Outpatient Rehabilitation Admission, Exclusion, Continued Stay, and Discharge Criteria
Policy/Purpose: Individuals seeking outpatient rehabilitation services will be considered candidates for services when certain criteria are met. The admission criteria include, but are not limited to, the below.
Responsible Personnel:
Admission Criteria: The criteria for providing outpatient rehabilitation services include the following:
- There must be an order for rehabilitation services, except for patients seen through direct access.
- Services are deemed to be reasonable and necessary.
- Services require the skilled services of a licensed therapist.
- The person served must:
- Be medically stable to the degree that participation in treatment is safe and beneficial.
- Demonstrate a significant functional limitation that alters or prevents participation in desired life functions.
- Be expected to make significant functional improvement within a reasonable period of time as defined by the therapist in the rehabilitation plan of care.
- Have the ability to learn and benefit from rehabilitation.
- Be able to manage his/her own personal care or have a caregiver available to assist.
- Have the ability to travel and attend appointments as scheduled.
Exclusion Criteria: The criteria for excluding one from receiving outpatient rehabilitation services include, but are not limited to, the following:
- Client demonstrates aggressive behaviors that post a threat to the safety of him/herself or others.
- Client has received a course of outpatient therapy for the same issues/goals and whose functional status remains unchanged or has not progressed.
Continuing Stay Criteria: Each of the following conditions must be met in order to justify continuation of services.
- Services continue to be reasonable and necessary.
- The patient’s condition and treatment plan require the experience and expertise of a skilled therapist.
- The patient is able to tolerate and participate actively in therapy.
- The patient demonstrates potential for functional improvement.
- Continuous progress has been demonstrated and documented in the clinical notes.
Discharge Criteria: Patients receiving outpatient rehabilitation services will be discharged from services when certain criteria are met. The discharge criteria include, but are not limited to, the following:
- The person served has achieved the goals that were established or updated in the most recent plan of care.
- Services are no longer reasonable and necessary or the services of skilled therapists are no longer required, except individuals who are self-pay for maintenance programs.
- The individual’s progress has slowed or temporarily stopped and he/she is no longer benefiting from the services of the program.
- The presence of medical, psychological or social problems hinder the individual’s ability to participate.
- An interruption in therapy services has occurred for greater than 30 days unless it is part of the plan of care.
- The physician requests that therapy services be discontinued.
- The person served is non-compliant with the program.
- The person repeatedly exhibits behaviors that cause safety concerns for others.
- The person served declines to continue care.
- The care of the person served is being transferred to another provider
- The person served has missed three scheduled appointments without contacting his/her clinic at least 24 hours in advance. These individuals will be required to obtain a new physician’s order before more appointments are scheduled.
Definitions:
Medical Necessity – Services deemed “reasonable and necessary:”
- Must be specific and effective treatments for the patient’s condition.
- Must require the expertise, knowledge, clinical judgment, decision making, and abilities of a therapist or therapist assistant that other staff, caretakers, or the patient cannot provide independently.
- Should be reasonable under accepted standards of practice with regard to amount, frequency, and duration.