SCI First 90 Days

SPINAL CORD INJURY BASICSNON TRAUMATIC SPINAL CORD INJURYT his book mainly concerns the first weeks after trauma – the CONGENITAL blink-of-an-eye onset of pa- ralysis due to various forms of Cerebral palsy is not so much an is- impact on the spinal column sue with the spinal cord; CP affects aleading to damage of the spinal cord. part of the brain that controls move-There are other pathways to spinal ment, and in more severe cases cancord dysfunction that do not typically involve paralysis. Most CP occurs ininvolve trauma, including conditions children at birth but can occur in thepresent at birth and those acquired first few years of life due to brain in-later via disease or medical error. fections or head injury. Acute care and medical manage- Friedreich’s ataxia is a degenera-ment are not directly comparable tive spinal cord disease that usuallybetween traumatic and non-trau- begins between ages five and 15. Thematic SCI. The rehabilitation therapy spinal cord becomes thin and losesprocesses can overlap in many ways, some of its myelin, the insulation onthough, as will certain psychosocial nerve fibers. FA is rare, one case inparameters, technology options, 50,000. There is no cure, but many­legal rights, community connections, symptoms can be managed.and on so on. Here are some of theways non-traumatic SCI happens. Spina bifida is a rare birth condi- tion wherein the spinal column does not fully form a protective coveringwww.SCI.first 90 days.com 39

SPINAL CORD INJURY BASICSof the cord. Children born with spina paralysis in arms and legs.bifida often undergo surgery soon Multiple sclerosis is a disease be-after birth to close the spinal column;in recent years doctors have even lieved to be caused by one’s immuneoperated on babies in utero, before system attacking the nervous system.they are born. While SB babies do MS can progress to weakness, incon-grow and live long lives, there are tinence, fatigue and paralysis. Theresometimes unique issues, including are medications for MS, designed toaccumulation of spinal fluid in the mute the immune response.brain (hydrocephalus). Acute flaccid myelitis: there is no Many aspects of SB parallel spi- more polio in the United States butnal cord trauma, such as bowel and there is a mysterious new scourgebladder incontinence, and lower limb that affects children in much theparalysis. About 1 in 1000 newborns same way as polio did. The Centersare affected by spina bifida, a num- for Disease Control and Preventionber that is declining due to improved began tracking acute flaccid myeli-maternal nutrition, especially the ad- tis in 2014. Several hundred childrendition of folic acid to the diet. have gotten it, causing sudden loss of muscle control in limbs and other Spinal muscular atrophy (SMA) is parts of the body. Some cases involvean inherited disease that affects the the muscles that control breathing,nerves in the brain and spinal cord this requiring mechanical ventilationthat control voluntary movement. to survive. There is no treatment.SMA usually affects children but thereis an adult-onset form too. Symp- Spinal cord infarction is a stroketoms vary between weakness and within the spinal cord or the arter-greater loss of mobility. A drug (Spin- ies that supply the oxygen-sensitiveraza) has recently been approved to spinal cord. Chances for recoverymodify the genes that cause SMA, are good but symptoms can includeleading to significant functional im- pain, weakness in the legs, loss of re-provement for some patients. flexes, loss of temperature sensation, incontinence, and paralysis.ACQUIRED Spinal tumors: overgrowth of tis-Lyme disease is a bacterial infection sue, e.g., cancer, can form tumors thattransmitted by a tick bite. Severe impinge upon the spinal cord, caus-cases can involve loss of function or ing motor and balance problems, weakness, spasticity and paralysis.www.SCI.first 90 days.com 40

SPINAL CORD INJURY BASICSAdvances in chemotherapy and mi- which a doctor and/or hospital maycrosurgery may be able to help. be liable and owe you compensation. Stroke: blood to the brain is (If you suspect that you have beenblocked by a blood vessel burst or by harmed by a medical treatment, con-a clot of some kind. The result usually sult with an attorney who is experi-affects one side of the body, and may enced with medical error. See p. 151.)include cognitive issues (memory,judgment, learning), weakness, and Here are several types of medicalparalysis. Clinical trials have shown error that can lead to paralysis:promise for stem cells to treat stroke. Birth injury: infants can suffer from Transverse myelitis is caused by lack of oxygen during birth, leadingan inflamed spinal cord, and leads, to brain damage, mental retardation,often quite suddenly, to loss of body motor deficits, or cerebral palsy.function below the level of damage.About one in three cases recover Anesthesia: too much anesthesiafully, about one in three join the can lead to brain injury or even death.world of paralysis. No therapies areavailable but symptoms are mostly Surgical error: neurological ormanageable. orthopedic surgery carries a risk of causing paralysis if blood flow to theMEDICAL ERROR cord is restricted for too long a time. Doctors have sophisticated tools toDoctor error is now the third leading monitor nerve function during sur-cause of death in the United States, gery; those intraoperative systemsbehind heart disease and cancer. The are far from being failsafe. Some-numbers are shocking: it was recently times a surgeon operates under thereported in the medical literature that assumption that monitoring is inmore than 250,000 deaths a year are place when it is not. This can result indue to preventable doctor error. damage to the spinal cord. Doctors who perform medical Sometimes doctors operate onprocedures on or near the spine can the wrong body part, or leave surgi-cause injury. There is an inherent risk cal tools inside the body. Preventablein many procedures, but it is often infection is often acquired in a hospi-the case that a treatment falls short tal setting and can cause injury.of the standard of care, and thus intothe realm of medical negligence, for Failure to recognize or diagnose conditions, including spinal cord dis- ease or stroke, can result in perma- •nent loss of function.www.SCI.first 90 days.com 41

People from across the country who are a ected by spinal cordand brain injury come to Craig Hospital in their time of need.What sets Craig apart is the partnership among sta , patients,and their families. This paired with our unyielding determinationestablishes a high bar for our culture, values, and dedication toconsistently produce world-class outcomes.Craig Hospital in Denver, CO, is a national nonprofitrehabilitation and research hospital. We have been recognizedfor the past 27 consecutive years by US News and World Reportas a top 10 hospital. Denver, Colorado craighospital.org

SCI: 90FIRST DAYSCHOOSINGA REHAB •MOVING ON TO REHAB •CHOOSING AN INPATIENT REHABILITATION FACILITY •INSURANCE & APPEALS •SOCAL REHABS RANKED •SUBACUTE FACILITIES www.SCI.first 90 days.com 43

CHOOSING A REHABMOVING ONTO REHABL et’s assume it’s been a few days medical/surgical or “med-surg” area. since the accident or incident It’s also possible you’ll be sent to a that injured your spinal cord skilled nursing or long-term care unit and sent you to the emergency until you’re up for rehab. room. If you are free of seri-ous complications and don’t require Things slow down a bit away fromround the clock emergency care, it’s the drama and urgency of the ER.not out of the question that you’ll be Now, while the hospital staff contin-shipped straight away to an inpatient ues to monitor your vital signs andrehab hospital, and if that’s the case, tend to your broken body, watchfulskip ahead to p. 48 for how that pro- at all times for infection, they can alsocess is supposed to work, and what begin to let you and your loved onesyou need to know. in on the cold, hard facts about what’s going on. Important: cold and hard If you have life-endangering com- are not the same as forever and ever.plications – coma, burns, internal Your body took a hit; nothing worksinjuries, broken bones, pneumonia, the way it used to. Some functionsetc. – or if you had some sort of sur- come back, some might not. Butgery the first day, you may stay in the don’t be discouraged by a predictionacute hospital, moved from intensive that sounds like a life-sentence. Therecare to a less intensive area called a are many reasons to keep hope alive.step-down unit, and then on to the Remember: it gets better.www.SCI.first 90 days.com 44

CHOOSING A REHABYOU HAVE RIGHTS of the larger trauma and rehab units in the region: “You have the rightMost hospitals have a written Bill of to effective communication and toRights for patients. Patients should participate in the development andknow that they are indeed the direc- implementation of your plan of care.tors of their own care. That doesn’t You have the right to participate inmean doctors and therapists will con- ethical questions that arise in thesult with you on all the details, but it course of your care, including issuesdoes mean you should know who of conflict resolution, withholdingyour primary doctor is, as well as the resuscitative services, and forgo-names and professional relationships ing or withdrawing life-sustainingof other physicians and non-physi- treatment.”cians you come in contact with. Regarding planning for the worst: Read everything they ask you to one option is to draw up an advancesign. Are you agreeing to arbitrate directive, a legal document that des-disputes in a way that may cost you ignates someone to make decisionsyour day in court? Are you agreeing on your behalf if you become inca-that the doctors who treat you are pable of understanding a proposedindependent contractors and not treatment or become unable to com-employees of the hospital? municate your wishes. (Download a free advance directive form from the You have a right to know what’s California Attorney General’s office,going on. You should be provided oag.ca.gov). Hospital staff have toinformation – privately and confiden- comply with these directives; all thetially, and in terms you can understand same rights apply to the person you– about your injury and related com- choose to manage your medical careplications, the course of treatment, as apply to you, the patient.and prospects for i­mprovement. Youshould be allowed visitors. You have REHAB STARTS IN THE TRAUMAthe right to refuse treatment. You can HOSPITALleave if you want to. The process of rehabilitation may Of course, some doctors and begin as soon as a day or two afternurses are better about explaining injury. It won’t be nearly as intensivethings than others. If you don’t follow as it will be in an actual rehab hospital,what was said, ask again. Be annoy- but trauma hospital therapists like toing if you have to. This is from LomaLinda University Medical Center, onewww.SCI.first 90 days.com 45

CHOOSING A REHABget going as soon as possible to build multiple transfers for imaging andyou up and prevent complications. other studies during the emergencyRespiratory therapists will make sure phase. This exposes skin to injury bythe lungs are clear and hygienic. Post- way of shearing (stretching). If it isSCI mortality rates have dropped expected you will be immobile fortremendously since the 1970s, due a while, a special bed may be usedin large part to better acute care of to minimize skin breakdown. It’s alungs and breathing. shameful statistic to report but pres- sure injury formation is said to occur Physical therapists won’t get to in 30 to 50 percent of patients withknow you well during your short stay new spinal cord injuries during thein the trauma hospital, but they may first month post-injury. This is enor-provide range of motion exercises mously time consuming, it delays theto strengthen and stretch muscles, rehab process, and it’s expensive. Itand to keep joints from getting doesn’t have to happen, and hospitaltight. Other staff will work with you staff know this.on ­positioning and seating, and ifneeded, speech and language skills, Bladder and bowel will for theand swallowing. The first time you most part be managed for you in thetry to sit up in bed you may feel ex- trauma unit but you’ll get the ideatremely lightheaded; this is called or- how this works, and perhaps you’llthostatic hypotension. This typically be able to learn some basic skills andimproves fairly soon. Once you can basic hygiene to handle some caresit up for a longer period the nurses on your own.or therapists may get you out of bedand into a wheelchair. There are lots of other things go- ing on with the body, and the mind. Skin care will always be a top con- This is a tough situation. There are allcern. The risk for breakdown is very sorts of emotions running throughhigh in the week following an acute your head. Depression. Anxiety. An-injury, for a number of reasons. Pres- ger. Larger trauma centers have asure injuries usually form on the skin psychiatric staff and other counsel-over bony areas such as the hips and ors. Take advantage if you can. Youtailbone. These areas are vulnerable should also be availed of all optionsbecause pain sensation may be lost, to manage pain.due to paralysis, brain injury, or medi-cations. It’s also likely that you’ll make There will continue to be a lot of assessments and tests in the firstwww.SCI.first 90 days.com 46

CHOOSING A REHABdays post-ER. What is the exact advocate for the patient. Someonen­ ature of your injury, what function needs to take charge of his or herwas lost, what other issues are press- interests, to be the point person,ing? This is necessary as plans begin the hub of information, and in someto form for how you will be rehabbed cases, the nag. It’s not an easy timeand eventually discharged and sent for anyone involved, but things arehome. You probably weren’t aware of going to be decided in coming daysit but discharge planning began the that may make a big difference to theminute you were dropped off at the person dealing with SCI. In a perfecttrauma center. situation, a patient advocate would suddenly emerge to handle all of this,DESIGNATE AN ADVOCATE making sure the patient’s needs are top priority. You may be able to findIt’s obvious right away that this is private services that do this (see So-a time to call in family and friends Cal SCI Hotline, p. 182). You may haveto help. No doubt your people are to take it on yourselves.freaked out and lost in this new world,and no doubt they have been all over In most trauma hospital settings, athe Internet, trying to process the case manager or social worker comesmadness of this major traumatic into the picture once you’re basicallyevent. If you’re lucky enough to have stable and able to pay attention tothis book in hand, you will know how important decisions ahead. One ofto dig deeper and faster, without hav- the first things you have to addressing to sort through the online noise. is where you are going next. Figur- ing out your next move begins right Here’s some advice to family and away. You will need to know detailsfriends of a newly injured person: about your insurance coverage, dis-Check the local and national re- cussed later in this chapter.sources listed on pp. 9 and 10. Theseplaces offer a lot of material, and No insurance? You aren’t alonesome have staff that can help. The – half of cases in a national SCI da-Reeve Foundation, for example, has tabase did not have insurance attrained resource s­ pecialists on call to the time of injury. Don’t worry, theyhandle inquiries related to paralysis can’t kick you out of the ER if you(call toll free 1-800-539-7309). don’t have coverage, and there are good rehab options in SoCal for all Get smart fast; someone needsto come forward and be the primary •patients.www.SCI.first 90 days.com 47

CHOOSING A REHAB CHOOSING ANACUTE INPATIENTREHABILITATION FACILITYO ne of the earliest and most sive, most appropriate post-acute essential decisions a person care. Why is a specialized SCI center with a new spinal cord injury better? On the next page. Steve Kir- has to make is where to go shblum, a distinguished SCI doctor, for rehabilitation. This is the describes why you’re better off in thestage of care that will prepare you hands of experts who see a lot of SCIfor the long term – getting your body cases in a comprehensive hospitalback into the best shape possible, setting.making sure you know how to takecare of your health, maximizing your How do the people at the traumaindependence out in the community center know you’re ready to go toonce you get back home. rehab? Once the occupational and physical therapists agree you can Once leaving the trauma hospital, withstand at least three hours of ther-it’s very important to find a special- apy a day, you’re pretty much goodized center to get the most inten- to go. If you no longer need i­ntensivewww.SCI.first 90 days.com 48

CHOOSING A REHABCOMPREHENSIVE CARE: PICKING each year? How many patients (likeTHE RIGHT REHAB SETTING you) are there now? Does the facil- ity feature an around the clock in-By Steven Kirshblum, M.D. terdisciplinary team of rehabilitation professionals under the direction ofChoosing the most appropriate a physician who specializes in spi-acute rehabilitation hospital is an nal cord injury medicine? Does theimportant decision. The goal of hospital offer advanced therapies,rehabilitation is to restore the skills evidence-based techniques andand abilities to perform daily tasks, leading-edge technologies?as well as to prepare you to returnhome and ultimately to work or Are psychology and neuropsy-school, and to your community. chology services available to helpInpatient rehabilitation facilities cope with the changes in your life?address the full range of medical,physical, cognitive, behavioral, Does the hospital provide a con-s­ ocial and vocational issues you tinuum of services, including outpa-may face. tient care and access to community resources. Is the facility accredited It is important to know, not all by CARF? ­rehabilitation centers are the same. Lastly, do the best you can to re- While proximity to home is an search your options. It is extremelyimportant consideration, treatment important to have a family memberfor spinal cord injury is complex and or friend visit the facilities you arerequires a comprehensive level of considering, if possible, and meetcare from an experienced team of with some of the staff who treatprofessionals including physicians, spinal cord injury. Ask questions. Benurses, therapists and psycholo- involved in the decision process.gists. Studies show that spinal cordinjury patients treated at a spe- Rehabilitation may not last longcialized, comprehensive hospital but the effects of proper care –achieve better outcomes than those long-term health and well-being –in other care settings. last forever. Good luck to you. Important items to look for: Dr. Kirshblum is Medical Director of How many spinal cord injuries the Kessler Institute, in New Jersey.does the rehabilitation facility treat He is co-author of the widely-cited textbook “Spinal Cord Medicine.”www.SCI.first 90 days.com 49

CHOOSING A REHABtrauma care but are not quite med- least by neurologists trained or boardically able to deal with the rigor of certified in rehabilitation medicine.daily rehab therapy, you may betransferred to a sub-acute unit called THE REHAB TEAMa skilled nursing facility (SNF, pro-nounced “sniff” in the ­rehab world). There is no formula to successful re- hab; it is a process that works best Skilled nursing facilities some- when tailored to the needs of eachtimes call themselves “post-acute patient. Rehab is a collaboration be-rehabilitation centers,” but it’s im- tween a person with a spinal cordportant to know that SNFs are not injury and a team of experts in medi-the same as inpatient rehabilitation cine, psychology, social services andfacilities (IRF). SNFs don’t charge technology. Here are the membersas much as inpatient rehab facilities of the rehab team you should find at(IRF), which may make them attrac- centers that treat spinal cord injury:tive to insurance payers. But SNFsoffer far less in terms of expert care; Patient and family. Of course thethey are usually run by nurses, or most important member of the re-worse, CNAs, with few doctor visits habilitation team is the person withand little or no physical therapy or a spinal cord injury. Your enthusiasmspecialized services. There is data and participation in the rehab pro-to show that people who leave an cess are essential. Your family andIRF return home faster, and healthier, friends are important, but this is yourthan those discharged from nursing time: use it well.care only. If you get sent to a SNF, youwill want to transition out of there as Rehabilitation doctor. A physiciansoon as you can. with a specialty in physical medicine, called a physiatrist, leads the rehab Ideally, your rehab experience will team. He or she coordinates patientbe overseen by a multidisciplinary care services with other team mem-team with training in neurology, reha- bers. Ideally, this doctor is board cer-bilitation nursing, occupational ther- tified in the SCI specialty.apy (OT), physical therapy (PT), andspeech and language therapy (SLT), Rehabilitation nurse. Rehabunder the leadership of physicians nurses and their assistants are ontrained in physical medicine and re- call 24/7 to help you set goals, planhabilitation (called a physiatrist) or at your care and reach maximum inde- pendence. Nurses are fully involved in medical care and prevention ofwww.SCI.first 90 days.com 50

CHOOSING A REHABA SPECIALIST DOCTOR’S LIST FOR cations do the physicians have, andCHOOSING A REHAB how many years of experience?By Ann Vasile, M.D. Can you meet or at least talk to the PM&R people before you are It is important to know who will admitted? How many days a weekbe treating you at an inpatient re- do the doctors personally see eachhab, and also whether that doctor or patient?team will be around to follow yourcare in the critical months post-in- Will there be a family conferencejury. Dr. Vasile explains: with the treating MD? Family con- ferences are important but are noHere are some questions to ask a longer routine, often assigned onlyprospective inpatient rehab hospital for ‘problem’ patients.to make sure your medical team hasthe skills and experience to meet Will the medical staff followyour needs: ­patients after discharge, and if not, what is the transition plan for outpa- How is the physical medicine tient care?and rehab (PM&R) staff assigned topatient: rotation or by diagnosis? Dr. Vasile, a board certified spinal(Rotation may mean you’ll be seen cord injury specialist for almost 25by a stroke or hip replacement spe- years, manages SCI in-patients atcialist). What Medical Board certifi- Tustin Rehab, Long Beach Memorial and Care Meridian; her outpatient practice is in Long Beach.complications. Your nurse will be an tation. Activity is an essential part ofimportant source for learning about recovery. Your PT will help to restoreSCI care, too. Some are specialized function to the extent possible, work-in important areas, such as pressure ing with you to improve movement,wound management. Ideally, your strength, and joint function.nurses are fully trained and certifiedin rehab care (CRRN). Occupational therapist. Occu- pational therapy (OT) is the key to Physical therapist. Physical ther- improving independence. Your OTapy (PT) is a crucial part of rehabili- will school you in activities of dailywww.SCI.first 90 days.com 51

CHOOSING A REHABliving (ADLs) related to work, school, geon, pharmacist, and perhaps onefamily, and leisure activities, includ- of the following:ing eating, bathing and ­hygiene andhome management. OTs recommend Respiratory therapist. Some in-adaptive equipment and tools. juries impact breathing. This is the team member trained to treat air- Case manager. The rehab case ways and lungs.manager is a specially trained s­ ocialworker who makes sure you are con- Speech language pathologist.nected to services and resources, Some spinal cord injuries affectparticularly those related to insur- communication, swallowing, mem-ance. A case manager helps you plan ory, judgment or cognition. Your SLPyour discharge from rehab to home. evaluates and helps manage these. Psychologist. Spinal cord injury is Wound care. Skin is vulnerablea life-changing event; a psychologist after spinal cord injury. Let’s hopecan help you process and cope with you don’t have to meet a nurse whoyour changing situation. The best specializes in restoring your skin tocenters also have specialized staff its healthy and infection-free state.to deal with sex, intimacy and familyplanning issues. See p. 114 for more. Dietitian. Nutrition is an important part of recovery. This expert will make Recreation therapist. Your rec sure you are eating what you need.therapist helps get you out in theworld and involved in social settings, Seating specialist. This personincluding recreation, sports and lei- helps line up the proper mobilitysure activities. equipment – chair, cushion, etc. – to get you rolling and back into the Chaplain. For those who seek community.counsel related to spiritual matters,the chaplain may help directly, or Vocational therapist. These areconnect the hospital and your home the specialists who assess your jobchurch or place of worship. skills and help arrange equipment, training and placement for getting Other specialists: Spinal cord in- back to work or school.jury usually involves multiple bodysystems, and multiple aspects of Driving trainer. Getting back onlife. Other specialists you will likely the road is a worthy goal, but youencounter include a urologist, pain will need special training and eval-management doctor, orthopedic sur- uation to adapt your driving. Many rehab centers offer a driver training program.www.SCI.first 90 days.com 52

CHOOSING A REHABWHEN DO YOU HAVE TO DECIDE? inpatient rehab hospitals are not all the same; some have shiny new build- How much time do you have to ings, some centers deal with moredecide on a rehab setting? Not much. cases of SCI than others, some haveMaybe just a few days after the time accreditations, and some may haveof injury. The sooner rehab starts, the special expertise.better, and lengths of stay in acutetrauma units are getting shorter. In In this book, the SoCal IRFs havethe 1970s a person with a spinal cord been broken into four main tiers,injury was kept in a trauma hospi- based mainly on expertise, patienttal setting for about 24 days. That’s volume and outside accreditation.down to an average of 11 days now, See list, beginning on p. 70.How much time do you have to decide on a rehab setting? Notmuch. Maybe just a few days after the time of injury. The soonerrehab starts the better.depending on complications, infec- After screening the rehabs, andtions, etc., according to the National making sure you and your insuranceSpinal Cord Injury Statistical Center. company are on the same page, call(It’s also true that IRF lengths of stay the ones that appear to meet yourhave declined – from 98 days 40 needs. Have someone visit them ifyears ago to about 36 days currently possible. What kind of SCI patient– less if you factor out the more com- volume do they see? Ask them ifplex cervical injuries.) there are other patients there now who have injuries similar to yours. Ask How to decide? There are basic them about staff-to-patient ratios.questions you can ask, per Drs. Kir- Ask them about their accreditation.shblum and Vasile, above. There aremore than 40 acute inpatient rehab Ask a prospective IRF if it par-facilities in Southern California. These ticipates in clinical trials for neware hospitals that are either known treatments; that demonstrates afor SCI care or who declare an inter- commitment to the SCI specialty.est in admitting new SCI patients. It Does the center offer any cool newmay not be immediately obvious, but equipment (body weight supportedwww.SCI.first 90 days.com 53

CHOOSING A REHABtreadmill devices, robotic ambulation fully in therapy programs. You alsotraining devices, brain-machine or- have to have to know where you’rethotics, exoskeletal ambulation train- headed after you are ready to leaveing devices, etc.), and will you be able rehab. Before you’re even in the door,to use any of it? the rehab facility has to make sure you have a discharge plan to home While the closest place to home or somewhere in the community. Nomay be the most convenient, with ad-Rule of thumb: the best rehabs are very specialized, offer acomprehensive treatment plan, and see a lot of patients withsimilar spinal cord injuries.vantages of support from family and plan, no admit. They don’t want to getfriends, it may not offer the level of stuck with you.service your specific injury requires.The rehab at your community hos- FACTORS TO CONSIDER WHENpital may welcome you as a new SCI SELECTING A REHABpatient – hospitals like to keep thebeds full – but if the facility doesn’t Number of new SCI/year: This is onesee many spinal cord injuries, the rest of the more important measures;of the rehab ward will be people three more volume means more expertise,times your age, there for stroke, brain more chances there will be othersinjury, or hip replacements. there with injuries similar to yours. Rule of thumb: the best rehabs Staff-to-patient ratio: More staffare modern, specialized, offer a com- generally means higher quality andprehensive treatment plan, and see a more personalized care. There arelarge volume of patients with similar minimum requirements set by thespinal cord injuries. state, such as one nurse for every five patients. More staff is clearly linked to There’s another important factor better functional outcome, includingin rehab choice: the place you want a reduction in complications such ashas to want you too. Patients have to pneumonia, urinary tract infections,be able to do the work and engage or skin pressure wounds.www.SCI.first 90 days.com 54

CHOOSING A REHAB Percentage SCI beds: inpatient Meet with medical team: It’s arehabs take care of trauma patients, good idea, as noted above by Dr.including SCI and brain injury; this V­ asile, to ask about who exactly yourmay also be the ward for strokes and primary SCI doctor will be.certain orthopedic patients (e.g., hipreplacements). A lower percentage ACCREDITATIONof SCI beds means most of the rehabactivities involve other conditions, This means a rehabilitation hospi-and certainly a patient population tal meets certain standards of caremuch older than you. set by independent outside inspec- tions. There are two main accredi- Discharge to home: This doesn’t tation agencies for rehabs, and onevary much between centers (around high level credential from the federal80 percent) but the higher the num- government.ber, the better patients are preparedfor return to the community. Lower The Joint Commission (JC) is anpercentage means patients are independent, not-for-profit organiza-headed back to the hospital, or to a tion that accredits and certifies aboutnursing home – not a good sign. 21,000 health care organizations and programs in the United States. Just Care for ventilator patients: Care about every hospital gets a JC cre-for high cervical spinal cord injury, dential; until 2008, hospitals couldinvolving mechanical ventilation, is not accept Medicare patients if theybeyond the expertise of most IRFs. did not have JC approval. There are a few other Medicare accrediting Board certified SCI doctor: This is agencies now, but JC still carries aimportant because it means a there’s lot of weight for Medicare compli-a physician on staff with specialized ance. Does a Joint Commission cre-training in spinal cord injury care. Find dential mean much for consumersout if this doctor will be your doctor. shopping for acute inpatient rehab?SCI is complex; board certification Not so much; JC has a “gold seal”recognizes this. accreditation for certain disease cat- egories – stroke, for example – but Nursing expertise: A better not one for spinal cord injury.trained staff makes a difference;having nurses with an advanced cre- CARF: An accreditation that isdential in rehab (Certified Registered much more relevant to SCI rehabRehabilitation Nurse, CRRN) is pre- is that of CARF (which used to bedictive of better patient outcome.www.SCI.first 90 days.com 55

CHOOSING A REHABcalled the Commission on Accred- consumer choices.itation of Rehabilitation Facilities). Of all the SCI rehabs in SouthernTo be awarded CARF accreditation,a f­acility must have specific staffing California, only four have the CARFand programs, and must pass an SCI credential (two of those are VAin-depth audit of its services. CARF hospitals). You might wonder why­offers certification for Comprehen- all SCI rehabs don’t attain this des-sive Integrated Inpatient Rehabili- ignation. It costs a lot of time, effort,tation Programs, a general rehab and money to get, and CARF is picky.hospital credential. This specifies that CARF also continues to raise the bar.coordinated and integrated medical Many IRF hospitals say they can take care of SCI patients without the needCARF Spinal Cord System of Care accreditation means a rehabis committed to SCI treatment in an outcome-based programacross the continuum of care.and rehabilitation services are pro- for the advanced credential. Doesvided 24 hours a day. CARF specialization matter for reim- bursement by insurance companies? A much more specialized CARF To a degree, yes, but not as much asaccreditation, the Spinal Cord Sys- you might expect. Except for sometem of Care, is awarded for both workers comp carriers, many insur-inpatient and outpatient services. ance companies do not insist onRehab centers with this credential accreditation as a key qualifier forpass another level of scrutiny, which inpatient rehab coverage.demonstrates a commitment to thetreatment of SCI in a coordinated, CARF certifications other thanoutcome-based program across the SCI? Some rehabs with accreditationcontinuum of care, from acute rehab from CARF also add stroke, or brainto outpatient services, community injury. Do these matter for SCI care?services and long term care. CARF Not directly, but these credentialsstandards for SCI accreditation are might highlight a hospital’s degree ofhigh; they are a valuable way to rate specialization in rehab care.www.SCI.first 90 days.com 56

CHOOSING A REHAB Model Systems. The highest level you are looking at have this covered?of certification in spinal cord injury Other services: Ask about driverrehabilitation is to be designateda U.S. Model Systems SCI Center. training. Nutritional counseling. Seat-There are 14 such centers in the U.S., ing and positioning specialization.with just one in California (RanchoLos Amigos, in Los Angeles). Model Recreation therapy: This subspe-Systems centers are high-volume cialty starts with the idea being that­facilities with deep expertise and social activity, including sports andcomprehensive, evidence-based re- rec, are helpful toward reintegrationhab and outpatient programs; the in the community.designation comes with federal fund-ing to enable these centers to carry Peer support: Connecting without research on SCI-related issues. those who have been through the SCI experience is an invaluable part Note: The Model Systems Knowl- of anybody’s journey into spinal cordedge Translation Center (msktc.org) injury. Does the IRF you are consider-is an excellent resource for SCI infor- ing have a support group?mation and factsheets (also availablefor traumatic brain injury). Family supports: Does the rehab have counseling or programs to helpOTHER FACTORS TO CONSIDER family members? Special medical care: Are there Outpatient care: Rehab does notphysical medicine doctors on staff? last long enough to prepare peopleThere better be. Special care is also with new injuries for the long roadneeded in urology, respiratory ther- ahead. Access to an outpatient facil-apy, wound management, spasticity, ity is essential; this assures continuitypain treatment, etc. of care in the hands of people with expertise you won’t find in a general Psychological services: This isobviously important for the newly •clinical setting.injured person trying to adjust to lifeon Planet SCI, but it’s an importantfactor for families and loved onestoo. Everyone is coping with loss andanxiety. Professional counseling canmake a huge impact. Does the facilitywww.SCI.first 90 days.com 57

CHOOSING A REHABGETTING THE MOST FROM REHAB ical therapy, working your active muscles. PT is what you make of it.By Andrew Skinner This cannot be said enough times: exercise is medicine. Work hardOK, you’re leaving the intensive care on getting stronger. Ask your PT ifhospital, headed for rehab. Yes, it there is work you can do when yoursucks, the whole deal is a nightmare. sessions are over; many rehabs haveAnd you may be thinking you’ll ride a gym you can use.it out, that everything will be OK.That may be true, you may walk out You’ll meet a lot with yourof there. But just in case you don’t, occupational therapist, too. OTsyou need to maximize your recov- teach you skills for managing yourery and prepare for going home. activities. You’ll work with a lot ofGet yourself ready for rehab. other therapists, including a psy- chologist – this thing isn’t easy and If you don’t think you’re ready there are coping strategies theyphysically or emotionally for five or can show you, and your family, somore hours of therapy every day you can better come to terms with– you may still be healing up from your injury.broken bones and surgeries – con-sider a transition to a skilled nursing One last thing: a key part of fig-facility until you are ready for rehab. uring this thing out is connecting toRemember, you only get a set num- people who have been where youber of rehab days. Don’t burn them are. There are many ways to con-if you can’t really use them. nect with your peers – see the first chapter of this book. Listen, this is an important time.Inpatient rehab stays are very short, Good luck. Don’t be afraid toand you have a lot to learn. So be reach out for help.prepared to hit the ground rolling ....be ready to get out of bed and work Mr. Skinner, a q­ uadriplegic sinceyour body, learn new skills. 2004, founded the Triumph Foun- dation, a s­ upport ­network for So, what to expect. You will people living with p­ aralysis. Seesee your doctor and nurses and ­triumph-foundation.orglearn about things like cathetersand bowel programs. Not fun. Youwill get a lot of one-on-one phys-www.SCI.first 90 days.com 58

CHOOSING A REHABINSURANCE DRIVES REHAB CHOICEI t would seem that the SCI con- course brings us to the topic of health sumer has lots of choices when it care insurance. comes to inpatient rehab, but do you really get to pick the one you If you have private insurance, or like? If money were no object, coverage through the Affordablethe answer would certainly be yes. Care Act, contact your insuranceBut money happens to be a pretty company as soon as possible to seebig object in the world of acute SCI. what is covered. Catastrophic injury insurance comes with many varia- Spinal cord injury is rare, but it is tions of coverage and deductibles,expensive. Only about 1200 new in- and perhaps caps on payments. Ifjuries a year occur in the SoCal region possible, get hold of your policy doc-but this will cost patients, their fami- uments and be prepared to read thelies and the health care system plenty fine print. Spinal cord injury, it won’t– billions of dollars, year after year. A take long to discover, is very com-quad’s first year costs, for example, plicated, and ridiculously expensive.can easily break a million dollars, andcould run five or ten times that over Do you have an insurance policy?his or her lifespan. The point is, your Keep reading. Don’t have insurance?choice of rehab setting has to begin Skip to the No Insurance section, p.with how it will be paid for, which of 62. You’re going to get treatment and care but you will most likely facewww.SCI.first 90 days.com 59

CHOOSING A REHABmore limitations on choice. As you’d expect, the least expen- There are many varieties of health sive health insurance includes the most restriction on choice of provid-insurance. Private insurance includes ers and the most out of pocket costspolicies you get at work, which might for the consumer. For consumersbe partly funded by your employer, shopping in the Covered Californiayour union or other organization. insurance marketplace, under the Af-Many individuals or families are cov- fordable Care Act aka Obamacare),ered by private plans – usually set there are four tiers of coverage:up as networks of clinics and hos- bronze, silver, gold and platinum.pitals. These include Preferred Pro- They offer the same essential healthvider ­Organizations (PPO), or Health benefits but vary in premiums andMaintenance Organizational (HMO), out-of-pocket costs: bronze plansor something called an Exclusive Pro-As you’d expect, the least expensive health insurance includesthe most restriction on choice of providers and the most outof pocket costs for consumers.vider Organization (EPO). have the lowest premiums but high- As you know if you have shopped est out-of-pocket costs, while plati- num plans cost more per month butrecently for insurance, there are offer more.countless ways coverage works, witha wide range of monthly premium For those who qualify, there’sfees, deductibles that come out of Medicare – generally you have to beyour pocket, and limits to what the over 65 for this to kick in but if you’reinsurance company will cover. (A de- under 65 and have a disability, you areductible is the amount you may have automatically enrolled in Part A andto pay medical care providers be- Part B after you have received Socialfore receiving any benefits from the Security benefits for 24 months.health policy. You may also be askedto pay coinsurance, a percentage of Medicaid, the federal/state healththe total amount billed.) insurance assistance program, is called Medi-Cal here in California. It’swww.SCI.first 90 days.com 60

CHOOSING A REHABa huge program, expanded all the and compensation for permanentmore by ACA legislation. One third physical impairments. Your employerof the state’s population is covered should be contacted immediately ifby Medi-Cal, at a cost of $17 billion to you have a work-related injury. Therethe taxpayers. There are income and are specific claim forms, as well asresidency requirements. Note: you timelines and rules. Know what yourdon’t have to be a U.S. citizen or have rights are. Know also you may havea green card to get Medi-Cal emer- to be assertive.gency services or long-term care. In2016 Medi-Cal expanded coverage to In California, workers comp med-about 170,000 undocumented immi- ical care has become much moregrant children under age 19. aligned with managed care net- works. This may not matter much in Those who get both Medi-Cal and the early, acute stage of a spinal cordMedicare are called dual-eligibles, or injury but it could become an issue ifMedi-Medis. As of 2014, a program disputes arise regarding coverage orcalled Cal MediConnect bundles all provider choice. Patients have certainmedical, behavioral health, long-term rights to seek specialized care out ofinstitutional, and home- and com- network. California’s workers’ compmunity-based services into a single system uses an independent medicalhealth plan. See calduals.org review process to resolve disputes about medical treatment. U.S. service veterans may have VAcoverage. It’s important to know if Because SCI is so complex, someyou qualify – the VA has highly skilled workers comp cases are managed byrehab care for spinal cord injury in third parties. Paradigm Outcomes, forboth San Diego and Long Beach. example, sets a high bar for getting(See sidebar p. 63.) injured workers top-tier rehabilita- tion, care and equipment – the com- Workers Compensation policies pany guarantees a better outcomekick in when you are hurt on the job. for the injured worker, believing thatWorkers comp insurance was de- investing in specialized medical at-signed as a sort of bargain between tention up front provides for a greateremployer and worker: employees quality of life and is less expensivegive up potential lawsuits for pain over time. Travelers Insurance, theand suffering in exchange for the em- largest private workers comp in-ployer agreeing to cover medical bills, surer, manages more than 250,000loss of wages related to the accident,www.SCI.first 90 days.com 61

CHOOSING A REHABw­ orkers compensation claims a year. Some private rehabs will acceptIn some cases the company offers a uninsured spinal cord injured patientsnurse concierge service to facilitate as “Medi-Cal pending.” They’ll admitaccess to care and to guide injured you to the hospital, cover your 30workers through the rehab process; days or so of rehab, uninsured, withthe company says this reduces costs, the expectation the state will step inand anxiety. with reimbursement. This is some- thing that has to be carefully worked It would be a wonderful thing out with medical staff and case man-for the spinal cord injury world if all agers at the rehab; don’t be afraid topatients got the high level service ask about this option.and concern for outcome across thelifespan that some injured workers In the bottom-line-driven man-get. But in the consumer SCI insur- aged care world, it is possible that noance world, your case is on a clock; insurance is better than having lousywhen the time runs out, when the insurance. A Medi-Cal pending ar-­reimbursement maximums have rangement may offer more choice ofbeen met, you are no longer the rehab facility than what might be re-company’s worry. imbursed by your bronze level HMO. Say your HMO has a contract with aNO INSURANCE? specific rehab unit after you leave the trauma hospital. You don’t choose,It’s not the end of the world. It means they do. (Patients have the right toyou will be enrolled in Medi-Cal as appeal the HMO designation, seesoon as possible. In the greater Los below.) A person with no insurance,Angeles area, no insurance often however, can approach any ­rehab;means you’re headed for the LA there’s no certainty a particularCounty system and Rancho Los f­acility will accept you as a M­ edi-CalAmigos Hospital in Downey. That’s pending, they are not required to, buta busy place, but a top tier rehab in many hospitals will.SoCal, and nationally. In San Diego,uninsured SCI patients are often re- READ THE POLICYferred to the University of California/San Diego. That facility contracts Policies have language regardingwith Sharp Rehab for acute rehab, catastrophic claims, and it’s a safeanother top tier rehab and a very bet most of us do not buy insurancegood choice. based on the quality of this cover-www.SCI.first 90 days.com 62

CHOOSING A REHABage. Like most insurance consumers, ARE YOU A VET?you probably have no idea what iscovered if something major happens. Are you a veteran and are you eligi- ble for VA health care benefits? This So, the first thing you must do is is essential to know because the VAcontact your insurance company’s has two major SCI rehab units in So-customer service office. Major in- Cal, one in Long Beach, the other insurers usually have their own case San Diego. They are fully accreditedmanagers who will be assigned to as comprehensive specialty careyour case while you are in the trauma units and are a great option – if youhospital. Find out who this person are a vet.is and how to be in contact. Alwaysdocument or record all discussions VA SCI Centers run an acutewith your insurance company, includ- med-surg unit for vets with SCI, buting the date, reason for the call, who also feature CARF accredited bedsyou spoke with and what was said. for both acute rehab and outpatient services, too. Get a copy of your policy docu-ments (if you can’t remember what To find out if you are eligible fordrawer you stuck them in, ask the VA services, call 1-877- 222-VETScompany to provide you with the full (8387) Monday - Friday between 5policy). Someone on the patient’s a.m. and 5 p.m. Pacific time. Also,side must dig in and read the fine you can apply online at 1010ez.med.print. Ask the trauma hospital to as- VA.gov. Eligibility can be complexsign you a case manager. but most often if you have a copy of your discharge papers (DD-214) the The insurance policy will spell out VA centers can establish eligibilityrehabilitation benefits. Your options within two working days.should be clearer once coverage isfigured out. Decisions then have to Another invaluable resource forbe made. Insurance companies like vets is the Paralyzed Veterans ofpatients who remain passive and go America, a national service organi-along with them. You don’t have to. zation that has a large staff of bene-Be prepared to fight for your rights. fits counselors. See pva.org The VA and the Department of De-fense (DoD) have an agreement di-recting all active duty new injury SCIpatients to the VA SCI Unit closest towww.SCI.first 90 days.com 63

CHOOSING A REHABthem, or closest to where they plan are too important to watch them flyto live after discharge. Such referral is by from the sidelines.supposed to occur within three daysof the injury onset, though it doesn’t Patients who are just days post-always work that fast and many DoD trauma alone cannot be preparedcase managers don’t know about the for any sort of negotiation with theiragreement. insurance coverage. It’s up to fam- ily, or friends, or even an outside ad-THE APPEAL PROCESS vocate, to jump in and take on the insurance company. This may startLet’s say the therapists and medical with a discussion, may evolve intoteam at the trauma hospital say you a negotiation, and could escalate toare ready to discharge and move on the realm of threat (with lawyers, orto rehab. And let us also assume that a newspaper reporter), or perhapsyour insurance company has figured onward to all-out litigation.it all out for you. They’ve looked atyour case and your diagnosis, cross You have to think of an appeal inreferenced that with your cover- simple terms: Your insurance com-age package, and then with a list of pany is not your friend, and not youracute rehab hospitals they do busi- enemy. It is simply a company youness with. They say, OK, here’s where have a contract with. As our friendsyou’re headed, for this many days. at the Patient Advocate Foundation (see p. 67) like to say, an appeal is a But what if this rehab hospital is contract dispute over the interpre-not on your list. It lacks the features tation of your plan and its coverage.and programs that you want. Is thereanything you can do? The process of appealing an i­nsurance company decision starts Yes. Insurance companies often with some dialog between you, ordeny coverage. Know this: You have your designated advocate, and aa guaranteed right to question any case manager from the company.decision made by your insurance Ask the case manager specificallyplan. Yes, this is a stressful time, first for the coverage you want. You maydealing with a life-changing trauma not succeed in an appeal with asituation, now adding the stress of phone call. You’ll likely need to file apushing back against the insurance more formal appeal, in writing. Filingcompany. This may seem to be too a complaint is a clearly defined right;much to take on. But these decisions the insurance company is requiredwww.SCI.first 90 days.com 64

CHOOSING A REHABto tell you how to do this. The strongest appeal usually in- Try to understand the language in cludes support from your medical provider. If your doctor is onboard,your plan – most have sections called you can get a letter explaining theCovered Benefits, and Non-Covered reason the treatment (or rehab facil-Benefits and Exclusions. Be aware ity) in question was requested andalso of some basic rights you have why your side thinks it’s necessary.in California, especially for managed Unfortunately, it can be difficult in acare plans. For example, you have busy trauma hospital to establish rap-the right to a second opinion, and port with a physician. The short-termthe right to see a specialist when you trauma setting does not lend itself toneed one. forming relationships with provid- If your insurance is employ-Patients who are just days post-trauma cannot on their ownbe prepared for any sort of negotiation with their insurancecompany. Enlist someone to advocate for you.er-based, your employer may in- ers. Still, the key to appealing rehabtervene and direct what the plan assignment is establishing medicalapproves. necessity. You must make a case that the treatment (rehab care) offered Can you get the rehab hospital of by your plan is below the standard ofyour choice to help you? Since you care, or “best practice,” of the reha-are not a patient there, that hospital bilitation field.has no standing with you; they canassess you, and can indicate their How are you, a lay person withwillingness to admit you, and per- limited exposure to trauma carehaps be ready to negotiate a single or physical medicine, supposed tocase agreement if they don’t have know what the standard of care isan existing contract with your plan. for an inpatient rehab hospital? YouThis is not uncommon but it won’t are not an expert. But you can statehappen unless there is pressure from the case that spinal cord injury isthe patient side. a complex medical condition thatwww.SCI.first 90 days.com 65

CHOOSING A REHABmust be treated by the highest level to participate in any external reviewof expertise. Explain that you don’t process. In California, members ofthink the necessary level of exper- HMO plans can file for a review withtise is available at the hospital the the Department of Managed Healthinsurance company has designated Care (see resources, next page).for you; the specialized services andexpertise you have identified at your A big issue in acute trauma care,choice of rehab are not found at the of course, is timing. You need a deci-one your plan has submitted. Use the sion made before the trauma hospitalnarrative on pp. 48-57 to establish is ready to discharge. So don’t wait.what you consider standard of care You or your advocate can requestfor treating spinal cord injury – espe- an expedited appeal by calling thecially categories for patient volume insurer directly; the insurer then mustand accreditation. make a decision within one to three business days. As always, keep track Ask the insurance company to re- of all correspondence and record allconsider, and to cover treatment at contacts with the insurance plan.the facility you have indicated. Yourplan manager may say, “no, your You may have options even whenchoice is out of network, this other the plan denies your appeal. It takes aplace is where we pay for rehab.” If great amount energy and resources,you are denied coverage this way, but if you’re committed and engaged,your insurer must provide to you in you can hire an attorney to escalatewriting the specific reason your cov- the contract battle with the insur-erage request was denied, including ance company. Most rehab referralwhat you need to do to appeal. You cases don’t require the patient sidehave the right to the see the full ver- to lawyer-up, but tenacity does paysion of the plan’s medical policy that off in dealing with insurance issues. Ifwas used to make the denial decision. you’re not getting the care you need, keep fighting. If you are not satisfied with yourplan’s response, you can request an Some very motivated patients andexternal review. An independent third their families have been known toparty looks at the health plan’s deci- contact local news media to attractsion, and will either uphold the insur- attention to their situation; insuranceance company or decide in your favor. companies don’t like this kind of pub-Your insurance company is required licity, and this may work to your ad- •vantage during negotiations.www.SCI.first 90 days.com 66

CHOOSING A REHABKEY RESOURCES: They say 60 percent of appeals tilt toward the consumer, not the insur-Patient Advocacy Foundation is ance plan. See dmhc.ca.gov or calla national non-profit that provides 1-888-466-2219.professional case managementand mediation services to Ameri- Medi-Cal Managed Care Officecans with chronic, life threatening of the Ombudsman: This officeand debilitating illnesses. PAF case helps solve problems from a neutralmanagers, assisted by doctors standpoint to ensure that Medi-Caland healthcare attorneys, serve as members receive all medically nec-liaisons between the patient and in- essary covered services for whichsurer. S­ ee patientadvocate.org plans are contractually responsible. By phone: 1-888-452-8609Covered California Issues? Assis-tance is available if you have con- Medicare appeal: If you disagreecerns about your health insurance with an initial decision from yourplan. Contact the Health Consumer Medicare coverage, you can ask forAlliance, which can help you work a reconsideration; you must do sowith your health insurance com- within 60 days of the date of thepany, the Department of Managed first denial. There are five levels ofHealth Care and the Department of appeal, including an independentInsurance; 888-804-3536 or health- review, a hearing before an Adminis-consumer.org trative Law Judge, an appeal to the Medicare Appeals Council, or youManaged Care Appeal: The state can take the case to federal court.Department of Managed Health If you believe you are being dis-Care offers Independent Medical charged from a hospital too soon,Review when health care service you have the right to immediateor treatment has been denied, review by Medicare’s Beneficiarymodified or delayed. Independent and Family Centered Care Qualitydoctors not part of your health Improvement Organization (BF-plan will review your case. Says the CC-QIO). The hospital can’t forceDMHC: “You have a good chance of you to leave before the BFCC-QIOreceiving the service or treatment reaches a decision. www.medicare.you need by requesting an IMR.” gov/Contactswww.SCI.first 90 days.com 67

CHOOSING A REHAB INPATIENT REHABILITATIONFACILITIES IN SOUTHERN CALIFORNIAThere are at least 40 acute in- Accreditation by CARF is a key patient rehabilitation facili- ranking qualifier. CARF is an inde- ties (IRF) that admit patients pendent international agency that with acute spinal cord injury in provides accreditation services at Southern California. the request of service providers. Rehabs vary in size, experience, The agency has established rigorousand in quality. Some of the higher vol- standards for physical medicine andume hospitals you may have heard of, rehabilitation, including a specializedothers are smaller community hos- certification for spinal cord injury.pitals with a rehab unit that may seeone or two SCI patients a year. Here, The CARF SCI System of Carethe IRFs have been broken down in certification provides coordinated,four tiers. case-managed, integrated services that address the needs of those All units listed below have a Joint served. According to CARF guide-Commission (JC) accreditation for lines, “These key components ofgeneral hospital. This accreditation care include, but are not limitedis important mainly to allow Medicare to, emergent care, acute hospital-billing; it is generally not regarded as ization, other inpatient rehabilita-a rigorous measure of quality. tion programs, skilled nursing care,www.SCI.first 90 days.com 68

CHOOSING A REHABhome care, other outpatient med- patient with spinal cord injury it mustical rehabilitation programs, com- meet specific standards for SCI care.munity-based services, residential A certified IRF must offer or arrangeservices, vocational services, primary care for bowel, bladder, cardiac, re-care, specialty consultants, and long- spiratory, spasticity, metabolic func-term care.” The SCI specialty includes tion, and musculoskeletal issues. Thea strong education component for center must also offer expertise andthose injured and for their families. counseling for peer support, nutri-The rehab focus includes interaction tion, sexual health, substance abuse,with others with similar injuries; life- driver training, environmental mod-long follow-up that takes into con- ification, vocational rehab, and as-sideration activity, participation, and sistive technology. Starting in 2017,Before you choose an IRF, contact each one that seems tomeet your needs. Ask about their SCI rehab facilities, staff,programs and specialties.quality of life; as well as participation a CARF certified IRF must also havein research and its application in clin- staff, equipment and skills to addressical medicine. (See carf.org). skin integrity and wound care issues. It is important to note that while Rehab units are also cited belowa CARF designation as a Spinal for having a Magnet certificationCord Injury System of Care sets a from the American Nurses Creden-higher standard for quality care for tialing Center; this recognizes a well-people with new SCI, a rehab that trained nursing staff in a low-turnoverhas a basic CARF accreditation for environment that focuses on nursingComprehensive Integrated Inpatient excellence and quality patient out-Rehabilitation must have the capac- comes (see nursecredentialing.org)ity and expertise to offer a 24-hourintegrated, interdisciplinary acute The Medicare system offers an In-rehab program, led by a trained re- ternet tool to help consumers choosehab doctor. If the program admits a an inpatient rehab; you can check it out at medicare.gov/inpatientre-www.SCI.first 90 days.com 69

CHOOSING A REHABhabilitationfacilitycompare but you they have staff and facility to providewill soon see there often isn’t enough rehab services for newly injured pa-information provided for each center tients with spinal cord injury. Patientto enable a reasonable evaluation. volume is generally fewer than one new injury per month. Before you choose an IRF, contacteach one that seems to meet your THE TOP TIERneeds. Ask about their SCI rehab fa-cilities, staff, programs and special- Rancho Los Amigos National Reha-ties; talk to the doctor who treats bilitation Center, Downey, is one ofSCI. Importantly, ask about patient only 14 federally designated Spinalvolume – are you going to be the Cord Injury Model System centers,sole spinal cord patient in a ward of and the only one in California. Thestrokes and hip replacements? hospital also is accredited by CARF for Comprehensive Integrated In-THE RANKINGS patient Rehabilitation. Rancho has taken care of people in need goingThe Top Tier units qualify as such back to 1888 when this big campusby high volume of new SCI patients took care of indigents as the countytreated each year, and by having a poor farm. Rancho was a major po-spinal cord injury specialty accredita- lio hospital through the 1950s. Now,tion, and by reputation in the physical as the rehabilitation arm of the Losmedicine field. Angeles County Department of Health Services system, Rancho is Second Tier units generally treat the largest IRF in the state and seesat least 25 new SCI patients a year, the most new spinal cord injury pa-and at a minimum are CARF accred- tients, at about 115 new traumaticited for Comprehensive Integrated cases a year. The outpatient programInpatient Rehabilitation; some in this follows a huge number of patients,tier have CARF credentials for other about 7,000. Rehab services arerehab specializations, such as brain staffed by a team of physical medi-injury, or stroke. cine specialists, including orthotics and prosthetics, seating, rehab en- Third Tier units are CARF accred- gineering, driver training, and lately,ited for Comprehensive Integrated neural prosthetics. Average lengthInpatient Rehabilitation but deal with of stay is about 26 days, comparedlower volumes of patients. The Fourth Tier are not accreditedother than JC, but state publicly thatwww.SCI.first 90 days.com 70

CHOOSING A REHABto the national average of 19 days for Sharp Memorial Hospital, part ofacute rehab. Discharge to community a system of four acute-care hospi-is 79 percent, which is about average. tals and three specialty hospitals, isRancho typically admits 10 or more located in San Diego; it’s the onlyC1-C4 injuries, patients who are more CARF-accredited spinal cord injurylikely to require long-term post-re- rehab in San Diego County; the levelhab skilled nursing care. Rancho is of care is ­expert and comprehensive.completing a $418 million renovation This ­r­e­ hab has a nursing care Mag-and campus beautification project net certification from the AmericanA recent clinical trial at Rancho, along with engineers fromUSC and Cal Tech, enabled a quad patient to drink a beer bymoving a robotic arm using only his mind.to construct a Wellness & Aquatic Nurses Credentialing Center. TheTherapy Center, new outpatient fa- newly renovated rehab unit featurescilities, and improved seismic safety. private rooms and has a strong out-A recent clinical trial at Rancho, patient medical program, fertilityalong with engineers from USC and program, peer support, and robustCal Tech, enabled a quad patient to sports and recreation program. SCIbring a beer to his lips by moving a patient volume is about 100 new SCIrobotic arm using only his mind. Ran- patients a year, which includes bothcho also works with USC scientists traumatic and non-traumatic injuries.for stem cell clinical research. Rancho The return to home percentage issupports programs in the arts, pho- well above average, at 95 percent.tography-as-therapy, and sports for 2999 Health Center Dr., San Diego,its patients and many alumni. Though CA 92123; 858-939-3400, sharp.comthe campus is growing, there’s stillan old-school California charm to St. Jude Medical Center, in Fuller-Rancho Los Amigos. 7601 Imperial ton, is one of the most qualified SCIHwy, Downey, CA 90242; 562-401- programs in California. St. Jude has7111, rancho.org a CARF spinal cord injury-specificwww.SCI.first 90 days.com 71

CHOOSING A REHABc­ ertification for both inpatient and SECOND TIER: LOWER VOLUMEoutpatient services and board cer- CARF ACCREDITEDtified spinal cord injury doctors onstaff. The facility also has a nursing Ballard Rehabilitation Hospital, Sancare Magnet certification. This is the Bernardino, is not well known outsideIRF designation for many spinal cord of the 909 – the four-million popula-injuries in Orange County. The an- tion Inland Empire. This 60-bed IRFnual SCI patient volume is around opened in 1993; it is certified by CARF50 cases, including traumatic and for Comprehensive Integrated Inpa-non-traumatic injuries. Discharge to tient Rehabilitation for both adults,community is 78 percent. Length of and for children and adolescents.stay, 14 days. Satisfaction from pa- Ballard also has CARF accredita-tients rated at 92 percent. Counseling, tion for stroke. Ballard sees abouteducation and support are featured 30 new spinal cord injuries annually,across the spectrum of trauma care which represents about 10 percentand recovery. A large outpatient cen- of all rehab admissions. The unit fea-ter sits across town a few miles from tures transitional apartments with fullthe main hospital. St. Jude is also the bedroom, bathroom and kitchen sohome of Dr. Suzy Kim, a board cer- patients can practice self-care skills.tified SCI doctor and contributor to Ballard is part of the Vibra Health-this book. stjudemedicalcenter.org care network, comprising IRFs, long term care and skilled nursing facilities Note: there are two large VA spi- in 18 states. 1760 West 16th St., Sannal cord units in the Southern Cali- Bernardino, CA 92411; 909-473-1200,fornia area, one in Long Beach and b­ allardrehab.comone in San Diego. Both are CARFaccredited in the spinal cord injury California Rehabilitation Institutespecialization for both inpatient is new to the area, having opened incare and outpatient services, and July 2016, on the West Side of Losshould be considered First Tier op- Angeles. It is a partnership betweentions in this listing. Alas, these rehab two prominent SoCal institutions,facilities are available only to U.S. Cedars Sinai Medical Center and theservice veterans. See p. 63 for more University of California/Los Angeles.about eligibility for VA health care Since UCLA and Cedars each supportservices. a Level 1 Trauma Center, SCI patients will likely transition from those emer-www.SCI.first 90 days.com 72

CHOOSING A REHABgency rooms to acute rehab at CRI. and semiprivate rooms in the acuteSelect Medical is the managing part- rehab unit, and a brand new 31-bedner, and provides the 138-bed center med/surg unit. Casa Colina is accred-with an instant reputation for qual- ited for Comprehensive Integratedity and comprehensive care. Select Inpatient Rehabilitation. The centermanages several top-level rehabs, also has a CARF-accredited 42-bedincluding Kessler Institute in New transitional living center where resi-Jersey, a CARF-spinal cord injury dential clients get up to six hours ofaccredited and SCI Model Systems therapy six times a week to developCenter. ­Select also manages more daily living skills and independence,than a dozen other large rehabs, in- supervised by physicians, neuropsy-cluding Baylor Institute for Rehabili- chologists, physical and occupationaltation, Cleveland Clinic Rehabilitation therapists, nurses, etc. Specialty ar-Hospital, and Emory Rehabilitation eas include ventilator weaning forHospital. While CRI has yet to admit select patients. Casa has a well-de-a large volume spinal cord injury pa- veloped outpatient medical program,tients, and all rehab services are not and is well known for its recreationyet available, the parent company and sports department. Affordablehandles about 400 new traumatic short-term housing is available forSCI cases a year. CRI says it will apply families. Casa sees around 100 newfor CARF specialization in SCI when spinal cord injury cases a year, whicheligible. All rooms are private. 2070 includes traumatic and non-traumaticCentury Park East, 424-5221-7111, SCI. Inpatients report 93 percent sat-c­ aliforniarehabinstitute.com isfaction with their experience here. In recent years Casa Colina has par-Casa Colina Hospital began in 1938 ticipated with UCLA and Cal Tech toin Chino, 40 miles west of LA, as a test brain implants for neural controltreatment center for children with of tablet computers. 255 East Bonitapolio. The hospital moved to nearby Avenue, Pomona, CA 91767; 909-Pomona in 1961 – opening 68 beds 596-7733, casacolina.orgright about the time acute polio wasno longer a problem. Casa shifted its Cottage Rehabilitation Hospitalfocus to traumatic injury. Casa Colina used to be called Santa Barbarais a large, architecturally integrated Rehabilitation Institute before join-campus on 20 acres, with private ing the Cottage group in 2007. Thewww.SCI.first 90 days.com 73

CHOOSING A REHAB38-bed facility has a history dating bara vibe. 2415 De La Vina St., Santato 1955 treating stroke, brain injury, Barbara, CA 93105; 805-569-8999,complex orthopedics, and spinal visit c­ ottagehealth.orgcord injury. Though not currentlyaccredited in SCI, Cottage had that Loma Linda University Medical Cen-specialty CARF designation until a ter began in 1905 when Seventh-dayfew years ago (it maintains CARF Adventists bought land in San Ber-accreditation in Comprehensive In- nardino County and built a medicaltegrated Inpatient Rehabilitation, and missionary school. This became afor stroke and brain injury, including medical college and over the nextpediatric). Most patients here are century a sprawling medical andfrom the northern reaches of South- teaching complex that includes theern California; the patient volume is only Level 1 Regional Trauma Cen-about 100 new SCI cases (includes ter for the Inland Empire countiesboth traumatic and non-traumatic of Inyo, Mono, Riverside, and SanSCI) annually, which fills 18 percent Bernardino. The Loma Linda re-of the beds. Stroke and orthopedic hab unit has a CARF credential forrehab represent more than half of Comprehensive Integrated Inpatientall patients. Over 80 percent of pa- Rehabilitation, including pediatrictients here are over 51. Local residents rehab. The unit also has a CARF cre-with SCI are cared for at the Keck dential for stroke care. The center’sCenter for Outpatient Services. Spe- East Campus opened a new 24-bedcialty services include an assistive rehabilitation hospital in 2010; theytechnology center, wheelchair seat- describe it as “an evidence-baseding and positioning, driver training, healing environment including itsaquatic wellness and fitness center, connection to nature, access to so-a wide range of recreation options, cial support, variety of options, elim-and caregiver services; the Coast ination of environmental stressors,Caregiver Resource Center (see p. and positive distractions.” The pa-131) is part of Cottage. The hospital tient rooms in the Tom & Vi Zaparaowns an exoskeleton, available for Rehabilitation Pavilion are private,qualified patients. Discharge to home very resort-like, featuring patios,is about 83 percent; 9.7 percent go healing gardens, and an event parkto skilled nursing facilities. Cottage for concerts. Loma Linda sees aboutpreserves a warm, friendly Santa Bar- 115 new SCI patients a year, about halfwww.SCI.first 90 days.com 74

CHOOSING A REHABof those from traumatic injury. SCI home rate is 80 percent. 2801 Atlan-patients fill about 10 percent of rehab tic Avenue, Long Beach, CA 90806,beds. Outpatient services are robust. 562-933-2000; memorialcare.org/Strong peer-support and commu- long-beach-memorialnity recreation access via the LomaLinda PossAbilities program, which Northridge Hospital Center for Re-also features grants, scholarships, habilitation Medicine opened in 1974discounted dental and prescription as a program of the Dignity Healthprograms, and Paralympic training. Network (39 hospitals in Arizona,Discharge to home percentage is California, and Nevada); the main78.1 percent, which is about average. hospital (the location of the old TV25333 Barton Road, Loma Linda, CA show Doogie Howser, M.D.) includes92354; 909-558-4484, east-campus. a Level II Trauma Center. The hos-lomalindahealth.org pital has a CARF accreditation for Comprehensive Integrated InpatientLong Beach Memorial is part of the Rehabilitation. The inpatient rehabMemorialCare Health System, which (about 18 percent SCI, vs. 40 percentincludes Miller Children’s & Women’s stroke) includes SCI medical special-Hospital (see p. 97). The rehab unit ists (there is a board-certified SCIhas a CARF accreditation for Com- physician here) who care for aboutprehensive Integrated Inpatient Re- 25 new traumatic SCI patients a year.habilitation. The facility also has a There is also a large outpatient pro-Magnet certification from the Amer- gram. Services include driver training,ican Nurses Credentialing Center. wheelchair sports, and therapeuticThis rehab unit is not a campus, nor recreation. Average age of patientsdoes it resemble a resort; LBM’s SCI is 62 but 16 percent of patients areunit is a wing of a big busy commu- under the age of 44. Northridge hasnity hospital complex, with a large an active patient support group. Thisgroup of physical medicine special- is the only facility in the Valley to offerists and the usual rehab therapists the ReWalk exoskeleton, helpful for(PT, OT, etc.). Volume is around 65 some patients to ambulate again. Dis-new SCI cases a year, most of those charge to home is about 75 percent.are non-traumatic. Length of stay is 18300 Roscoe Blvd, Northridge, CA14.5 days, compared to the regional 91328; 818-885-8500, dignityhealth.average of about 18. Discharge to org/northridgehospitalwww.SCI.first 90 days.com 75

CHOOSING A REHABNOT LOCAL BUT AS GOOD AS 91, well above the national average.­REHABILITATION GETS The PEAK (Performance, Exercise, Attitude and Knowledge) CenterCraig Hospital is everything you is Craig’s large community fitness/could ask for a in specialized s­ pinal wellness center, also part of thecord and brain injury hospital. Craig Reeve Foundation NeuroRecoveryis a 93-bed, high-volume facility Network. Half of Craig patientslocated in the Denver suburb of come from out of state. A numberEnglewood. This is by most mea- of California patients with acute SCIsures the premier rehab facility in travel to Craig every year; it’s a two-the country for spinal cord or brain hour plane trip from most airports ininjury – for many reasons: narrow the Southland. There is a culture offocus on neurotrauma; very high hope and possibility at Craig. 3425medical staff specialization with S. Clarkson St., Englewood, COvery little turnover; willingness to 80113 craighospital.orgtake the most difficult cases; strongfocus on family support, including Free Craig Nursing Advice Line:free housing for out of town fam-ilies; top-tier outpatient services; Medical question? Craig hospitaldedication to patient education; fields health-related calls daily fromtop-notch research department. all people living with spinal cord injury. This is for anyone, not just forCraig admits about 500 new trauma Craig alumni. Calls also come fromcases a year; there are about 55 family members, health care pro-inpatients at any given time with viders and others who need expertspinal cord injuries, and 30 with advice for non-emergency medicaltraumatic brain injuries, plus 50 or issues, e­ ducational materials, and60 outpatients. About 1,400 out- caregiving. Monday to Friday, 8 a.m.patients visit the hospital each year. to 3 p.m. (Mountain Time Zone),Discharge to home percentage is 1-800-247-0257 or 303-789-8508.www.SCI.first 90 days.com 76

CHOOSING A REHABTHIRD TIER (CARF ACCREDITATION, Providence Little Company of MaryLOWER VOLUME) Medical Center, San Pedro has CARF accreditation for CIIR, and also forCitrus Valley Centers for Rehabilita- stroke; Magnet certification. 1300tion, West Covina, CARF accredited West Seventh St., San Pedro 90732;for Comprehensive Integrated Inpa- 310-832-3311, c­ alifornia.providence.tient Rehabilitation (CIIR), and for org/san-pedrostroke; 1115 So. Sunset Ave., West Co-vina 91790; 626-962-4011, cvhp.org Providence St. Joseph Medical Center, Burbank, CARF accredita-Eisenhower Medical Center, Rancho tion for CIIR, and stroke. 501 SouthMirage, is CARF accredited for CIIR, Buena Vista St., Burbank 91505; 818-has a Magnet certification.39000 843-5111, california.providence.org/Bob Hope Dr., Rancho Mirage, 92270; saint-joseph760-340-3911, emc.org Scripps Memorial Hospital, Encini-Mission Hospital, Mission Viejo, has tas, has CARF accreditation for CIIR,CARF a­ ccreditation for CIIR, and also also for stroke and brain injury; Mag-for pediatric rehab and brain injury net certified. 354 Santa Fe Dr., Encini-for adults and children. Has a Magnet tas 92024; 760-633-6501, scripps.orgcertification. 27700 Medical CenterRoad, Mission Viejo 92691; 949-364- South Bay Rehabilitation Center at1400, mission4health.com Paradise Valley Hospital, National City, has CARF accreditation for CIIR,Palomar Health Rehabilitation Insti- also for stroke; 2400 East Fourth St.,tute, has CARF accreditation for CIIR, National City 91950; 619-229-3249,and also pediatric rehab. 555 East paradisevalleyhospital.netValley Parkway, Escondido 92025;760-739-3000, palomarhealth.org Tustin Rehabilitation Hospital/ HealthSouth. Does not have a CARFProvidence Holy Cross Medical credential but qualifies for Tier 3 asCenter, Mission Hills, CARF for CIIR, the home base for board certifiedalso for pediatric rehab, and stroke. SCI medical specialist Dr. Ann Va-Magnet certification. 15031 Rinaldi sile. 14851 Yorba St., Tustin 92780;St., Mission Hills 91345; 818-365-8051, 714-832-9200, tustinrehab.comcalifornia.providence.org/holycrosswww.SCI.first 90 days.com 77

CHOOSING A REHABNOT IN SOUTHERN CALIFORNIA BUT FOURTH TIER (LOWER VOLUME, JCA TOP TIER CA REHAB CENTER ACCREDITATION ONLY)Santa Clara Valley Medical Alhambra Hospital, 100 South Ray-Center in San Jose, the largest mond Avenue, Alhambra 91801; 626-SCI rehab center in Northern 570-1606, alhambrahospital.comCalifornia, reports a patient volumeof about 85 acute traumatic spinal Arroyo Grande Hospital, 345 Southcord injuries annually. SCVMC is a Halcyon Road, Arroyo Grande 93420;Level I Trauma Center; the hospital 805-489-4261, dignityhealth.orgfeatures an ICU-type RehabilitationTrauma Center, where patients Bakersfield Rehabilitation Hospital/receive early and aggressive care. HealthSouth, 5001 Commerce Dr.,For many years Valley Med was a Bakersfield 93309; 661-323-5000,Model Systems SCI Center; it is now healthsouthbakersfield.comCARF accredited in spinal cordinjury specialization for both adults Centinela Hospital, 555 E. Hardy St.,and adolescents, and for both Inglewood, CA 90301; 310-673-4660,inpatient and outpatient services. centinelamed.comSCVMC is also CARF accredited forComprehensive Integrated Inpatient Desert Regional Medical Center,Rehabilitation, as well as for stroke Palm Springs, 1150 N. Indian Canyonand brain injury. The hospital Dr., Palm Springs 92262; 760-323-website claims more SCI-board 6511, desertregional.comcertified physicians than any otherrehab center on the West Coast. Garfield Medical Center, 525 N.The rehab’s Women with Disabilities ­Garfield Ave., Monterey Park, CAHealth Care Clinic addresses the 91754; 626-307-2130; garfieldmedi-unique needs of women with SCI. calcenter.comSCVMC has a strong peer support/alumni network. SCVMC is active Glendale Adventist Medical Center,in clinical trials, e.g., working with 1509 Wilson Terrace, Glendale 91206;Stanford to evaluate stem cell 818-409-8000, adventisthealth.org/therapies. 751 S. Bascom Ave., San glendaleJose, CA 95128; 408-885-5000,scvmcrehab.orgwww.SCI.first 90 days.com 78

CHOOSING A REHABGlendale Memorial, 1420 So. Central St. Vincent Medical Center, 2131 WestAve., Glendale 91204; 818-502-1900, Third St., Los Angeles 90057; 213-dignityhealth.org/glendalememorial 484-7111, stvincent.verity.orgHollywood Presbyterian, 1300 Tri-City Medical Center, 4002 VistaN. Vermont Ave., Los Angeles, CA Way, Oceanside, CA 92056; 760-614-90027; 213-413-3000, hollywood- 2673, tricitymed.orgpresbyterian.com UC Irvine Health, has a Magnet cer-Huntington Memorial Hospital, Pasa- tification, 101 The City Drive South,dena, Magnet certification, 100 West Orange, CA 92868; 714-456-7890,California Blvd., Pasadena 91105; 626- u­ cirvinehealth.org397-5000, huntingtonhospital.com UC San Diego Medical Center, has aMethodist Hospital of Southern Magnet certification, 200 West ArborCalifornia, 300 W Huntington Dr., Dr., San Diego 92103; 858-657-7000,Arcadia, CA 91007; 626-898-8000, health.ucsd.edumethodisthospital.org University of Southern Califor-Presbyterian Intercommunity, 12401 nia/Keck Medicine, 1500 San PabloWashington Blvd., Whittier, CA St., Los Angeles 90033; 323-442-90602; 562-698-0811, pihhealth.org 8789, keckmedicine.orgSan Diego Rehabilitation Institute/ Valley Presbyterian Hospital, 15107Alvarado Hospital, 6655 Alvarado Vanowen St., Van Nuys, CA 91405;Rd., San Diego 92120; 619-287-3270,alvaradohospital.com •818-782-6600, valleypres.orgSt. John’s Regional Medical Cen-ter, 1600 North Rose Ave., Oxnard,CA 93030; 805-988-2500, visit­dignityhealth.org/stjohnsregionalwww.SCI.first 90 days.com 79



CHOOSING A REHABPOST-ACUTE CAREPeople with traumatic inju- skilled nursing is a necessary step for ries may no longer need the many patients – you may be trying intensive services of an acute to wean from a ventilator, or perhaps hospital but may not yet be you have been deemed “medically strong enough to move on complex,” needing to get healthierto rehab. In that case, there are op- before you can move on to rehab, andtions for post-acute care, including then to home.nursing homes, and long-term acutecare (LTAC) hospitals. Is this a good There are hundreds of nursingchoice? Ask this question: does care homes in the SoCal area, some ofneed to be directed by a physician? them full of long-term care patientsIf so, that points toward long-term (the old folks home model). Your doc-care. If a doctor is not needed on a tor or social worker/case managerdaily basis, it may mean transfer to a should be able to make a recommen-skilled nursing facility (SNF). dation. There are all sorts of factors to weigh. Is the facility nearby, and is Generally speaking, it’s a good it safe? Does it smell OK? Is the foodidea to avoid nursing homes. SNFs good? Can your pet visit you? Do youoffer little or no therapy or rehab, and have to adhere to a strict schedule forminimal physician contact. Of course meals? Be sure and have someonewww.SCI.first 90 days.com 81

CHOOSING A REHABvisit facilities that seem right. Centre for Neuro Skills (CNS) spe- The Medicare website features a cializes in intensive traumatic brain injury rehabilitation; because thosecomparison tool that lists every nurs- with spinal cord injuries often haveing home in the U.S. The homes are a brain injury too, CNS also offersgraded on overall rating, health in- post-acute care for SCI. With facili-spections, staffing and quality mea- ties in Bakersfield, Los Angeles, Sansures. For example, a search of Los Francisco, and Dallas, CNS offersAngeles turns up 324 nursing homes patient-centered, real-world-basedwithin 25 miles of the city; you can, for rehab services aimed toward mea-example, filter out only the facilities surable treatment goals. CNS be-that have a “much above average” lieves that given the right therapy atrating (there are 74 such units). See the right time by experienced pro-m­ edicare.gov/nursinghomecompare fessionals, clients can regain a “nor- mal rhythm of living” and steadily If more doctor-directed care is re- work towards successful communityquired, there are a number of LTAC re-entry. CNS is CARF accredited forfacilities in SoCal. These sub-acute Interdisciplinary Outpatient Medicalunits are also called a transitional care Rehabilitation with a brain injury spe-units. Most patients in long-term care cialty, and for Residential Rehabilita-stay for about four weeks. tion. neuroskills.com CARF offers certification for CareMeridian is a large multi-stateskilled nursing and LTAC; none are provider of post-acute rehabilita-listed in either category in California. tion services for people with brain and spinal cord injuries. The services Remember, the goal is to move are delivered in community-basedtoward the best possible inpatient settings; participants receive struc-rehabilitation facility (IRF). Skilled tured support integrated with worknursing facilities sometimes make and community participation. Inthe case that they provide adequate, Southern California, CareMeridianequivalent rehab care. Not always so. operates what they call sub-acuteIRFs are required to have significantly neurorehab units in Artesia, Chats-higher staffing levels and provide worth, Cowan Heights, Escondido,much more direct care to patients Garden Grove, LaHabra Heights, Lathan SNFs do. Here are some options to considerfor for post-acute care in the greaterSouthern California area:www.SCI.first 90 days.com 82

CHOOSING A REHABMesa, Northridge, Oxnard, Santa Rehab Without Walls is a sort ofAna, Santa Barbara, Woodland Hills. customized home delivery rehabCareMeridian Winways, located in model. The goal, says the company,Orange, is CARF accredited for In- “is to provide care in a comfortable,terdisciplinary Outpatient Medical familiar environment, to help pa-Rehabilitation with a brain injury tients experience better outcomes.”specialty, and also for Residential Treatment plans, which may includeRehabilitation. C­ areMeridian offers up to six hours of therapy a day, arefamily counseling and training for based on a physician’s orders, andthe family to make the transition to address specific patient goals. Rehabhome as smooth as possible. See Without Walls, accredited by CARF­caremeridian.com for Home and Community Services, works closely with insurance payers;Kindred Hospitals, a national chain they have been able to apply outpa-of rehabs, provides specialized care tient, home health, SNF, and inpatientto medically complex patients who benefits, as well as workers compen-require longer recovery time. The sation. RWW operates in 12 states,company operates long-term acute including three divisions in California.facilities in Baldwin Park, Brea, La Mi- The SoCal office covers Los Angeles,rada, Los Angeles, Ontario, Rancho Orange, Riverside, San Diego andCucamonga, Perris, San Diego, West portions of San Bernardino and Ven-Covina, Santa Ana, Gardena, and tura counties. rehabwithoutwalls.comWestminster. kindredhealthcare.com Other: Medicare lists several otherRehabCare is affiliated with Kindred, LTAC units in the area, including Bar-providing contract therapy services low Respiratory Hospital, Los Ange-in skilled nursing facilities. Several fa- les; Monrovia Memorial Hospital; andcilities in SoCal. rehabcare.com •Vibra Hospital, San Diego.Promise Hospitals is a national groupof long term care facilities, includ-ing units in East LA and San Diego.p­ romisehealthcare.comwww.SCI.first 90 days.com 83

CENTER OF RESTORATIVE EXERCISE About Us What is Restorative Exercise? C.O.R.E. (Center of Restorative Exercise) Restorative Exercise is a personalized and is a state-of-the art, niche health & wellness, fitness & performance facility that provides progressive corrective exercise fitnesslife-enhancing benefits of ongoing Restorative program designed and conducted by a Exercise for, but not limited to, the one in five certified Restorative Exercise Specialist. Americans living with a disabling condition. The program is based upon a client’s goals C.O.R.E. is staffed with certified RestorativeExercise Specialists and equipped with unique and focuses on improving function, independence and self-efficacy. Additionally, and specialized equipment. Restorative Exercise aims to improve and/or prevent the secondary complications and degenerative changes that typically follow a physical disability, disease and/or musculoskeletal injury. Call today and schedule your evaluation818.718.CORE(2673) | www.centerofrestorativeexercise.com 9667 Reseda Blvd. Northridge, California 91324

CHOOSING A REHABLIFELONG REHAB: ACTIVITY AND EXERCISEE xercise is the gateway to San Diego, opened in 1988, the first health and well-being. This community based, disability-friendly is true for everybody, but for gym, the first non-institutional facil- people with mobility limita- ity promoting accessible exercise. “If tions, it is even more essential there is a cure-all beneficial to mostto work the heart, stretch the joints every condition that a person can suf-and move the body. Activity can fer,” said founder Bill Bodry, a para-lead to recovery for some; vitality plegic, “exercise is it.” He wasn’t sureand quality of life are assured for all. what he ought to do to get fit, and ofHere are some SoCal fitness centers course he could not find a facility thatfor the wheelchair community. Note: would accommodate him. So Bodryinsurance coverage may be an option pulled a non-profit board together,but most likely you’re on your own. A got local government to subsidizemedical release is required by most some rent, hired a physical therapistfacilities. and opened Challenge Center.Challenge Center, La Mesa Bodry, now retired, witnessed “lit-Challenge Center in La Mesa, near tle miracles” at Challenge Center on a regular basis. He says he and thewww.SCI.first 90 days.com 85

CHOOSING A REHABstaff never made bold statements thing better.” Thomas met Ted Dardz-to clients about recovery. “We never inski, an athletic trainer in La Jolla. Tedguaranteed any particular result. But hadn’t ever worked with a paralyzedwe did guarantee that whatever is person but got Thomas to tap into hispossible will be possible here.” spasms as activity, and to use repet- itive patterning of movements and Challenge Center is staffed by weight-borne exercises to his advan-­licensed physical therapists. See tage. Thomas eventually regainedwww.challengecenter.orgProject Walk got started because Mike Thomas wasn’t­satisfied. He was paralyzed, C7 incomplete, in a car wreck inCuba in 1998. Got to be something better, he figured.Project Walk, Carlsbad the ability to walk. Project Walk alsoThe SCI marketplace has validated offers a home-based program. pro-Project Walk’s sports trainer method jectwalk.comof rehab-as-a-lifestyle therapy. Themother business, based in Carlsbad, Project Walk, Claremontfigured out early on how to monetize Hal Hargrave, 17 and just out of highhope for recovery; PW clients typi- school, was spinal cord injured, C5/6,cally spend $3000 or more a month, in 2007. Just days after leaving Casasometimes for years. Colina Rehab, he became a regular at the Carlsbad PW, twice a week for Project Walk got started because six years. Motor function recoveryMike Thomas wasn’t satisfied. He was was modest but Hargrave got a lotparalyzed, C7 incomplete, in a car of mental, emotional and social ben-wreck in Cuba in 1998, shipped to efits from being a Project Walker. He’sMiami for rehab, then came home healthy, much more confident andto California hoping for some recov- self sufficient, and that’s a direct pay-ery at the VA hospital in San Diego. off, he says. “Exercise, if you stick toHe was discharged and pronounced it, it’s medicine.”“rehabbed.” Not acceptable, saidThomas. “There’s got to be some- Hargrave and his family startedwww.SCI.first 90 days.com 86

CHOOSING A REHABthe Be Perfect Foundation, a charity again. After six months of inpatientto help SCI folks. Project Walk Clare- rehab at Northridge Hospital, and sixmont, a collaboration with Be Perfect, more as an outpatient, “My insurancebegan in a small space – actually, a company deemed me pretty much re-racquetball court – donated by the habilitated. I was still in a power wheel-Claremont Club, a fitness/tennis club chair but my body was just starting toin town; Hargrave brought in a trainer respond; sensation was blotchy butto work with a group of his spinal cord there were flickers of movement.”injured friends. The club later offeredhim a much larger space, rent-free, In 2000, he got connected to ki-to expand. Hargrave and his parents nesiologist Taylor K. Isaacs. “I saidopened a PW franchise in Claremont. to him, with my motivation and your education, we’re going to make it See www.claremontclub.com, happen.” Baker’s body responded.click on Project Walk for more. He regained sensory function, and eventually was able walk using a caneProject Walk, Los Angeles for support. Baker still calls himself aAccording to the company, the LA- recovering quadriplegic; at this pointarea facility, 5051 Exposition Blvd. in he trains mostly for maintenance. “IfLos Angeles, very close to the La Brea I stop working out even for a shortstation of the Expo Line rail system, while, my body feels like lead.”will serve as the base for PW researchand development programs. They Baker, his mother Laquita Con-hope to work with universities and way, and Isaacs opened the Centerbiotech companies in the SoCal area for Restorative Exercise (CORE) in“to advance stem cell, electrical stim- 2011. It’s an attractive space, busy,ulation and robotic studies.” There’s upbeat, with a warm, communitya body-weight supported treadmill vibe. The center, recently expanded,on site. For more, search “locations” hosts social events and lectures.at projectwalk.com Baker says CORE is careful aboutCORE, Northridge what they promise. Of course folksAaron Baker was injured in 1999 at may calibrate their own expecta-C4/5/6, age 20, crashing a motor- tions after seeing the founder get upcycle. He says his doctors gave him and walk away from his wheelchair,little chance of ever feeding himself but that’s not the point. “We do not promise recovery. We do say that if you do not pursue a healthy life-www.SCI.first 90 days.com 87

CHOOSING A REHABstyle of activity and movement, your able for stress reduction, relaxation,body will succumb to the secondary physical activity, improved energy,complications of paralysis – and you healthy eating, and for promotingwill not improve.” centerofrestor- a healthy balance of mind, bodyativeexercise.com and spirit. It includes yoga, Zumba, Pilates, adapted dance, gardening,Orange County Goodwill Fitness and lots of cardio-fitness. Brand newCenter, Santa Ana Aquatic Therapy Center just opened.The OC Goodwill center, now in its Membership is $10 a month for un-The Strides method works on functional movement,strength, cardio training, load bearing, and stretching, alongwith emotional, psychological, and nutritional coaching.seventh year, occupies a modern, limited use. See rancho.org, click on12,000 sq. foot space in an office park “patient programs.”not far from the 55 freeway in SantaAna. This is a beautiful facility, the San Diego State University’s Adap-biggest, best-equipped public dis- tive Fitness Clinic is a community out-ability-centric gym in the Southland. reach program through the SchoolThe center features a huge range of of Exercise and Nutritional Sciences.state of the art, fully-accessible exer- The program serves individuals of allcise gear. Dues are low – $30 a month, ages with physical and neuromus-with aid for those who can’t swing cular disabilities, as well as trainingthat. ocgoodwill-fitnesscenter.org for students majoring in pre-physical therapy and fitness specialist empha-Rancho Wellness Center opened in sis. See ens.sdsu.edu/fitnessclinic2011 at the Rancho Los Amigos Rehabcenter in Downey to promote health Strides SCI Functional Fitness,and physical activity for people with San Juan Capistranodisabilities, their families, and for the Ex-Project Walk trainers Jason Wans-community. Many classes are avail- treet and Josh Salic started Strides inwww.SCI.first 90 days.com 88