CHAPTER 5: PHYSICAL AND REHABILITATION MEDICINE IN HEALTH CARE SYSTEMS
5.4 Physical and Rehabilitation Medicine in Health‑Care
Systems: Postacute Levels of Care
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Peter A. Lim1,2
1
Department of Rehabilitation Medicine, Singapore General Hospital, Singapore, 2Department of Physical Medicine and Rehabilitation, Baylor College of Medicine,
Houston, TX, USA
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Curative, Preventive, and Rehabilitative Medicine
For much of the history of health care, the curative imperative
has dominated and associated specialties have flourished.
In pharmaceuticals, the early potions and antibiotics have
progressed to biologically‑active drugs and stem‑cell therapy.
The quick‑handed barbers with sharp blades capable of
performing amputations within seconds have advanced to
complicated surgical reconstructions and multiple‑organ
transplants. The rudimentary microscope and Roentgen X‑ray
machines have gone on to computerized tomography, magnetic
resonance imaging, positron emission tomography scans, and
DNA testing. They all have in common a focus on finding the
cause of disease or injury, and curing it.
It was subsequently recognized that much more has been achieved
in preventive medicine and public health. Clean water and proper
sanitation have saved millions of lives, and vaccinations have
prevented the loss of many more. Public health strategies and
policies such as quarantine and contact tracing of infected patients
has been successful in limiting catastrophic epidemics in more
recent times. Laws including safety belts and restraints, crash
helmets have mitigated the impact of trauma. Public education on
issues ranging from eating right, smoking cessation to exercising
have had good albeit sometimes only partial success.
In the continuum of health care however, it is only relatively
recently that rehabilitative medicine has received deserved
attention. Across the world, economic development and
cultural changes with improving health indices are resulting
in the phenomenon of aging populations. As life expectancies
lengthen, so has incidence of disabilities with a direct
correlation between age and number affected.[1] In addition,
society increasingly values bigger, faster, and higher. Motor
vehicle accidents, violent sporting pursuits, work‑related
trauma, injuries, and falls may result in brain, spinal cord,
and back injuries, repetitive stress disorders and other related
health problems that require rehabilitation.
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© 2019 The Journal of the International Society of Physical and Rehabilitation Medicine | Published by Wolters Kluwer - Medknow
Physical and Rehabilitation Medicine in the
Health‑care System
Physical and Rehabilitation Medicine (PRM also known as
rehabilitation medicine [RM]) is part and parcel of a good
health‑care system. Depending on the type, level, and case
mix of the hospital, potentially 5%–10% of patients will
require inpatient rehabilitation services. A recent study from
Canada[2] using a Stroke Rehabilitation Candidacy Screening
Tool (SRCST) revealed that 37% of stroke patients were
appropriate candidates for inpatient rehabilitation. The
SRCST included the AlphaFIM® score, ability to follow
commands, rehabilitation goals, functional improvement
demonstrated over time, verbal consent to participate, and
rehabilitation readiness including tolerance to sitting and
medical stability.
The South Australia Government has stated that as its
population ages, the need for rehabilitation services
will increase, and that rehabilitation is part of all patient
care. It should be provided acute care, ideally for a short length
of stay (LOS) with a straightforward program before discharge
home, or until transfer to a specialist rehabilitation unit where
a formal multidisciplinary program is provided to facilitate
independence and attainment of goals.[3]
In a large multicenter cohort analysis on 5739 patients with
acquired brain injury, spinal cord injury, peripheral and
progressive neurological conditions undergoing specialist
rehabilitation in England, functional outcomes, care needs, and
cost efficiency were evaluated. All groups showed significant
reduction in dependency between admission and discharge on
Address for correspondence: Prof. Peter A. Lim,
Department of Rehabilitation Medicine, Singapore General Hospital,
169856, Singapore.
E‑mail: peter.lim.a.c@singhealth.com.sg
This is an open access journal, and articles are distributed under the terms of the Creative
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remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
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For reprints contact: reprints@medknow.com
How to cite this article: Lim PA. 5.4 Physical and rehabilitation medicine
in health-care systems: Postacute levels of care. J Int Soc Phys Rehabil
Med 2019;2:S87-92.
S87
 Lim: Physical and rehabilitation medicine in healthcare systems: Postacute care
all outcome measures used, with reduction in weekly care costs
of 760, 408, and 130 pounds/week in the high‑, medium‑, and
low‑dependency groupings, respectively.[4]
PRM plays an important role in the development of new
approaches and strategies for improving the care and
rehabilitation of patients with disabilities. This includes clinical
trials, and the difficult but crucial task of data collection and
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rehabilitation database analysis.
Services Provided by Physical and Rehabilitation
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Medicine
The classic RM physiatrist has two main distinct roles:
i. Management of the complicated “fragile” or potentially
unstable rehabilitation patient with specialized needs, for
example, spinal cord or traumatic brain injuries, severe
strokes, multiple sclerosis, cardiopulmonary diseases,
cancer, and renal failure patients on hemodialysis. These
patients require physician supervision and specialist
intervention for complications such as spasticity,
thromboembolism, anticoagulation, and depression while
undergoing an intensive multidisciplinary rehabilitation
program. Typically, the goal is for a discharge home
within a relatively fast time period
ii. Consultation and management of the rehabilitation
needs and complications of more stable patients though
the continuum of care from community hospitals,
day rehabilitation centers, and to nursing homes. This
will require a close collaboration and coordination
with the therapists, geriatricians, palliative care, and
family medicine physicians who may be a part of the
rehabilitation care.
There are also PRM physicians who work mostly or
exclusively in the clinic or ambulatory care setting. These
include specialists in nonoperative pain management, sports
medicine, and outpatient occupational injuries. They are well
suited for undertaking this role in comprehensive assessment
and diagnosis as well as rehabilitative management of such
patients.
i. The training of a physiatrist or PRM physician includes not
only medicine but also a neurological and musculoskeletal
emphasis that includes anatomy, physiology, psychology,
and biomechanics. This enables a comprehensive holistic
assessment and treatment plan based on the functional
as well as medical perspective. An X‑ray is not seen as
only bones, joints, and soft tissue but also its potential
for range of motion, strength, endurance, spasticity, and
pain.
ii. The PRM physician is trained in and has a good
understanding of many “languages” including that of a
physician, surgeon, psychiatrist, therapist, social worker,
orthotic and equipment specialist, and prosthetist. This
enables the PRM physician to function as the ideal
orchestra conductor of the medical rehabilitation team.
S88 The Journal of the International Society of Physical and Rehabilitation Medicine ¦ Volume 2 ¦ Supplement 1 ¦ June 2019
Postacute, Acute, Subacute, and Long‑term Care
Rehabilitation
The terms acute and subacute rehabilitation are often difficult
to precisely define and delineate. The term “postacute”
rehabilitation may more suitably cover the continuum of care
though which rehabilitation occurs, from the hospital into the
community. The PRM physician may initially be involved in
rehabilitation triage and care while the patient is still in the
hospital intensive care unit (ICU), with prehabilitation prior
to surgery, and in the optimization of a patient’s condition
before chemotherapy. A period of inpatient rehabilitation
stay may subsequently be needed where the patient receives
intensive comprehensive rehabilitative therapy intervention
of 3 hours or more, while medical management continues
under the physiatrist. For patients requiring lower intensity or
“slow‑stream” rehabilitation, a skilled nursing facility (SNF) or
step‑down community hospital stay for a longer period may be
appropriate. Some patients require physiatrist follow‑up in the
settings of nursing homes/extended or long‑term care (LTC)
facilities for maintenance rehabilitation programs to avoid
deconditioning and physical deterioration. Occasionally, the
physiatrist may be involved in home‑based care and assisted
living programs.
Settings for Postacute Care
The US National Stroke Association’s Complete Guide to
Stroke (1st Edition, 2003) refers to the option for rehabilitation
at different locations including: (i) rehabilitation unit in the
hospital, (ii) subacute care unit in the hospital or extended care
facility, (iii) a rehabilitation hospital, (iv) home with outpatient
therapy, (v) stroke day program, (vi) LTC facility providing
therapy and skilled nursing care, and (vii) home therapy.
The US model allows differentiation for postacute rehabilitation
interventions and the following is based on Centers for
Medicare and Medicaid Services (CMS) publications.
Inpatient Rehabilitation Facility
Inpatient rehabilitation facilities (IRFs)[5] may be freestanding
rehabilitation hospitals or rehabilitation units within acute care
hospitals. They provide an intensive rehabilitation program
with patients able to tolerate 3 hours of intense rehabilitation
services per day. Group therapy may be included but not be the
majority of therapy provided and must be well documented.
At least 60% of a facility’s total inpatient population must
require treatment for one or more of 13 conditions, namely, (i)
stroke, (ii) spinal cord injury, (iii) Congenital deformity, (iv)
Amputation, (v) Major multiple trauma, (vi) Fracture of
femur (hip fracture), (vii) Brain injury, (viii) Neurological
disorders, including multiple sclerosis, motor neuron diseases,
polyneuropathy, muscular dystrophy, and Parkinson’s
disease, (ix) Burns, (x) Active polyarticular rheumatoid
arthritis, psoriatic arthritis, and seronegative arthropathies, (xi)
Systemic vasculitides with joint inflammation, (xii) Severe
 Lim: Physical and rehabilitation medicine in healthcare systems: Postacute care
or advanced osteoarthritis involving two or more major
weight‑bearing joints (elbow, shoulders, hips, or knees)
with joint deformity and substantial loss of range of motion,
atrophy of muscles surrounding the joint, (xiii) Knee or hip
joint replacement (with bilateral joint replacement surgery,
extremely obese with Body Mass Index of at least 50, or age
85 or older).
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In general, there must be significant functional impairment of
ambulation and other activities of daily living (ADL) that has
not improved after an appropriate, aggressive, and sustained
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course of outpatient therapy services or services in other
less intensive rehabilitation settings immediately preceding
the inpatient rehabilitation admission. However, the patient
has potential to improve with more intensive rehabilitation.
Patients with comorbidities secondary to the principal
diagnosis may also be included under certain conditions,
e.g. significant decline in functional ability requiring intensive
rehabilitation treatment unique to IRFs that cannot be
appropriately performed in another care setting. IRFs provide
intensive rehabilitation services using an interdisciplinary
team approach in a hospital environment and for patients with
complex nursing, medical management, and rehabilitative
needs. The patient must:
• Require multiple therapy disciplines ( physical
therapy (PT), occupational therapy (OT), speech‑language
pathology, or prosthetics/orthotics), at least one of which
must be PT or OT
• Require an intensive rehabilitation therapy program,
generally 3 hours/day at least 5 days/week; or in certain
well‑documented cases, at least 15 hours within a
7‑consecutive day period
• Reasonably be expected to actively participate in and
benefit significantly from the intensive rehabilitation
therapy program
• Require physician supervision by a rehabilitation
physician, with face‑to‑face visits at least 3 days/week
to assess the patient both medically and functionally and
to modify the course of the treatment as needed
• Require an intensive and coordinated interdisciplinary
team approach to the delivery of rehabilitative care.
Long‑term Care Hospital
LTC hospitals (LTCHs)[6] are certified under Medicare as
short‑term acute care hospitals, but generally treat medically
complex patients who require long‑stay hospital‑level care.
For Medicare purposes, they are generally defined as having
an average inpatient LOS >25 days.
LTCHs use the Medicare Severity‑LTC‑Diagnosis Related
Groups (MS‑LTC‑DRG) as a classification system. This is
similar to the MS‑DRG; the CMS uses under the Inpatient
Prospective Payment System but weighted to reflect the
different resources used by LTCHs. Each patient stay is
grouped into an MS‑LTC‑DRG based on diagnoses (including
secondary), procedures performed, age, gender, and discharge
The Journal of the International Society of Physical and Rehabilitation Medicine ¦ Volume 2 ¦ Supplement 1 ¦ June 2019
status, and has a predetermined average LOS which is the
typical for such a patient.
Skilled Nursing Facility
The terms SNF, nursing facility or home, and convalescent
home may often be used interchangeably. They all describe
residential facilities that provide on‑site 24‑h care, but the
SNF[7] is a facility with a higher level of care provided by
trained individuals including registered nurses, licensed
practical nurses, physical therapists, occupational therapists,
speech‑language pathologists or audiologists, and medical
social workers. These services may be for a period of
rehabilitation from an illness or injury, or for those needing
LTC on a continuous basis due to chronic medical conditions.
Skilled nursing and skilled rehabilitation services are those
services furnished according to the physician orders.
Comprehensive Outpatient Rehabilitation Facility
Comprehensive outpatient rehabilitation facilities (CORFs)[8]
provide coordinated outpatient diagnostic, therapeutic, and
restorative services at a single fixed outpatient location, for
rehabilitation of injured, disabled, or sick individuals. PT,
OT, and speech‑language pathology services may be provided
in an off‑site location. Core services to be provided include
consultation and medical supervision of nonphysician staff,
establishment and review of the plan of treatment and other
medical and facility administration activities, PT services,
social or psychological services.
Postacute Care in Singapore
Introduction
Singapore is a city‑state in Southeast Asia with a population of
5.6 million. Although an island only 720 km2 in size (smaller
than New York City), Singapore is a major international
city engaging in activities such as trade and transshipments,
information technology products, financial services, and
biotechnology. From a third world country at the time of
achieving independence about 50 years ago, Singapore in 2016
had a per capita gross domestic product (GDP) of SGD 73,167.
Health‑care statistics are excellent with an infant mortality rate
of 2.4 deaths/1000 live births, and life expectancy of 82.9 years
in 2016. It has a doctor to population ratio of 1:430, nurse ratio
of 1:140, dentist ratio of 1:2550, and pharmacist ratio of 1:1950.
There are a total of 1693 physiotherapists, 1067 occupational
therapists, and 524 speech therapists. This was achieved on
a national health‑care expenditure of 4.6% (2011) of GDP.
However, Singapore has committed to increasing expenditures
significantly to cope with one of the fasting aging populations in
the world, with those aged 65 years and over expected to grow
from about 11% currently to almost 20% in the year 2030.[9,10]
Health‑care system
About 80% of acute and hospitalization care takes place in
the public sector under the charge of the Ministry of Health
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 Lim: Physical and rehabilitation medicine in healthcare systems: Postacute care
Singapore, and only 20% in the private sector. The reverse is
true for primary care services where 80% is provided by private
practitioners and 20% by the public sector. The step‑down
care sectors including nursing homes, community hospitals,
and hospices are often run by voluntary welfare organizations,
although most are funded to a large extent by the government.
There are three medical schools in Singapore: the Yong Loo Lin
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School of Medicine, National University of Singapore (NUS)
founded in 1905 is a leading medical educational and research
institution in Asia, the Duke‑NUS Medical School which
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emphasizes medical research and education follows a US
curriculum in collaboration with Duke University North
Carolina, and the Lee Kong Chian School of Medicine has a
curriculum developed and implemented in partnership with
Imperial College London.
Nurses receive diploma‑level training from two polytechnic
institutes, and undergraduate degrees from NUS and
overseas tertiary institutions. Postgraduate qualifications
for rehabilitation may be obtained locally or overseas.
Physiotherapists and occupational therapists may earn
undergraduate degrees from the Singapore Institute of
Technology or overseas. Speech therapists typically obtain
undergraduate degree from overseas, but a masters’ level
degree is available at NUS. Prosthetists and orthotists are
usually trained overseas and the de facto national prosthetic
and orthotic center is sited at the Foot Care and Limb Design
Centre. There are also several legacy private practitioners with
recognition based on apprenticeship programs.
All Singaporeans are covered under the 3Ms of Medisave,
Medishield, and Medifund. [11] Medisave is a national
medical savings scheme into which individuals put aside
part of their income. This personal health savings account
can be used for hospitalization, day surgery, and approved
outpatient treatments. Medishield is a low‑cost voluntary
catastrophic medical insurance plan. Medifund provides for
needy Singaporeans to pay their medical bills and is based on
household income for eligibility and amount of assistance.
The government provides large subsidies for hospitalization
as well as other medical and rehabilitation expenses, based on
the patient’s choice of hospital bed class. The “A” class private
bed is single room, air‑conditioned, with attached bathroom
and the patient’s choice of doctors - the patient pays full fare.
On the other end is the “C” class where there are multiple
beds in a cubicle with shared bathroom and assigned doctors.
However, this bed choice carries a 65%–80% subsidy.
In addition, the government has several other programs relevant
for those with disabilities.[12] The Interim Disability Assistance
Programme for the Elderly provides SGD 150–250 monthly
for up to 72 months for those unable to perform three or
more out of 6 ADL including washing, feeding, dressing,
toileting, mobility, and transferring. Elder Shield pays SGD
300–400 monthly for 60–72 months for those with inability to
perform at least three of the six ADLs. The Home Protection
Scheme is a mortgage insurance that protects members and
S90 The Journal of the International Society of Physical and Rehabilitation Medicine ¦ Volume 2 ¦ Supplement 1 ¦ June 2019
their families against losing their public housing apartments
in the event of death, terminal illness or total permanent
disability. The Dependants’ Protection Scheme is an opt‑out
term insurance scheme, which covers for a maximum payout
sum of SGD 46,000 for death, terminal illness, or total
permanent disability.
Through its Agency for Integrated Care, the government
coordinates day rehabilitation centers across the island, Day
Care and/or Rehabilitation Facilities, Senior Activity Centers,
Community Health Centers with general practitioners, Home
Medical, Home Nursing, Home Therapy, Home Personal Care,
and Meals on Wheels. There are also Caregivers Training
Grants, Seniors’ Mobility and Enabling Fund (for assistive
devices such as wheelchairs, transport, and home health‑care
consumables), Pioneer Generation Disability Assistance
Scheme of SGD 100 monthly for those with disabilities and
born before 1950, Medical Escort and Transport, Community
Health Assist Scheme to subsidize doctor and dentist visits,
Foreign Domestic Worker (FDW) Grant of SGD 120 monthly,
FDW Levy Concession for Persons with Disabilities, and
Medical Fee Exemption Card.
Rehabilitation medicine in postacute care
PRM or RM in Singapore has a relatively recent history.[13]
Singapore is a country with capability for biologic transplants,
readily available joint replacement surgery, state‑of‑the‑art
cardiac and cancer treatments, as well as being a center
for cutting‑edge genetic and stem cell research. It is home
to international collaborations of academic medical and
health‑care institutions such as Duke University and Johns
Hopkins from the USA, Imperial College London from the
UK, and Curtin University from Australia. There is however
a situation of expanding needs and insufficient capacity, partly
because of rapidly changing demographics and culture. As an
Asian country with a culture based on Confucianism, families
and neighbors have traditionally taken care of the elderly
and those with disabilities. Along with the country’s rapid
development however, family sizes have plummeted (fertility
rate of 1.24 children per female in 2015) to where the previous
situation of many adult children and family available at home
to provide care rather than being out in the workplace (female
workforce participation rate of 58.1% in 2013) no longer
exists. Neighborhoods have also changed, from the communal
spirited, care-providing kampungs (villages) to fast‑paced
high‑rise living where next‑door neighbors may not know
each other’s names. Rehabilitation which emphasizes function
and independence has hence become an important part of the
health‑care continuum.
The first specialized RM unit in Singapore was founded
at the Tan Tock Seng Hospital in 1973 with a focus on
providing rehabilitation for orthopedic and spinal cord injury
patients. The pioneering RM physicians then were sent by
the Ministry of Health for diploma‑level training at RM
rehabilitation centers in Australia or the United Kingdom.
RM physicians with training and certification from Australia,
 Lim: Physical and rehabilitation medicine in healthcare systems: Postacute care
UK, US, and Canada were also eligible for licensing and
specialist accreditation. To cater for patients with amputation,
the Artificial Limb Center was established in 1981 with
prosthetic staff sent to Japan for training or recruited from
Taiwan and Hong Kong. In the early 1990s, a post‑Internal
Medicine (IM), 3‑year RM specialist training program
was established locally. On successful completion of the
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program, the graduate was eligible for the title Fellow of the
Academy of Medicine Singapore (RM) and recognized as a
RM physician. This program incorporated an elective year
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of clinical fellowship internationally, with most graduates
going to major rehabilitation institutions in the United States
including Baylor College of Medicine Houston and Harvard
Spaulding in Boston. In 1998, RM was formally accredited
as a distinct medical specialty by the Specialist Accreditation
Board, Ministry of Health, Singapore.
Subsequent RM departments or units providing comprehensive
multidisciplinary rehabilitation were established at other
public hospitals across the island: Changi General Hospital
in 1998, Singapore General Hospital in 2000, and National
University Hospital in 2008. These physiatrist‑led units
have a full complement of rehabilitation staff including
nurses, physical therapists, occupational therapists, speech
pathologists, medical social workers, and prosthetists/
orthotists as needed. They have the capacity to manage
medical care and rehabilitation of the most complicated
patients including severe strokes, tetraplegic spinal cord
injuries, traumatic brain injuries, renal dialysis, multi‑trauma,
and cancer patients. There are presently a total of 37
credentialed and accredited physiatrists in Singapore, with
14 more in training. Almost all practice in the public health
care and academic sector with the largest numbers based at
Tan Tock Seng Hospital and Singapore General Hospital, both
major tertiary teaching hospitals and the main training sites
for RM in Singapore. The rehabilitation physicians also work
in the community with a presence in the smaller community
care hospitals, day rehabilitation centers, and nursing homes.
There has been a recent shift of approach from the traditional
British‑based system of medical training and Membership or
Fellowship with the Royal College of Physicians or Surgeons,
to one that is more American. In 2010, the residency system
was established in Singapore with Accreditation Council for
Graduate Medical Education – International (ACGME-I)
recognition. As of 2014, trainees who choose to specialize in
RM must first complete a residency in IM before competing
for a 3‑year RM Senior Residency (PGY 4–6) training position.
With the compulsory IM residency as a prerequisite to
RM training, rehabilitation physicians are trained and
able to manage patients acutely from the ICU into the
medicosurgical wards. The main RM departments have
early reach‑in arrangements with other departments, go into
the ICU and acute wards to assess and triage patients for
rehabilitation, as well as help manage early complications
of immobility. There are comprehensive RM units led by
The Journal of the International Society of Physical and Rehabilitation Medicine ¦ Volume 2 ¦ Supplement 1 ¦ June 2019
physiatrists and equivalent to IRFs at all the major public
hospitals. Patients discharged from the hospitals and
new patients referred for rehabilitation assessment and
management are seen in the specialist outpatient clinics or
ambulatory care clinics of the hospitals. The RM physicians
also have visiting consultant privileges at the step‑down
community hospitals which are similar to LTCHs and
SNFs, and at day rehabilitation centers which are similar
to CORFs. The RM presence is currently limited in the
nursing homes, and typically their residents are assessed and
reviewed in the hospital ambulatory care clinics. Nursing
and therapy interventions prescribed are then provided
within the nursing home or by way of a readmission to the
RM unit when more intensive intervention is needed.
Singapore has many foreign domestic workers (FDWs) or
“maids,” who live within the home and are primarily hired for
housework, cooking, and childcare. They however frequently
take on or are hired for the role of primary caregivers for
disabled patients and provide some of the postacute care.
The initial rehabilitation program may hence also need their
training as caregivers, including care of feeding tubes, bowel
and bladder management, transfers, range of motion, and
simple exercises.
Conclusion
The need for rehabilitative care gains importance with aging
populations across the world in conjunction with increasing
rates of acquired disability. Up to 5%–10% of a hospital’s
patients may require inpatient rehabilitation services, with
37% of stroke patients being appropriate candidates. In a
large cohort analysis with spinal cord injury, acquired brain
injury, and other neurological diagnoses undergoing specialist
rehabilitation, there was shown to be significant reduction in
functional dependency and weekly care costs.
The physiatrist or PRM physician may work in the ambulatory
care or clinic setting with nonoperative pain, sports medicine,
or occupational injuries. The classic role of the PRM physician,
however, focuses on in-hospital management of complicated
rehabilitation patients with specialized needs, extending this
expertise along the continuum of care into the community and
LTC facilities. Care may hence occur at different postacute
locations including the IRF, LTCH, SNF, and CORFs.
Postacute rehabilitative care in Singapore is quite well
developed and includes organized physiatrist – led rehabilitation
units and programs at different levels and locations, including
public, private, and academic sectors. There are also strong
national health‑care funding systems and professional training
institutions for health‑care providers in most rehabilitation
disciplines.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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 Lim: Physical and rehabilitation medicine in healthcare systems: Postacute care
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