Setting Up a Stroke Rehabilitation Unit

During MD residency, one may learn skills and get a degree. What they may not learn is financial aspects of care, administration and other issues are equally important in staying viable in health care. Unfortunately, post-degree employment requires one to know this to survive. Specific training for this is nice, but a luxury many cannot afford. What alternatives exist? PART 1: RECONNAISSANCE Hospital boards on hiring will insist on having a state-of-the-art department like the current wonders. They offer anything, but the cost may not be overtly stated. They want big revenue. Knowing the neighbourhood is the first critical step. Where is the nearest similar centre? Whom do they serve (Socio-economic Status)? Who will give patients for your service? How much per month? What severity of cases will you treat? What basic and advanced services do you need for that group of patients? Financially what is their viability? How long can they keep following up with you/how frequently? When you start approximately how many numbers per month will you have initially? Reconnaissance is critical. Having built a reputation take time to retrospect on your annual growth of inpatient (IP) and outpatient (OP) and make a growth plan. All that remains is having a hunger to grow and being more marketable than the upcoming competition. This way you won’t be left behind. What really helps is having a comprehensive care guide based on the available evidence custom-tailored to the country.[1] Know yourself: Why are you in this? Doctors have a fiduciary duty to patients. At some point, altruism is the foundation for action. This also determines how much time and effort you will invest in work. One must support family and make a name for themselves. That comes from good outcomes. Satisfied patients are your best marketing tool. While it is challenging in rehabilitation, the other path is to have more/newer/different treatment options. Employer: The varieties are Government Medical College Hospital/District Hospital/Primary Health Care Centre, Corporate, Non-Governmental Organisation, Private teaching and Private clinic. Conventionally, government servants will have maximal accessibility to patients but may not have the latest technology. Vice versa may be the case in private settings. To stay relevant, many of the latest developments come from this sector. The government has a fixed salary progression scale, whereas the extremes are possible in private. Employees: Who is there in the team outside the patient: you, auxiliary staff, etc., These are your regular expenses. Some are also your revenue stream. They take 15%–30% of their total monthly income as their salary (more for seniority). Naturally the more employed, the more they should generate. Therapists slow down with age until they retire. Juniors bring in the bulk revenue. They come to learn from good seniors. The ratio of senior to junior is very important (1:2 is optimal). Some paramedical societies have positioned themselves where they demand larger salaries at the outset. They should be made to work harder and bill higher for that purpose. There are limits to what you can do based on who is in your team (tracheostomy patients, autonomic instability, etc.). PART 2: LOCATION, LOCATION, LOCATION Cities will often have major hospital chains specialising in fancy services at touch-and-go frequency with a heavy price tag. Most of them will have a feeding basin of 10–20 km. Small clinics might tap into a 5 km radius. They may also have more regular follow-ups. Of course, bigger centres will have more numbers and as a result will have subspecialities such as neurology and even stroke centres. Smaller centres might receive sub-acute/chronic stable stroke survivors in small numbers. This norm can be defied by investing in technology. PART 3: TIERS OF CARE The below is framed in terms of daily IP/OP stroke volume, services offered, goals of care and what is needed for each. Tier 1 Basic: no IP/1-5 OP per day, services offered are what is needed for therapists and minor interventions by the physiatrist. This is often a day-care service based in a clinic. Often nurses and PT are the only auxiliary staff, with or without OT. This means swallow-related work is done by the physiatrist. As the population is medically stable, it’s likely these issues will be just maintenance/palliative. Botox with a nerve stimulator is an option. If the centre also serves pain patients, then ultrasound procedures are an option. The key marketing angle is ease of access and follow-up. The centre needs to be designed accordingly. Competition is often with local therapy clinics. Tier 2 Intermediate: 1–20 IP/5–15 OP per day, Physical Therapy/Occupational Therapy/Speech and Language Pathology/Medical Social Workers/Rehab nurses. This is often a freestanding building on a hospital campus. Neurology may be present and will be sending patients. If strokes are admitted for acute care but not coming to PMR either approach/enquire why or inform administration of the potential revenue loss. Physiatrists will need to be on-call and handle acute care issues, along with standard rehab needs. On top of the prior mentioned, one can now introduce robots and other technologies into care. Many corporate hospitals fall into this domain. The key marketing angle is expressions of superiority. Whether this is reality or not is relative. Of course, this is ‘the best’ compared to the prior. Competition is often local therapy clinics and basic physiatry clinics near the patient. Tier 3 Advanced: While infrastructure is similar here, what differs is the addition of research staff. This is often a teaching department of physiatry and the goal is preparing future generations along with publishing in indexed journals. Non-invasive brain stimulation and other rare techniques are hallmarks. Being uniquely posed in the chain of care this centre can collaborate or compete with the prior mentioned centres. In the latter, both patients and physiatry win because all participants get credit. Tier 4 Community: Anything goes as far as staffing and infrastructure. This is where NGOs really shine, and the goal is maintenance/palliative care or community-based rehabilitation. Portable technology and individual skill dominate. It is a wonderful venue for budding physiatrists to get into due to sheer volume of exposure, expenses being covered to a degree and eventually feed into one of the prior mentioned. There is no existing competition for this. PART 4: CARE PATHWAY FOR LIFE Regardless of what tier you fall into all Physiatrists must be able to provide a care pathway for the rest of life. Ultimately, stroke rehabilitation is more than paramedical therapy services. As the neurological window of recovery wraps up at 12 months, care thereafter is maintenance or palliative. Therapists no longer add value. A care plan for the remainder of life is key. This plan should both meet the patient/party-educated expectations and be cost-effective. The key player here is the patient family, and the all-star on this field is the physiatrist who knows the work of everyone on the team. This one-person army can teach the family what is needed, how to do it, and monitor progress via telerehabilitation. PART 5: ASSOCIATED REHAB SERVICES THAT STEM FROM OR RUN PARALLEL TO THIS TO BOLSTER YOUR UNIT Cardiac: This is what all stroke survivors need as much if not more than aspirin. Robotic: A simple acute care robot like a supine Motomed Viva is a great place to get started and bolster the work of PTs, who may not be able to work as much as this in a day. HBOT: No other stroke intervention heals the damaged brain. This is the foundation for a better-than-usual outcome.[2] Peripheral nerve surgery: Selective tibial and median neurotomy are useful in patients with hypertonia with a restricted range of motion who also have some degree of antagonist-selective voluntary motor control. While cases might be low, outcomes (when the patient is chosen correctly) are good. Drug pump implants: This may not be needed for the majority of patients, but useful and a feather in the cap for generalised spasticity. PART 6: SEEING GREEN Either you see green in the form of envy, or you see green in the form of money. This sounds horrible because no one gets the health care to be jealous or rich. We do it to take care of people. Good patient outcomes are what make a difference and give us satisfaction. If you are your own boss, you need a successful business model. If you’re not your own boss, then you must respond to someone else, and they will only care about money and reputation. PART 7: BUMPS IN THE ROAD AND NAVIGATING THEM While physiatry is the star of stroke rehabilitation, the biggest obstacle we face is ourselves. Many graduates are honed in Physical Medicine and are shy of rehabilitation. As a result, they cannot toe the line when an employer asks for a neuro-rehab centre to be set up. Any fool can write physiotherapy on a paper and step back. In some place, this has been the practice for a few decades. Some of our allied colleagues believe that not only this is all we do. Some feel that they can do the same. The complexity of rehab is lost on them as they often have no exposure to it as MBBS trainees. Mainstreaming physiatry into MBBS is critical for humanity, regardless of who feels otherwise. As individuals, we can bombard NMC with information to the same effect. Regardless this is for the association executive suite to tackle. Much of health care is moving towards cashless systems. Who gets what care is decided by insurance companies who often hire non-medical people to make these decisions. Until patients get access to us, some reimbursed service will get them instead. They will write consults to therapists and believe they are the rehab specialists. Some corporate hospitals have an intricate system that empowers PMR while deceiving the insurance companies. This is a great way to build up a robust service. Stroke rehab mimics abound. The most common is the local therapy clinic. The next step up is an Ayurveda spa with therapists.[3] Another common mimic is the corporate/private non-physiatrist who knows what we do and fears us, or is ignorant and thinks they can replace us. Another is the needle jockey who refers everything to a therapist after their fun injecting. Clinicians like this don’t know what to do with the worst strokes. If you can do something for those patients, most will happily refer to you. Consider it getting your foot in the door. What do we do with these patients? What separates us from them is knowing how to use the ICF in care. The only answer to this microaggression is to define yourself by good outcomes and pray that common sense prevails. CONCLUSION Be so good that no one can ignore you.