CURRENT COMMENT The Selection of Rehabilitation Centers By MORTONA. SEIDENFELD P HYSICIANS and their paramedical colleagues are becoming increasinglj concerned about finding suitable rehabilitation facilities for their patients The question is frequently asked “why are there so many different kinds of places for rehabilitating the patient with disabilities?” The reason for this question is the confusion that exists regarding the nature of the rather wide variety of centers at which rehabilitation programs are being carried out. It is a justifiable question when we recognize that there are at least nine different types of centers described by Redkey.’ These include ( a ) treatment centers; ( b ) medical rehabilitaticn centers; ( c ) state vocational rehabilitation centers; ( d ) sheltered shops; ( e ) single disability centers; ( f ) community-typ? centers; ( g ) insurance co. centers; ( h ) workmen’s compensation centers and ( i ) speech and hearing centers. The practitioner who is dealing primarily with patients suffering disabilities as the aftermath of rheumatic disease is not likely to be equally interested in all these various types of facilities. However, if he is to make the best use of local facilities it would seem highly desirable that we have a clear understanding of what we can expect from the various types of centers we do use. To this end, Redkey’s basic report “Rehabilitation Centers Today”2 has been reviewed and treated in a somewhat different fashion from the original form in order to compare certain aspects of one type of center with that of another. Thus, the results may be helpful in aiding clinicians and others to understand the particular values m each type of rehabilitation center services. In his basic study: out of an estimated 100 centers, Redkey succeeded in getting reports from 77 centers, of which 65 were ultimately used. The data was obtained only through 1956. There are undoubtedly more centers today. However, his data has been broken down into the several categories described by him in his earlier report1 in order to see something of how these different types of centers operate. It was soon recognized that the majority of centers reporting (82.7per cent) consisted of only three types, the treatment center, the medical rehabilitation center and the community-type centers. Since these are the most universal form currently in operation, the balance of this report will be limited to comparative data on just these three categories. These three categories of centers are defined as Redkeyl has suggested. (Underlining is our own.) The Treatment Center . These are usually very small . . most often have a narrow range of services. They frequently begin with only physical therapy and occupational therapy services, do not have a medical director and do work on the prescription of the referring physician only From the Department of Medical Care, the National Foundation, New York, N . Y. 557 558 CURRENT COMMENT They tend t o limit their work to orthopedic cases. They are relatively inexpensive, limited to outpatients and usually operated by nonprofit corporations established for the purpose . . . They frequently come into being becausc? physical medicine services in community hospitals are undeveloped ... The Medical Rehabilitation Center . . . of more reoent origin . . . an expression of the insreasing medical imr~ortrmceattrihzcted to the new medical specialty of physical medicine and rehabilitation. Because of th-ir setting in a hospital or a medical school, they emphrisize very early introduction of rehabilitation procedures in medical care. Some of them hsve developed unusually good facilities for diagnosis and may engage in training programs. Their greatest contribution has been im physical t%~~totation, . . thus far, as a class, been slow to serve extensively the tuberculous, cardiacs, epileptics or the mentally retarded . . . for the most part [they hace] only slowly introduced psychological and social smvices, o f t m not on n concentrated basis. Their contribution in the way of vocational services, with one or two exceptiony, lzas been insignificant . . . Idtie to1 greater interest in the meclical side of rehabilitation and their tendency t o think of rehabilitation as a medical specialty rather than as a long process. The Community Center These are of several varieties; many have developed out of more limited treatment centers, and most offer a fairly wide range of services. They are operated by nonprofit corporations and are notable for flexibility in planning and increasing attentim to psychological, social and to some extent, vocational programs. They are often outpatient centers, although a number have beds and others are adding them. Keeping Redkey’s definitive statements in mind, let use examine briefly the comparative data on some of the aspects of these three types of centers based on the Redkey data. A study of the findings strongly suggests that in most areas of service the medical rehabilitation centers and the community rehabilitation centers offer a great deal more service to the patient than the treatment center is likely to have available. However, few if any of these types of centers offer adequate psychiatric screening or therapy. It would seem logical, therefore, to deduce that treatment centers should be reserved for those patients with minimal needs for anything other than physical therapy, occupational therapy, psychological services and social work. There is also strong evidence of a very heavy preponderance of physical therapy and occupational therapy services in the treatment center while the medical rehabilitation center is more likely to have its greatest professional personnel assigned to the total medical care program. The discrepancies are often emphasized further when one realizes that many of the treatment centers have no medical personnel, no nursing staff, no psychological services. This is far less true of the medical rehabilitation centers and the community rehabilitation centers. All three types of centers carry heavv loadings of patients in the three major areas of patient care, and the task is to select the type of center that is most likely to render maximum service to the patient. One way one may arrive at a decision regarding the selection of the most suitable type of center would SELECTION OF REHABILITATION CENTEHS 559 be to weigh the extent to which each type of center offers the broadest service program and the relative cost of such services per patient treated. It is necessary to recognize that functionally these centers differ from one another with reference to the type of patient that i s served in each. Treatment centers serve outpatients predominantly. Only two of the nine treatment centers reported in the Redkey study served any inpatients whatever. Actually, in the nine centers a grand total of 5317 patients were served in a year, only 7 per cent of whom were treated on an inpatient basis. The per patient cost a5 based upon the total number of patients served and the estimated annual budget reveals great variation with a range of $57.40 to $551.16,over-all cost per patient. The mean expenditure per patient for this type of center was $118.49.If we limit our attention to the treatment center serving outpatients alcne, the average per patient cost is $169.93. Medical rehabilitation centers, contrary to some opinion, serve nearly as many outpatients as inpatients. Of the 22 centers in the study reviewed here, three did not send in reports that covered their patient load and annual operating budget. Of the remaining 19, only one served OP’s only, two served inpatients only, and 16 served both types of patients. Of the 19,775 patients served, 56 per cent were in the outpatient service and 44 per cent inpatients. The average cost per patient varied from a low of $37.62 up to a high of $2,622.70in an institution serving inpatients only. The high for institutions serving both types of patients was $2,592.89.The mean expenditure per patient was $319.24. The community-operated rehabilitation centers totaled 20, three of which did not have adequate reports of patient load or annual operating budget. The overwhelming majority (95 per cent) of the patients were treated on an outpatient basis. Four of the 17 centers do accept inpatients and in these four centers the 0P:IP ratio is 2:l.The average cost per patient is $191.03 in centers carrying only OPs (13) and $363.59 in the four centers with combined OP-IP programs. The vast majority of patients are served on an outpatient basis in all three types of centers, with only the medical rehabilitation center serving any sizeable proportion as inpatients. This would suggest that as matters exist at the present time it would be most wise to utilize the medical rehabilitation center for all patients requiring maximal medical attention while undergoing rehabilitation. The cost per patient will be high; nevertheless, for the amount of service available it is less expensive than similar services offered by commmity-operated centers. On the other hand, patients who can profit from outpatient care can be placed in the community-operated center at very little increase in cost over that of the so-called “treatment center” with the likelihood of more adequate services being offered. While the data at present is both “skimpy” and not too reliable, the trend indicated warrants the above assumption until further study establishes the fact more reliably. The acceptance of patients under 16 years of age has not received the attention it warrants. This study reveals that 100 per cent of the treatment 560 CURRENT COMMENT centers accept patients under the age of 16 with these patients constituting on the average 24 per cent of the patient load. About three-fourths of the medical rehabilitation center with somewhat less than 18 per cent of their total patient load constituted this category of patient. Eighty per cent of community rehabilitation centers accept such children representing about 24 per cent of the total patient load. It is clear that a much needed area of extension of rehabilitation center services, especially to medical rehabilitation centers, is in the field of juvenile rehabilitation. Proper development of such programs would lead not only to improved care but to better medical, social and psychological outcomes for the child and adolescent patient growing into adukhood. REFERENCES 1. Redkey, H.: Rehabilitation Centers in the United States and Canada in ‘‘Prooeedings of the Institute on Rehabilitation Center Planning,” U. S. Departnient of Health, Education and Wel- fare, 1959, pp. 33-48. 2. Redkey, H.: Rehabilitation Centers Today. Rehabilitation Service Series, Government Printing Office, Washington, D. C., 1959. Morton A. Seidenfeld, Ph.D., Assistant Chief, Division of Research and Demonstration Grants, Office of Vocational Rehabilitation, Department of Health, Education and Welfare, Washington, D. C .