Ep 28: How to be Successful in Inpatient Rehab as an OT Practitioner with Courtney the OT

This summer, Elevator Impact, the Amplify Therapy Summit hosted by Amplify OT. It's happening July 30 through August 2, 2025. It is 100% virtual and free to attend select sessions with live panels and pre-recorded content focused on OT policy, reimbursement and workforce issues. If you want extended access and up to 15 CEU hours, upgrade to the Explorer Pass starting at just $99. You can shape policy, feel inspired and achieve new heights with the Amplify Therapy Summit. Register now at AmplifytherapySummit.com or using the link in the show notes. I'll see you there. Insurance doesn't know the patient. They don't know anything about them other than what they see on paper. So the way that we reflect them on paper, we have to be mindful of that. And how there may be someone getting cut your last covered day is going to be in four days and you're like crap. Hi, I'm Clarice Grote and welcome to the Amplify OT podcast. I'm an occupational therapist by trade and a policy long by choice. This podcast is here to help you survive and thrive in the U.S. healthcare system through a better understanding of policy, advocacy and value-based care. So let's dive in. Hey, it's Clarice from Amplify OT. Before we start today's interview and episode, I just want to let you know that we were having a little bit of difficulty with audio while recording this podcast. So you may hear a couple moments where audio kind of drops out. There's a little bit of gap. But overall, I think we were able to edit it where it sounds pretty good and we've got the overall message across. I was so excited to chat with Courtney. It tightens so well with the podcast episode last week where I chatted with Alyssa about acute care and discharge planning and then to follow it up with Courtney and inpatient rehab. So where we were sending patients from acute care to inpatient rehab and speaking about her experiences from that perspective was just such a valuable transition. I also wanted to let you know that in two weeks, we'll be having another episode come out with Brandy, Archie, all about durable medical equipment. So it was so fantastic and completely serendipitous that these podcast episodes lined up so well. So you'll hear me and Courtney talking about DME and recommending equipment, especially as part of discharge planning because you will notice a common theme is discharge planning. And if you are having difficulty with discharge planning, we do have a free discharge guide. It's part of amplify OT that you can download. I will link it in the show notes or you can visit amplify OT dot com for slash discharge to download our free occupational therapy discharge guide that has tips and tricks as well as a map of the continuum of care to help you with that hard task of discharge planning to make sure that you're making a successful discharge plan for your patients. All right, well, without further ado, let's go ahead and dive into this podcast episode with Courtney the OT. If you don't follow her on Instagram, you should and I'm just so grateful to have her today. All right, enjoy. All right, everyone. Welcome back to the amplify OT podcast. I'm so excited to welcome Courtney from Courtney the OT, the OT. They don't teach you about on Instagram. Courtney has one of the best accounts, I think. I always love watching your stories and seeing what's going on because you do such a good job of like connecting with people, even though they're not in front of you. And that is not always not a skill that a lot of people have. So obviously, I think that would come in handy for you as an OT, but welcome to the amplify OT podcast. I'm glad you're here. Thank you so much for having me. It's an honor. I feel like I am in the presence of this celebrity myself. So you love this. We love this. It's an OT celebrity. Social media has a lot of downsides. Don't give me wrong, but I will say one of the major upsides is definitely connecting with other clinicians because like we never would have met without Instagram or like I mean half the OT creators and I don't guess influencers for lack of a better word. You know, I wouldn't have met any of them without social media. Yeah, exactly. Yeah, thanks for having me here. So I've worked as an OT for five years. The first four, four and a half years was in skilled nursing and then actually June 13th will be one full year that I will have been. So a couple weeks and they'll be a full year that I've been working in grass. Yeah, thank you. Inpatient rehab. So it was quite the realization that I had actually this morning. I was like, oh my gosh, it's almost been a year. But it's been really cool not only to learn, but to see the differences in the two settings and to see obviously the role of OT is the same, but just really unique to see a different perspective of what OT looks like in a different setting. So it's been really, really fun. It's fine. I'm also only five years out. So we've, I was graduated right around the same time and I feel like always hitting that like one year market, any new setting is always an accomplishment. Like I think, especially like when you're at new grad too, like the first three months are always the worst. And I know when I worked in a Q care, I napped like every day for like the first three months because I was so exhausted trying to learn something new. But yeah, I think what you hit that one year, you like finally kind of realize that you feel like you kind of know what you're doing. You've hit that rhythm. You're not like having to think so hard every morning. And that's always nice. I'm sorry. You said three months for me was like six to nine months. Just three months for the worst. And then like six months, you hit a little bit more of a same. I mean, to be fair, my first job was only at it for nine months, then I started the process over. Yeah. So starting PR and that in itself, I feel like just prolongs the struggle of a new grad because you don't have a consistency and you know, structure to ease into everything. So maybe that's why my new grad hot messness lasted so long. I don't know. I'm still hot mess. I'm just not a new grad anymore. Yes. Well, I think, you know, technically five years, some people still define as new grad. So until you hit six, you might still be in that category. And I agree, definitely starting PR and because then you're not like working every single day, it kind of draws out that process a little bit. Oh, for sure. Lots of positives to PR and through because then you get a little bit more of a mental break. You're not just like drinking out of a fire hose every day. Exactly. So you worked in SNF first and obviously so today we're going to talk about inpatient rehab, which I actually did my level two in inpatient rehab. It was not for me. The early mornings were not for me, the showers were not for me. My field work was great. My supervisor was great, but I will admit I do not like inpatient rehab. But the fact that I'm an acute care therapist and acute care is where I love to be. I think the people who like IRF and the people who like acute are two kind of different people. Yeah. I mean, I've never worked in acute. I have zero into an acute. So I can't entirely speak on that, but I definitely from what I've heard and learned about it, it's very different. You have far less time with these people and it's just such a different setting. Oh, yeah. You're talking like 30 minutes, a couple times before they discharge versus an inpatient rehab. You get a lot more than that. Oh, yeah. That's where I kind of learned that I wasn't the kind of therapist that likes to like really get to know my patients. Like I can live without seeing them make a ton of progress. I like just devils and discharges. See I like live for the interpersonal like connections that I make with patients that brings my heart so much joy. And I think that's what's so beautiful about a profession is like there's such a go like a large scope as far as like settings that fit so many personalities and and what works for you. So it's so beautiful. It breaks my heart anytime I see new grads post that they feel like the profession might not be for them or they're just you know so overwhelmed that they're thinking about leaving and I totally get feeling that way. But I think we just do ourselves such a disservice by putting one too much pressure on ourselves to be successful. I see so many new grads and students who are like, I'm going to be the best OT as soon as I graduate and you're not. You're going to be good enough to be able to get licensed and that's it and that's fine. But you know, there are so many different opportunities and settings, which is part of what drew me to the field. Because how many different options there are because if you don't like one, then just try another because sometimes you may really struggle and you know like I know there are some people who just are not acute care therapist. You have to be really detail oriented and go with the flow and it's just kind of constant chaos. And if you can't operate like that, acute care is not for you, but you may really thrive in a setting like inpatient rehab or SNF or you have a little bit longer time and your schedules are not going to fall apart because everybody's you know in an x-ray or coding. Yeah, we have a dialysis center in our hospital and so I have a patient in my case with my dialysis. There's a risk of dialysis needing to take some free and it just puts the day to shambles. To put it nicely, yeah. No dialysis is like the vein of every therapy practitioner's existence because it can really just destroy a day. Oh, because they're gone for four hours, four hours of them being there and then they come back just pooped. Yeah, they're just wiped out afterwards. I had that trouble at home health to trying to schedule visits and folks who are on dialysis and it was always a nightmare and then same thing in the hot like if they were on dialysis, then you just they're you're just going to see him tomorrow. It wasn't going to happen that day. Yeah, but I'd love for you to tell me and tell us like what for you has been the biggest difference you think between SNF and inpatient rehab. Honestly, one of the big things for me was the type of patient that I was getting but also the case load. So the type of patient obviously you have to really qualify. qualify for inpatient rehab. I have to have somewhat of a discharge plan, even if I feel like some people fib on their discharge plan just to get in. That drives you crazy. But then they also have to be able to three hours of therapy five days a week. So my case load, I only oversee, I think only it feels like a lot, but I oversee eight patients. Whereas when I was in school, nurse and eight oversaw like 20 to 25 depending on staffing. And so it was very difficult to patients, you know, efficiently and effectively and work on discharge planning and all that stuff for that many patients. It was very overwhelming and stressful. See how that kind of stuff burns people out because you're just firing it all cylinders, trying to put out fires and oversee this and plan this and order this and all that kind of stuff. Whereas it knows overwhelming at times, but it's eight people. And I can manage it better than 25. I was listening to a podcast the other day where they're talking about burnout and what's exhausting to people. And it's not necessarily the size of your case load. It's what you're talking about like that administrative piece, right? Where you're kind of overseeing their plan of care and making referrals. And so it's not just the patient itself and the caseload, but how much extra you're having to think about on top of that, their progress notes, all that kind of stuff. And so the bigger your caseload is than inevitably then two, some more of the administrative burden that falls on your lap. For sure. And I mean, I had a team like a speech therapist and a therapist, when I was in skilled nursing, it wasn't quite as structured like room assignments and room blocks were not very structured in skilled nursing where I met now. These are very like team block oriented. So I have two PT partners because they work 12 hours so they work opposite days and then once speech therapy partner and the way that we split setting up caregiver training, ordering DME and communicating with all the stuff, giving handouts for this, making HEPs, we kind of split the load and case very well. So it again helps managing all of the intricacies. Yeah. And I wanted to go back to what you said around, you know, someone really has to kind of qualify into inpatient rehab. Cause I think that's something that a lot of folks don't realize. And we kind of talked about, I actually just talked with, you know, Alyssa from genuine, genuinely OT and she works in acute. And we're talking about how difficult it can be sometimes to get people into inpatient rehab. And it's a little bit of kind of a game of trying to make them sound functional enough that they can tolerate the three hours of therapy, right? Because that's one of the admission criteria that's laid out by Medicare is that they have to, you know, or to get reimbursement in patient rehab. The patient needs three hours of therapy by two disciplines, five days a week minimum. And so if they can't tolerate three hours of therapy, the earth isn't going to want to take them because then they won't get reimbursed. But then you also can't have them be so functional that they don't need three hours of skilled therapy a day. And so it kind of just gets, it's kind of this funky game from like the acute care side of like, okay, how do we, how do we document that they're really motivated, really engaged and can really benefit from inpatient rehab, but also make sure to certain extent that they're not progressing so quickly that insurance will deny them going to earth or that the earth won't accept them. One or the other. Yeah. And we see that like from some of the neighboring hospitals, like when we read their notes, it's definitely interesting. It's something I didn't really think about because when you work in SNF, like this is people's last spots, it's, you know, you don't necessarily have to qualify for SNF too much extent. And so there's so many more rules of sorts. When qualifying for earth. And it makes sense because inpatient rehab is a lot more expensive. And I mean, it does have, you know, because you have 24 hour nursing in inpatient rehab. And you do have that in SNF as well. But then you also have physicians in inpatient rehab. Sometimes they're in the hospital. And then you also have that 60% rule. So you have to have 60% of patients who need a specific qualifying diagnosis in order to go into earth as well. So I remember, you know, if you had a patient that was denied because they didn't have a qualifying diagnosis to go to inpatient rehab, it's because that 60% rule. But the diagnoses are ones that make sense and probably ones that you see a lot of neuro amputations. Some of you are like the people who you think would need three hours of therapy a day versus like a lot of your patients with dementia and some of your kind of just like failure to thrive folks, they're going to go to SNF. They're generally not going to go to inpatient rehab. Absolutely. And you know, sometimes I feel like the outside of 60% slips through, makes it into inpatient rehab. And we work with it, but definitely say a little bit of everything. But for sure, definitely have your own neuro and the amputation, the transplants. And we have a really big research hospital near where I work. And so we get a lot of really interesting unique cases from them, which is cool. But how often, or I guess, how long do you spend with your patients each day kind of on average? The first day or the day of eval, obviously, every patient gets an evaluation from occupational therapy, physical therapy, and speech therapy. And so it's always after speech therapy evaluates the patient. The speech therapists will let us know, hey, I'm not picking them up at all. They don't need speech. Or hey, I'm going to pick up for 30 minutes, or I'm going to pick up up for 60. So we then adjust our plan of care based on going to pick them up or not. And so if it's 60, about four, 60 minutes, and it's, you know, 60, 60, 60, if it's 30, then it's 30, 75, and 70. So, you know, the time in which I spend with a patient does kind of vary depending on if we're good speech or not, my patients that don't get speech and get 90, 90 of each discipline. Like I mentioned, I oversee eight patients, and I provide six hours of patient care in a treatment day. So in six hours of patient care, we have schedulers, and I prefer 60 minute sessions. I don't like 30 minute sessions because I feel like I can't accomplish anything. So I request 60 minute sessions for all my patients. And I understand that that means I'm going to be two patients in a day that I'm not going to be able to read. That's what our code is help with. They help with kind of the offload. I understand that. And I do work from 30 to 60 minutes. If I request the longer session, then I have to request that and I can, but it's typically 60 minutes. Yeah, I think that that lines up with kind of my experience. And I think it's very common that then speech kind of says what they're going to do because they tend to see the patient, usually for the least amount of frequency, or they don't pick up as many patients and then OT and PT generally just kind of split the minutes like that because I think even, I'm trying to think back to my experience, it was maybe every now and then you'd have a patient who would spend two hours with PT and one hour with OT, but that was not very common. It was usually kind of 50, 50. Yeah, there's definitely one off. We actually just had like a brief meeting with our manager about this exact topic where, you know, for the staffing models, you know, it's tough. If you ask for two hours of one discipline and one of the other that kind of messes with, you know, the availability that you have of that discipline. Now, either can be a variety of ways that someone's time gets split, but, you know, so long as they're getting, like you said, those two disciplines are today, three hours, five days a week. Now, I feel like one thing that folks complain about a lot and I complained about this, at least this is how my inpatient rehab facility was, is that there's not always a lot of time to go to the bathroom because you have to meet those minutes that they schedule you so close back to back. Does your facility better about that or is it kind of the same complaint where you go in the morning and then you got away till lunch? I will say that I am blessed. There's a bathroom right in the middle of the unit where it's like right next to my block of rooms. So if I, you know, take a quick potty break, I don't feel like it's the end of the world. I have to meet my own needs, you know, so right? Or if like a patient is, you know, say we just kind of went like, 80s or whatever and they're like brushing their teeth at the sink and I can safely or maybe the CNA is like doing something. Where do I like leave a patient during a session to go to the bathroom? Right. Or I just wait. So I have, I actually have a huddle every day at 11 o'clock. So I have a 15 minute little break in the middle of my day where I can, you know, the bathroom. I don't know. I guess if I have to go, we'll go. I don't know. That's right. Take care of you first, you know, the business can wait. Yeah. Good for you. See, that's what we got as practitioners, we got to stand up for ourselves and we got to stand up for our bathroom breaks. Oh, yeah, absolutely. I mean, there have even been times where like say they're just wrapping up breakfast to be like, all right, so breakfast. I'll be back in less than two minutes. Take those last couple bites and I'll be right back. Listen up. 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We're an affordable program with faculty support tools, a code alignment, and real-world examples that prepare your students for field work and clinical practice. So now is the time to join over a dozen universities who are dedicated to preparing their students for the realities of healthcare. Learn more at the link in our show notes or at amplifyot.com/program. We can get your students started as soon as next week. So no matter where you are in your clinical career, the amplifyot learning platform is here to support you. Yeah, and you know, sniffs are pretty heavily regulated especially because they're nursing homes and there's also just a lot more abuse and skilled nursing facilities and nursing homes and there are in inpatient rehab, I think especially because the staffing ratios are so different. The staffing ratios tend to be pretty decent in inpatient rehab because the reimbursement is there to support those staffing ratios. Versus I feel like a lot of times I did four hours of care in a sniff and I never went back. I don't care and I remember I did not find a nurse for like the first three hours of my shift. Yeah, that that happens. I will say the skilled nurse the one I worked at was at the best at least. Well, that's good. Yeah, and it's you know always there's bad apples and there's good apples. It's about finding finding the ones that work for you and that you can feel good about your work and for sure, you know, how can we help lead the change, right? And I wanted to you know touch on you're talking about the discharge plan and I think you and I talked about this a little bit beforehand of kind of playing off of some of my policy knowledge and some of your lived experiences of why they need to have a firm discharge plan and we can talk about that. But I wanted you to kind of explain kind of from the inpatient rehab perspective and your perspective as to what kind of that discharge plan looks like because that is kind of a unique feature of inpatient rehab because of the continuum of care that sniff does come after in patient rehab versus in sniff. You're not going to go from sniff to earth. There's a reason why herbs want a more firm discharge plan when they come in. But I'd like you to kind of talk about that as to what that looks like from your perspective. Yeah so with discharge plans of course we're supposed to have one when they come to us. There are definitely situations where things change. They thought they had a plan and for whatever reason it's no longer an option. But what I find is that you know we have goals as a facility on the number of patients you know return to community means if they were in assisted living before doesn't count against us because of the environment. It's not a facility. So whether it's independent living assisted living home with family home alone whatever that is a non return to community would be to skilled nursing or an LTCH or return to acute. So obviously as therapists we can't entirely control return to acute but we also can't control if someone has 40 steps to enter their home and they're non-way very non bilateral lower extremities or they have it walked in so long or whatever. I swear they think we have magic once sometimes and I am very grateful that there is something like skilled nursing as a resource for the patients who truly need it and I will say I think if you're working in an inpatient rehab facility setting the goal is always to try your absolute best to get them back home in a safe manner and knowing that skilled nursing is that fallback plan. There's will appreciate that might because they you know people greeting on their backs when there's an uptick and people going to nursing or or anything like that. Part of that other thing that's probably a challenge and I know this is a field nursing and inpatient rehab is basically an inpatient rehab is called the CMG the case excruciating and so they take a diet someone's diagnosis a coded diagnosis any type of complexities or comorbidities and then it kind of put it there a little algorithm that's how it sounds that's what the absolutely you should you should hear their office building it's like that all day long and I should say okay we'll based on this algorithm you we will cover you 10 days and this is for Medicare patients this is not private insurance or commercial insurance but it's really frustrating when sometimes insurance just doesn't cover people long enough to get them to a point to where they can go home and so navigating that can be a challenge as well. Yeah and I think that's especially true because the inpatient rehab has its own kind of case mix group and that's a little bit more similar to kind of a DRG and acute care but you still have like the section GG component that's their functional score right which would place the film and what like 20 oh gosh I'm going to get it wrong it's like 2018 or something around there it doesn't really matter but because it's section GG now no more film and inpatient rehab if you haven't worked in inpatient rehab in a while that may be used to you but in SNF they have PDPM which is even more you know it's a more complicated case mix group and a lot of facilities make decisions based on what they think Medicare might allow or you know the home health agencies do that too where even though Medicare doesn't limit visits they don't you know Medicare is generally not the one who's telling you when it's time to discharge the facility may kind of make a decision based off of what they think the reimbursement's going to be or what they think you know it's all based off of some kind of random well it's not necessarily random but based off of kind of historical claims data and then you've got your Medicare Advantage plans and they really like to they really like to kick people out. Yeah well and I will say any patient rehab care tool not actually yeah but they're I don't want to say some amounts but they're like fraternal twins I think is a good way to put it. They're the same same questions there's like a couple of slightly different wording but they've been continuing to standardize them so home health SNF and inpatient rehab all use section GG and they may still call it the care tool through the IRF-PIE and then LTCH has like a shortened version of it because it was the care tool when it first came out it was the care tool and then they kind of renamed it and they may still call it sometimes an IRF that's still call it the care because they still call it the care like an LTCH but it's the same questions which is easier for CMS because that's part of why they changed it is because the FIM was different from the rug levels and so you couldn't compare patient progress as they move through. Yeah little history less for the impact act. Yeah there you have it and like you said with that quality measure and that's something that especially in post-cute care you know therapy really can have a big impact on quality outcomes. Inpatient rehab is unique because it still has that fee for service element in its reimbursement structure where it requires like three hours of therapy a day so it's still like it's still it's kind of like a partial value system but it's still also partial volume because they're requiring a certain volume of therapy versus the other settings are much more of that value-based payment where it's a little bit more they're not technically bundled payments but they kind of operate like them so it kind of effectively is somewhat like a bundled payment and so you don't have required minutes like in SNF you know you start the rug levels they're gone and so there's no like Medicare set requirement that a patient receive x amount of therapy per day like you have that an inpatient rehab which I think really kind of opens up opportunities for different types of interventions because you have that time. Oh for sure. I think a lot of our some of the more popular accounts that even we see on Instagram where they show these really unique interventions many times the only reason they're able to do those is because of how the reimbursement structure is set up because you guys have a an hour to an hour and a half with a patient versus like in acute care there's no way I'm getting somebody into like a standing machine. Oh yeah yeah the prep work for half of these things is what takes the bulk of the time whether you know getting someone set up on the excite which is like a basically an Easton tower that has functional programs programmed in and the setup of that you know it doesn't do this individual muscle contraction but are like a functional reach or teeth brushing or self feeding so you're putting these sticking all the the little lead Easton pads on all over the shoulder and the arm and in that kind of stuff and then so you set it up but then as we know with research for neuro recovery you have to do practice you have to do these high reps and for that and it self takes a long time so yeah it's I'm very grateful to have those ones to be able to accomplish those types of things because there's allow me to really utilize some really unique skills and get creative and have fun with it. And I think that's the benefit and so if you're someone who really likes kind of thinking outside the box and doing some of those really higher things especially you know neuro I think is such a perfect diagnosis for inpatient rehab because you do need those high reps and that's something even I've kind of wondered about and would like to look in further as I decide what I want to do in the future but something I'd really like to look into is how you know whether or not because of our reimbursement structures it's kind of taken out some of the value that therapy brings because if you look at the research like you said it really requires a lot of these high reps a lot of like kind of prolonged intervention and checking back in but because of how our reimbursement structures are set up and sniff or home health or even outpatient it's near impossible to kind of provide the care that's actually really evidence based for some of these diagnoses. Oh. Yeah, absolutely. Impatientry, I was just such a unique setting, and I think it's a fantastic one for some of those higher level diagnoses, or I guess lower level. The more functionally impaired folks, and I had that at Impatientry, we had two, where we had like meetings almost every day, or case management meetings. So, there is a very team-based approach to figuring out how can we get someone home and what's needed to get them home, because they're so complex. A lot of times they require different equipment. And so, is that something that you participate in, especially as an OT and recommending equipment, or helping order different DME for their house, or how does that look? Absolutely. So, the way that where I work works is by day seven, no matter how long someone's anticipated to stay by day seven, we should have DME orders in, and at least attempted to set up caregiver training. So, one week in, we have to have addressed DME and caregiver training, unless, of course, they don't live with anyone. So, DME, we either go into our little thing and meta-tech and put, no, they don't need DME, even if we think they might end up going to skilled nursing, because if someone's going sniff, you don't order DME, because they're going to another facility, and the other facility will order that for them. But we still put it in, so the orders there, in the events that they don't go sniff, and they get to go home, or whatever. So, that's one way, again, discharging from day one, is that not what we get taught all the time, is like, you discharge from day one, and so we pretty much created a rule, because we've done a lot of trial and error of learning of how do we maintain that metric of return to community, and one of our initiates was day seven, you have to have DME and you have to have initiated caregiver training to some extent. Yeah, to address things early on, to kind of set expectations. But yes, I do order DME, typically, you know, I'm collaborating, again, with my PT counterpart, trying to discuss, you know, understanding that if they're Medicare and most private insurance's follow a lot of Medicare guidelines when it comes to DME. So, one walker or wheelchair, once every five years, a bedside commode, once every five years, they can, you know, if we're going to recommend a wheelchair, we're given a handout and we're going to buy a walker. You know, we want insurance to cover the more expensive of the two or whatever. But interestingly enough, hear me out on this. This happens to me yesterday. I had an order for a bedside commode, denied, because the patient is walking 60 feet. I said, what? Yeah, it's just because someone's walking 60 feet doesn't mean they can get up after toilet. And what about night time toilet in routine? So it had made me sit back and reflect, was like, did I, you know, use justification strong enough that I need to be better at my wording. And thankfully the patient, I mean, you're in this patient is not entirely a polytrauma, but has a lot going on to where one of their struggles is getting up from the toilet. So I basically had to like teach other compensatory ways of like how to safely get on and off their toilet and modify it. But sometimes they come back around and don't cover it. Yeah. And especially with bedside commodes oftentimes, they won't cover a bedside commode. Or it's part of their requirements that they can't have a bathroom like on the same floors to where they're staying. And so if it's not documented, then that may be why they approve it sometimes. But like if they're going to have to stay on a floor that doesn't have a bathroom, they might approve the bedside commode. But if they have a bathroom on that same floor, they often will not approve the bedside commode and that 50 feet thing. I know that's definitely true for wheelchair. So if you can walk more than 50 feet, they will not approve a wheelchair, which is insane. That is insane to me. Right. Yeah. Cause it's one of those things where, you know, how Medicare. And it's like, cause I just talked to someone else about DM me. So there's another episode on DM me coming out, but talking about how we have to be careful how we justify or sometimes too. The third part is with documentation, do we purposely sometimes hold people back because we know it's going to be better for them to try and get approval for some of these resources. You know, and that's kind of something that we've talked about even in acute care, like there's nothing in the guidance that says that if a patient walks longer than 150 feet, they can't go to inpatient rehab. But a lot of inpatient rehab facilities will not take someone if they can walk 150 feet. So there are a lot of patients in acute care where we'd walk them only 100 feet and then head back to the room, even though they could walk further, but we know that they need inpatient rehab for all these other resources, but we wouldn't walk them far enough to get them refused from her. So it's kind of an interesting, interesting game that we play as therapists to try and figure out how can we get people access to the resources they need with also not. We'd never want to endorse doing anything fraudulently, but it's an interesting system we work in. For sure. Even in patient rehab, the folks that are not on Medicare and they're on their private insurance. So those are the people that aren't necessarily insurance isn't putting them through their little algorithm and spitting out a specific date. Sometimes it's a week by week they get weekly authorization. So there's definitely times where I'm like, I really shouldn't progress then to supervision quite yet because we're trying to get off for another week. Exactly. Like they have other things that still really benefit from, you know, I'm not going to put a mod I quite yet. Like I need to see, like, you know, you have to, you have to kind of dance that line. You don't want to make them because sometimes we get excited because we see them progress and then how they look on paper doesn't necessarily reflect how they are a person. And insurance doesn't know the patient. And so the way that we reflect them on paper, we have to be mindful of that and how there may be someone getting cut, you know, your last covered date is going to be in four days and you're like crap. Yeah. And I, you know, that was even hard lessons that I had to learn in acute care. But yeah, it's so important to document your skill to document what's going on with the patient. And I think as therapists, as practitioners, you know, we so much want to give people the benefit of the doubt or, oh, well, you know, I gave them like a little, you know, I gave them a little bit of a touch to balance them. But I bet they could have done it without me. We like to always see the glasses have full, which is, you know, fine, I'm not saying anyone needs to be sad all the time. But sometimes when we give people too much benefit of the doubt or we paint too rosy of a picture, we actually end up hurting our patients instead of helping them instead of being really more objective in what we're documenting and thinking about that insurance piece because that's another part of it too. So we don't think about these pieces. We're really hurting our patients because it's a reality that they're living with that we're really going to truly be holistic that financial component that insurance component is part of a holistic look at a patient's care. Absolutely. And it's funny. You bring that up that is something that I've seen over the years with students and new grads and how we score people on evaluation and that I can talk a whole podcast episode just about this in itself. Because it was a learning thing for me myself when scoring on evil, it is just in our part of her. We want to give people the benefit of it out so much. Oh, they brush their teeth in bed at Sothebasis. No, do they brush their teeth in bed at home? Right. If baseline is standing at the sink and they can't stand without two people holding them up. No, they are not Sothebasis for oral hygiene because you're not capturing that true burden of care. And so capturing the true burden of care is something to keep in mind when you are documenting because that is where insurance is looking for that burden of care and they're looking for the safety. Oh, I love when I'm doing my little weekly plan of care updates. I love throwing in like their re-hospitalization and fall risk. Yeah. Oh, we love those little buzzwords. I always feel so like, yeah. And why do we throw those in there? Because it's expensive. Yes, it is so expensive. And insurance is want to avoid spending more money. Right. And that's part of understanding that influence, whether that's the quality measure, because there are also quality metrics around falls and hospital readmissions, but also falls and hospital readmissions are extremely costly. So insurance would rather pay for an additional week of inpatient rehab, which isn't cheap, then pay for another hospitalization. And so if we can justify that in our notes, you have a much more compelling argument than well, the patient was modest today and they really need to be at stand by assist. They're going to be like, well, it's not me who has to wipe myself. But if you can say, well, you're the one who's going to have to pay for the fall when they can't get up from the toilet, that's a little bit more of a compelling argument to that private insurance company. If you're ready to level up your occupational therapy practice, Medbridge is the partner that you need with hundreds of evidence based courses, plus resources on documentation, policy, and even patient education. Medbridge supports you at every stage of your OT journey. What sets Medbridge apart for me is that it doesn't just focus on clinical skills. It also offers training on reimbursement, compliance, and advocacy. Topics that we talk about all the time here on the show, and here's the best part. As an Amplify OT listener, you get $101 off an individual Medbridge plan when you use the promo code AmplifyOT at checkout. And students, you can use AmplifyOT student for up to $75 off your subscription. So just head to Medbridge.com or check the links in the show notes to get started. When you sign up through these links, you're not just investing in your own growth. You're also supporting Amplify OT's mission to keep our resources accessible and advocacy focused. Absolutely. I, I had a patient who has a specific type of private insurance that I guess this is a patient who lives alone and, Unfortunately, if they could get like three more weeks with us, I feel like we could maybe get them to a point where they could be alone. But due to not the best family support or availability, honestly, I think skilled nursing is the best for this patient. Well, this insurance is infamously known for not authorizing for skilled nursing. Yeah. Unfortunately, this patient has no other option. So it's like, you know, when I was justifying the need for my recommendation to skilled nursing, it was this patient is not safe to be home alone. This patient is a high fall risk. This patient has a very high risk of re-hospitalization. This patient would benefit from the continued skilled interventions from an occupational therapist and another care. So like having to throw those words because it's like, I don't know how else to like tell you guys without grabbing your shoulders and shaking you that like it blows my mind that this is someone who truly would benefit from this level of care. And like the hoops that they make you go through, but then there's some people where it's like they don't ask questions. They just authorize anyone to go to these facilities. Like the difference isn't insurance. It makes me lose my mind a little bit. It's very frustrating. And I agree. Like even from the acute care side, we knew which Medicare Advantage plans would never approve someone to go to inpatient rehab. And so we would always make sure with those patients to kind of make sure that we were very early on prepping them for the fact that they were most likely going to go to SNF, that we would ask their insurance, but most likely they would not go. And here's where things get really frustrating is this is where we start talking about the difference between covered and approved. And this is especially true, right? In your private insurance, which are Medicare Advantage plans are run by private insurance companies is that what's so frustrating and heartbreaking is that patients will call their health insurance provider and say, well, is this covered? And they'll say yes, because SNF and inpatient rehab are technically covered. They're listed as covered benefits. But there's a difference between that and when they approved to pay for it, right? That's the kind of whole thing of the DNA. Like is the commode covered? It's covered. It's covered benefit, but they're not going to pay for it. And that's what's so hard, I think, for a lot of patients to understand. And that's where I think they're built a lot of mistrust in the healthcare system, which is really unfortunate because then they think that we didn't do our jobs to try and justify it for them. But that's what's so frustrating with a lot of these plans is when it's a covered benefit, but you know that that patient is never going to get access to that benefit because they deny it all the time. Yeah, it's very frustrating. And I will say this, all the things that we're kind of talking about, I did not know as a new grad. I just want to preface that. Like, I didn't know this stuff. I learned it through practice, but V, I will go to my case manager and say, explain this to me, because patients will ask you this. They'll ask these types of questions about things. And I say, here's a deal. I have very limited knowledge on the intricacies, especially as it relates to your specific payer source. Let me send the case manager in to follow up. But then I'll circle back and be like, okay, help me understand this because that is how we learn these things. All of this knowledge, I'm not going to lie and say I get some CE on this stuff. Like, no, I didn't. I learned from the people that are around me in my workplace. So this is my little TED Talk on, like, utilize your co-workers to learn about the other disciplines that impact your daily workflow and your patients and all that. Yeah. And I learned a lot from my case managers and like that very issue, like what you're talking about, I didn't know this stuff was a new grad either. I mean, I worked in Home Health as a new grad. And frankly, I did some things that were most likely illegal because my company told me they were okay. And I didn't know. And that's part of why I started my company in the first place. I started to amplify OT. It was to get practitioners access to this kind of information that's easier to understand than trying to read the Medicare document by yourself. That's why I created my course. So if new grad Courtney could have taken a course that was specific to occupational therapy and reimbursement, that's why I talk about, you know, in my Mastering OT policy course, all through all the different settings because they all interact. Because even if you're an inpatient rehab, you still kind of have to know what SNF and Home Health cover because you're referring people to those services. Absolutely. So it's not always enough just to know, like if you're in Home Health, your position's a little bit easier because you're kind of at the end of the food chain. You know, usually you're just discharging patients or maybe they're going to outpatient, but especially when you're higher up in that continuum of care, like acute inpatient rehab and SNF, you really have to know what comes after you and understand kind of hospice and who qualifies for that because we're referring patients to those services. And if we don't know who's qualified for those services, then we're not really making successful plans. And then that makes the case managers life hard and then they don't like OT because we're not making their life difficult. Yes. I mean, helping understand the other settings to help set expectations is very important. You know, when I'm recommending that these patients have Home Health, I always tell them, like just so you know, it's maybe only going to be two to three sessions a week. Right. For an hour at a time. And that's like if you're lucky and that's, you know, as far as how many sessions, that is up to the discretion of the payer source and whatever the recommendation is of that therapist. So, right. You know, people are like, oh, I'm just going to go home with Home Health and like, that's not every day. And that is not to cook for you. That is not to clean for you. That is therapy and check your vitals. It is for nothing else, you know, and that is such a huge, the patients always think, oh, well, Home Health or like they had a surgery 15 years ago and they had Home Health then. And that is not the home health of today. The age of daily age visits is long been gone. And so if we think about that too, where, you know, when you're talking about patients ask these questions, I mean, that's again, part of what spurred me to learn about a lot of this stuff is that I got asked all the time, does my insurance cover this or what is my insurance cover? And I never liked just being like, I don't really know. And especially like in some other settings, I didn't have access to a case manager like in Home Health versus I had a lot of access and acute care. But I wanted to learn so that I could help my patients navigate it because if it's confusing to us, the people who live and work in healthcare every single day, I mean, we can only imagine how horribly confusing it is for our patients. I know because I've watched my family try and navigate the healthcare system and I'm like, okay, here's the questions that you need to ask. Here's what you need to look for. This is how you look at the quality ratings of these different settings and pick which one's going to work for you. And that's for like, if I didn't have that kind of knowledge, you know, my family would have had such a hard time navigating, discharging from a hospital. And so our patients really are relying on us to kind of be that navigator for them. Oh, yeah, you may not have all the answers. But knowing how to guide them to your knowledge and you know, the more you can provide obviously the better, but at least knowing the basics of how to steer them and help expectations and when conversations reach a point where you can't confidently answer anymore, it's okay to say, you know, I don't know the answer, but let me go ask or let me go find someone who can answer for you. Right. Yeah, we never want to make promises, especially around insurance and coverage. That is one of my pro tips, never promise someone that they will receive something when they discharge or, oh, I guarantee you'll get OT when home health comes out because you do not know that or I guarantee, you know, or, oh, yeah, Medicare always pays for this because that is not a promise that you want to make. Then you don't want to build that mistrust with patients in the healthcare system because there is a lot of trust. We are in a really strong position of power that we don't always really recognize that power dynamic that we have with patients. And so we have to be really mindful of that. A lot of patients will believe whatever it is that we say because we're medical providers. And so we have to really make sure that what we're telling them is accurate. I always have to kind of check myself with that to be completely honest. Like sometimes I forget the power that my role has and I'm like, wait, I actually kind of am a big deal. I'm a big deal. And I tell myself sometimes. Yeah. I think, I don't know, we just kind of get lost in the flow and then it's like, oh, wait, yeah, no. I just had a family member the other day sit down kind of unaware with sitting there with a pen and paper and she's like, okay, so what OT recommendations do you have for me? I was like, oh my gosh, she has a pen and paper. She's ready. Like she wants notes. Oh my goodness. Details. Trust and believe in your discharge packet. You'll have my instructions. You don't have to write anything down. I guess print it out for you. But appreciate the enthusiasm. And how much they look to us for guidance. I mean, even my family, when my grandmother was in the hospital, they're like, well, no one will tell us what her true status is. And I'm like, it's because they don't know. And they don't want to promise you that they're going to get better because they don't know that she is. And so they're just going to tell you that today was a good day because they can't make a prediction because what if it's wrong? And too, I think about that of like making recommendations. That was another kind of hard lesson I learned as a new grad is that because I recommended equipment, families would buy it, whether they really could afford it or not, because a healthcare worker recommended it to them. And they kind of expected that I would consider that I surely I wouldn't recommend it if it wasn't worthwhile. And maybe it was a good recommendation. Like maybe they needed the reach or they needed, you know, whatever it was that I said they needed. But did they really need it? Do they need it versus buying dinner tomorrow? You know, and if I don't consider that financial component, then I'm really not being a good therapist. So one of the things when I do give kind of education, maybe like a handout on certain pieces of equipment, if it's something like what I always tell people or what I have found at least with my laptop at work is that Amazon is the most printer friendly website. I try to pull things up on Walmart target or whatever random website. And it just is a printer friendly like things get jumbled. So I always tell people this handout is for Amazon. However, where you choose to buy it, I was like I circled or highlighted the name of the equipment and this is the general features that I'm recommending whether you go to a thrift store of Facebook Marketplace, a family friend or whatever. I don't care where you buy it from so long as it is in good condition and it has these features that you know do x, y and z that is what I care about. So that was like set that purpose of like you don't have to make an Amazon account and purchase something. You know maybe you have a granted that's very Amazon savvy. I find that a lot of times I'm like "What is your fit?" or "You granted?" like can they help you? But yeah and like for example like with hipkits I always tell them there's about 40 different hipkits on Amazon and ranging from $25, $20 to like $50, $60 depending on how much you want it. The bare minimum works just fine. If you want to go up and beyond pop-off sits like go for it. Like more power to you. And sometimes just asking like one of the questions that I learned to ask is like there's ways to ask about insurance or about money in a way that's not condescending because it is a touchy topic because you never want to be like can you afford this because it sounds judgmental. And I always found the best way to kind of address some of those is to ask people are we in a situation where you want skies the limit recommendations like everything and then you'll figure it out or do you want really only the stuff that is absolutely essential cannot live it out like what is our financial situation. And that kind of opened up a conversation at least so that way I'm not giving them a list of all the like would be nice devices that then they feel pressure that they need to buy for. Instead I'm better able to tailor my list of like okay if I had to pick two pieces of equipment that are really going to make a break you know make a difference in your life these are what I recommend versus some folks want everything you know they've got no budget they want all the gadgets and the gizmos and I'll give them a list you know and that's a good way to kind of approach that that's still can taking into consideration their financial well-being because we don't want to cause them financial harm just like we don't want to cause them physical harm. For sure absolutely I agree. Well good. We'd be bad if I didn't agree. Yeah you don't want to do that argument on the podcast right we'll just let me know. So we did get a couple questions on social media for you so I want to make sure we answer them really quickly in rapid fire before we close off so first question recommendations for students starting a level two field work who have never observed in inpatient rehab. I would say be ready to absorb all the things ask the questions take notes don't take mental notes if they're not going to stick take the physical notes and abbreviations new to write it down literally bring in a I tell students bring a notebook write things down whatever you need to do to help you be successful should work for your CI communication with your CI and the exact topic you know how do you learn how do you get feedback how do you retain things we learn about feedback styles and all that stuff in grad school right so like it comes full circle but also just kind of accepting the fact that it's a very fast-paced setting and you have to be very detailed oriented and so finding whatever your workflow looks like I'm very checklist oriented in any of my workflow items my checklists my spreadsheets I share with my students but finding the system that works for you to help keep you on top of everything. Yeah and give yourself a break it's okay not to know everything oh for sure fieldwork I think is one of the most stressful experiences because you don't really don't really have a handle on things like you do at least by time you graduate but also you know that the person who is supervising you has a huge impact on your ability to do what you want to do you already spend all this money and now you're just hoping that the other other person is going to be supportive and that's a it's a tough situation again another time where especially us as who are supervising students can need to check our power as well and check the ego and make sure that we're doing our due diligence with our with our students that's our hard spot. All right second question and last question tips for managing a busy caseload and productivity and inpatient rehab. So for managing a caseload I literally made a spreadsheet like I have like a word document that has eight rows and I have different columns I have columns for so it's like their name the room number in the attending physician and then I've got a row or a column for the general diagnosis that's I could get rid of that one but then I have what DME they own what DME don't need column for if the DME order is in a column for a caregiver training has been set up scheduled we're done and then a little bit about their oh their discharge date and then a little bit about the home setup you know lives alone in a single story home with two steps to enter walk in shower with grab bars but like the general whatever these are all pieces of information I'm getting now my e-vail that I'm literally just copying and pasting into this little spreadsheet and I'm very visual so I have this color coded it's slightly obnoxious it's what I have to make that work for me but that's how I manage things I can visually see who's got what in and what's missing what I need to follow up on today do you have that for sale somewhere because I feel like you should I feel like that's something that people would buy for me corny thank you for that idea I don't know I do that might be I think that would be helpful because that was I mean other therapists I know that I work with have kind of a somewhat version these are like you know in these 12 hour therapists they have to give a handoff to each other each day so their handoffs are like but that's what inspired me was like this handoff concept just a handoff to myself every single day so and then you know I have checklist for my e-vails and my discharges that is like you know the things that I have to get done but productivity you know I am blessed and that I worked a little over four years in skilled nursing to where I've conquered pretty good point of service documentation I know I feel like I'm probably one of the few therapists that do point of service documentation and it's mostly just because that's in my blood and there are ways to do it legally and ethically in case anyone's wondering or a plenty of ways to do point of service documentation because I am also a supporter of point of service documentation as long as it's legal and ethical and there are plenty of ways to do it and frankly I found it very beneficial in a lot of settings to make sure I'm capturing accurately what's happening but also really forces you to go over the plan of care with the patient which is really important for sure yeah and there's definitely sessions where I don't touch my computer for you know sessions at a time and that's okay I don't mind documenting during lunch you know spending time everyone's opinions on that is different but if I'm you know type in a couple things in between bites that doesn't bother me personally and I typically don't have too much to do over lunch yeah so I don't know and then it's once you get used to your EMR system obviously things go a lot quicker you know how to abbreviate things you know how to be more concise with your verbiage that makes a big difference I think in grad school we learn how to be wordy in grad school and then all of a sudden you know the text box that you get only allows so many characters and you're like crack how do I say this real quickly yeah I feel like that's always the big thing when I have new fieldwork students is breaking them of the habit of writing in full sentence paragraphs like nope it can just be patient blah blah blah doesn't have to be the patient greeted me with a warm affect you know like no just straight to the point cut out almost 90% of those words yeah absolutely it's always the challenge but yeah well I think those are fantastic tips and I think you know it's fine because you said before we talked when we were talking about doing a podcast that you're like well I don't know if I can talk too much about the policy side but you know we talked about like all a lot of the things that you talk about are all informed by policy and insurance and reimbursement and once we kind of realize that that's where that stuff is coming from it makes it a lot easier to know one word to look for information but then two also how to know to check it as well that makes sure that you're getting told the right information and it just helps the system make more sense because it is a system with rules and laws and all sorts of stuff and knowing how it works makes things a lot a lot less friction frictionless a lot less difficult yeah absolutely well thank you Courtney for your time I'm so glad that we finally got to connect and chat and talk all about inpatient rehab and I look forward to seeing you all over Instagram well thank you for having me it's a pleasure in an honor and yeah you know where to find me I'm always there in some way or another yes if you don't follow Courtney follow her on Instagram at Courtney the OT anywhere else that people can find you not really I mean I guess TikTok but honestly I really don't like the stuff I post on TikTok is also on my Instagram yeah that's how I am TikTok is a very very long afterthought TikTok is just where I get the ideas and like I make the stuff in there so yeah all right well thank you so much Courtney and I will talk to you later all righty thank you if you made it this far I want to just take a moment to say thank you so much for listening to the amplify OT podcast and I hope you're feeling a little more inspired and prepared to amplify your value and the value of occupational therapy if you found yourself at any point thinking gosh I guess policy is isn't that dull and boring, and you're definitely going to love how we talk about policy and advocacy in the Amplify OT learning platform. There's a link in the show notes where you can sign up today so you can take an immediate next step towards emerging as a competent clinician. And of course, don't forget to follow the Amplify OT podcast so that way you never miss an episode. And you know, while you're there, why don't you go ahead and leave us a five star review because that's the best way to help others find the podcast too. And of course, thank you so much to Jessica Ricchio for editing this podcast and for all of you for giving me a reason to record it. You're now officially part of the OT Amplifier community and you are now prepared to go out there and advocate for OT because remember, if we don't advocate for occupational therapy, then who will?