Overview
Rehabilitation and chronic disease management are key CCM domains. Case managers coordinate care across the full continuum from acute rehabilitation through long-term community support.
Rehabilitation Goals
Restore function, maximize independence, prevent secondary complications, facilitate community reintegration; CM coordinates multidisciplinary rehab team across all settings and phases of recovery.
Disability Models
Medical model (disability = individual impairment to fix) vs. Social model (disability = society's failure to accommodate); ICF framework combines both perspectives into a holistic view of functioning.
Chronic Disease Burden
Chronic conditions (diabetes, COPD, heart failure, CKD) account for 90% of US healthcare costs; CM focuses on self-management support, preventing exacerbations, and coordinating evidence-based care.
Workers' Compensation
State-regulated system covering work-related injuries; CM coordinates medical care + return-to-work; vocational rehabilitation is arranged when the injured worker cannot return to prior occupation.
Rehabilitation Continuum
| Setting | Criteria | Services | CMS Requirements |
|---|---|---|---|
| Acute Inpatient Rehab (IRF) | Needs intensive therapy; medically complex | PT, OT, SLP, nursing 24/7; physician daily | ≥3 hours therapy/day; 60% rule (qualifying diagnoses) |
| Subacute Rehab (SNF) | Medically stable; needs skilled care | PT, OT, SLP up to 3 hrs/day | Skilled nursing need; Medicare Part A |
| Long-Term Acute Care (LTAC) | Medically complex; avg LOS >25 days | Complex medical + rehab needs | Ventilator weaning, complex wounds |
| Outpatient Rehab | Community-dwelling; functional goals | PT, OT, SLP; scheduled visits | Physician order; functional progress |
| Home Health | Homebound; skilled care need | PT, OT, SLP, nursing, HHA | Homebound; physician order; intermittent |
| Day Rehabilitation | Community-based; daily structured program | Structured therapy without overnight stay | Transition from inpatient |
Rehabilitation Team Members
Physical Therapist (PT)
Evaluates and treats mobility, strength, gait, and balance; key for ortho, neuro, and cardiopulmonary rehab. Develops therapeutic exercise programs and functional mobility training.
Occupational Therapist (OT)
Focuses on ADLs, IADLs, fine motor skills, and cognitive function; provides adaptive equipment recommendations and home modification assessments for safe independent living.
Speech-Language Pathologist (SLP)
Addresses communication, cognitive-communication deficits, and swallowing disorders (dysphagia); critical role post-stroke for language recovery and safe oral feeding.
Physiatrist
Physician specializing in physical medicine and rehabilitation; leads the interdisciplinary rehab team; prescribes therapy programs, manages spasticity, and oversees medical rehab care.
Rehabilitation Nurse
Coordinates care, monitors medical status, provides patient and family education, and promotes functional independence throughout nursing care — reinforcing therapy goals around the clock.
IRF 60% Rule
At least 60% of IRF patients must have one of 13 qualifying diagnoses (stroke, hip fracture, TBI, SCI, etc.) to maintain IRF status; CM must verify eligibility before arranging IRF admission.
FIM (Functional Independence Measure)
| FIM Score | Level | Meaning |
|---|---|---|
| 7 | Complete Independence | No helper needed, performed safely |
| 6 | Modified Independence | Device or equipment used |
| 5 | Supervision | Helper needed for oversight only |
| 4 | Minimal Assistance | Client does ≥75% of task |
| 3 | Moderate Assistance | Client does 50–74% |
| 2 | Maximal Assistance | Client does 25–49% |
| 1 | Total Assistance | Client does <25% |
FIM consists of 18 items: 13 motor items (self-care, sphincter control, transfers, locomotion) + 5 cognitive items (comprehension, expression, social interaction, problem solving, memory).
ADLs vs IADLs
| ADLs (Basic Self-Care) | IADLs (Complex Activities) |
|---|---|
| Bathing / grooming | Managing medications |
| Dressing | Managing finances/bills |
| Toileting | Shopping / meal preparation |
| Transferring | Housekeeping / laundry |
| Eating | Using telephone/technology |
| Ambulation / mobility | Transportation to appointments |
Disability & Assessment Frameworks
ICF Framework
International Classification of Functioning — assesses Body Functions/Structures, Activities, Participation, AND Environmental/Personal Factors; provides a holistic, biopsychosocial view of disability beyond diagnosis alone.
Barthel Index
10-item functional assessment measuring ADL independence (0–100 scale); widely used in stroke rehabilitation; simpler than FIM but provides a quick snapshot of functional status and change over time.
Rancho Los Amigos Scale
8-level scale (I=No Response → VIII=Purposeful-Appropriate) for TBI recovery; guides treatment goals and family education at each stage of cognitive and behavioral recovery after traumatic brain injury.
Workers' Comp Return-to-Work Categories
Full duty, modified duty (light work), transitional duty, permanent partial disability, permanent total disability — CM coordinates appropriate category based on functional capacity evaluation results.
Chronic Disease Management by Condition
| Condition | Key CM Focus | Warning Signs for Action | Evidence-Based Interventions |
|---|---|---|---|
| Heart Failure | Daily weights, fluid/sodium restriction, medication adherence | Weight gain >2 lbs/day, edema, SOB | ACE inhibitors, beta-blockers, diuretics; self-monitoring education |
| COPD | Smoking cessation, pulmonary rehab, inhaler technique | Increased dyspnea, sputum changes | GOLD guidelines; bronchodilators; action plan for exacerbations |
| Diabetes (T2DM) | Glycemic control, foot care, eye/kidney screening | A1C >9%, hypoglycemia, wound non-healing | ADA standards; DSMES (diabetes self-management education) |
| CKD | Blood pressure control, protein/sodium restriction, nephrology co-management | Rising creatinine, proteinuria, declining GFR | KDIGO guidelines; early nephrology referral; dialysis planning |
| Asthma | Trigger avoidance, controller vs rescue medication education | Nighttime symptoms, decreased peak flow | NAEPP guidelines; written asthma action plan |
| Hypertension | Medication adherence, lifestyle modification, home BP monitoring | BP >180/120 (hypertensive crisis) | JNC guidelines; DASH diet; sodium restriction |
Self-Management Support Programs
DSMES
Diabetes Self-Management Education and Support: structured education on blood glucose monitoring, nutrition, foot care, sick day management, and preventing complications; CM facilitates referral to accredited program.
Pulmonary Rehabilitation
Supervised exercise training + education for COPD/chronic lung disease; reduces hospitalizations, improves functional capacity and quality of life; strong evidence base for reducing exacerbations.
Cardiac Rehabilitation
Structured exercise + risk factor modification + psychosocial support post-MI, bypass surgery, or heart failure; significantly reduces mortality and readmissions; CM coordinates referral and adherence.
Palliative Care vs Hospice
Palliative care = comfort-focused support that can occur alongside curative treatment at any stage; Hospice = comfort-only, life expectancy ≤6 months, patient elects to forgo curative treatment.
Disease Management Programs
Population-level programs using registries, evidence-based protocols, and proactive outreach; CM identifies high-risk patients for enrollment using risk stratification tools and predictive analytics.
Advance Care Planning
Conversations about goals of care, values, and treatment preferences BEFORE a crisis; includes advance directives, POLST (Physician Orders for Life-Sustaining Treatment), and healthcare proxy designation.
Discharge Planning
Post-Acute Care Options
SNF, IRF, LTAC, home with services, home health, outpatient rehab — CM matches patient need to setting based on clinical criteria, functional status, caregiver capacity, and insurance coverage.
Discharge Planning Process
Begin at admission; assess patient/caregiver needs; coordinate with the interdisciplinary team; ensure durable medical equipment (DME), home health, and follow-up appointments are arranged before discharge.
LACE Index
L=Length of stay + A=Acuity of admission + C=Comorbidity (Charlson index) + E=ED visits in past 6 months = readmission risk score; higher score = more intensive post-discharge CM intervention needed.
Practice Quiz — 10 Questions
Memory Hooks
Rehab Continuum
Most intensive to least: IRF (3hrs/day) → SNF (skilled) → LTAC (complex) → Outpatient → Home Health
FIM Scoring
7=Complete independence, 4=Minimal assist (client does 75%+), 1=Total assistance (client does <25%)
Medical vs Social Disability Model
Medical model: impairment to treat. Social model: environment/society creates disability through barriers
Heart Failure Red Flags
Weight gain >2 lbs/day signals fluid retention → immediate CM action → prevent hospitalization
DSMES
Diabetes Self-Management Education and Support — structured program covering monitoring, nutrition, foot care, medication, sick days
Palliative vs Hospice
Palliative care alongside curative treatment at any stage. Hospice = comfort-only, ≤6 months prognosis, curative treatment stopped
Flashcards (click to flip)
IRF vs SNF: key admission criteria differences
IRF: ≥3 hrs therapy/day, 60% qualifying diagnoses, medically complex. SNF: needs skilled care, medically stable, Medicare Part A coverage, up to 3 hrs/day therapy
FIM scale: what do scores 1, 4, and 7 mean?
1=Total assistance (client <25%). 4=Minimal assist (client ≥75%). 7=Complete independence (no helper, safely performed)
18 FIM items breakdown
13 motor items (self-care, sphincter control, transfers, locomotion) + 5 cognitive items (comprehension, expression, social interaction, problem solving, memory)
ADLs vs IADLs — give examples of each
ADLs (basic): bathing, dressing, toileting, transferring, eating, ambulation. IADLs (complex): medications, finances, shopping, meal prep, housekeeping, transportation, phone
Heart failure self-monitoring: when to call the CM/provider?
Weight gain >2 lbs in 1 day or 5 lbs in 1 week; increased shortness of breath; worsening edema — these signal fluid overload requiring immediate intervention
Palliative care vs hospice
Palliative: comfort + curative treatment, any stage, any prognosis. Hospice: comfort-only, ≤6-month prognosis, patient elects to stop curative treatment
What is pulmonary rehabilitation?
Supervised program of exercise training + education for COPD/chronic lung disease; reduces hospitalizations, improves exercise tolerance and quality of life
LACE Index components
L=Length of stay, A=Acuity (emergent admission), C=Comorbidities (Charlson index), E=ED visits in past 6 months. Higher score = higher readmission risk
Study Advisor
Beginner Path
Start with rehab setting criteria (IRF vs SNF vs home health) and the FIM scoring scale. Understand that IRF requires ≥3 hours therapy/day and the 60% qualifying diagnosis rule before moving to more complex topics.
Intermediate Path
Study the FIM 18 items breakdown, ADLs vs IADLs with examples, and chronic disease management focus areas (heart failure weight monitoring, COPD action plans, DSMES for diabetes self-management).
Advanced Path
Master the ICF framework and how it differs from medical and social models, the LACE Index for readmission risk stratification, vocational rehabilitation categories in workers' comp, and palliative care vs hospice distinctions with clinical criteria.
Exam Focus
High-yield items: IRF 60% rule and qualifying diagnoses, FIM 7=independent / 4=minimal assist / 1=total assistance, heart failure weight gain red flag (2 lbs/day), DSMES as the gold standard for diabetes education, and palliative vs hospice distinction including the ≤6-month prognosis criterion for hospice.
Quick Review
IRF=3hrs/day + 60% rule; SNF=skilled care, medically stable; FIM 7→1 (most→least independent); HF=weigh daily, >2 lbs=call; DSMES=structured diabetes education; palliative=any stage with curative; hospice=≤6 months, comfort-only.