an inpatient bed section’s function is designated as comprehensive inpatient rehabilitation it must be accredited by CARF.

The rehabilitation environment of care requires that rehabilitation beds are co-located in the same designated area, and that treatment areas provide opportunities for patients to interact with each other as part of the rehabilitation process. The physical location of inpatient rehabilitation beds varies. Rehabilitation bed units may be in their own designated area or may be located adjacent to acute medical services, such as neurology and general medicine. Rehabilitation beds may also be located in a designated area of the CLC.

The focus of the CIIRP is on meaningful functional improvement and successful community re-entry. Goals are identified in mobility, activities of daily living (ADL), instrumental activities of daily living (IADL), productive activity, and preparation for home and community. The treatment program has a specific timeframe and is goal-oriented with a focus on practical life-skills training. Treatment interventions are individualized and cost-effective, incorporating the Veteran, the Veteran’s family, and caregiver education and preparation for the Veteran’s transition back into the community. Patients usually remain in the CIIRP until goals are met, maximal functional improvement is achieved or it is determined that the needs of the patient would be better served within another continuum.

Each CIIRP program has admission criteria and an admission screening process. This level of care is appropriate for patients with one or more conditions requiring treatment by a rehabilitation team, at a level of intensity that can be provided more effectively and efficiently within an inpatient rehabilitation program. Patients are admitted from various sources, including the same facility, another VA medical facility, military treatment facilities (MTF), community medical facilities, and home. NOTE: Most programs offer short-stay evaluations, as needed, to determine ongoing care needs.

The Rehabilitation Continuum of Care Chart of Recommendations describes programming for specific rehabilitation services across the continuum of care. The Rehabilitation Continuum of Care Algorithm provides a decision tree for determining the most appropriate level of rehabilitation services for a patient with identified rehabilitation needs.

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