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Clarice Grote, MS, OTR/L

Occupational Therapy in Inpatient Rehab (IRF)

Inpatient rehab facilities (IRFs) are a unique and interesting setting that allows for innovative therapy, extensive one-on-one time with patients, and the opportunity to see some pretty unique clinical scenarios. The role of occupational therapy in inpatient rehab is an important one for both meeting reimbursement criteria and achieving optimal outcomes for patients!

Inpatient rehab facilities are sometimes called acute rehab or acute rehab units (ARU), but to keep things simple for this article, we’ll call them the same name as the Centers for Medicare & Medicaid Services (CMS), which is an inpatient rehabilitation facility or IRF. 

By gaining a better understanding of how inpatient rehabilitation facilities (IRFs) operate, you can help understand the value of occupational therapy in inpatient rehab and help the right patients get the right care! 

In this article, we’ll cover

Ep. 28: How to Be Successful in Inpatient Rehab as an OT Practitioner 

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What is Inpatient Rehab?

An Inpatient Rehab Facility (IRF) is an integral part of the post-acute continuum of care. It serves as a specialized setting where patients can receive intensive therapy to regain their functional abilities. Patients also receive 24-hour nursing care and frequent physician oversight by a rehab physician.

Inpatient rehab facilities can be part of an acute care hospital or they may be an independent rehabilitation facility. For example, when I worked in acute care, one of the floors was an IRF, so patients would be formally discharged from acute care and then transferred to the IRF unit, all without ever leaving the hospital or their bed. Others would be transferred out to a stand-alone facility that was only an inpatient rehab facility.

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How does Medicare pay for inpatient rehab facilities?

IRFs are covered by Medicare Part A under a bundled payment model called the Inpatient Rehabilitation Facility Prospective Payment Structure, or IRF PPS. The payment is based on the patient’s reimbursement impairment code (RIC) and then further broken down into the case-mix group. The case-mix group includes the patient’s age, physical and cognitive function, and primary diagnosis or impairment.

To collect this data, IRFs complete the Inpatient Rehabilitation Facility Patient Assessment Instrument or IRF-PAI which is required by Medicare. The IRF-PAI is completed at admission and discharge at a minimum and collects important information like the patient’s diagnosis, comorbidities, functional levels, and more. Occupational therapists in inpatient rehab can facilitate accurate scoring on this assessment to facilitate accurate quality outcomes and accurately capture patient data.

To learn more about this payment model, check out our course in the Amplify OT Membership.  

Become an OT Amplifier! you should feel good about what you do. Emerge a confident clinician who knows their value. Join the Amplify OT Membership Today. Image shows 5 screens with previews of the Amplify OT membership courses and groups.

Criteria for Inpatient Rehab Admission

To be admitted to an inpatient rehab facility, patients generally have to meet the following criteria: 

  • Must be able to tolerate 3 hours of skilled therapy a day, 5 days a week
  • Need two skilled therapy disciplines 
  • Have a qualifying diagnosis under the 60% rule
  • Be of a functional impairment level that needs intensive rehabilitation
  • Is not appropriate for a lower level of care such as SNF or home health. 
  • Needs 24 hour nursing oversight 

Much of this information is collected during a  preadmission screening. This screening looks at prior level of function, current medical records and therapy documentation, their medical condition, anticipated discharge destination, and other factors to determine if they can tolerate intensive rehab and if they are expected to make improvement. 

IRFs are incentivized through quality measures and payment to only accept patients who are anticipated to make good functional improvements and be able to discharge home vs to a SNF or Long-Term Care. IRF is not a setting for maintenance therapy. They also generally focus on whether or not they have a “qualifying diagnosis,” which is where the 60% rule comes in.

What is the 60% rule for IRF?

The 60% rule states that 60% of the patients in a given IRF must have one of the following 13 diagnoses:

  • Stroke
  • Spinal cord injuries
  • Congenital deformity
  • Amputation
  • Major multiple trauma
  • Hip fracture
  • Brain injury
  • Certain neurological conditions (e.g. Parkinson’s MS)
  • Burns
  • Three arthritis conditions for which outpatient therapy has failed
  • Hip or bilateral knee replacement with a BMI >50 or >85 years old 

So, if your patient has one of these diagnoses, they have a better chance of being accepted to an IRF compared to a patient who does not. Whether or not a patient is eligible to go to IRF is often determined by screeners who work for that inpatient rehab facility. These positions are often filled by therapy practitioners who review therapy notes, medical records, and speak with the patient to determine if they are eligible for inpatient rehab. 

Medicare requires that patients receive at least three hours of therapy for a minimum of 5 days per week. This is also known as the 3-hour rule. 

The patient must also receive at least two different therapy disciplines, one of which must be either occupational therapy or physical therapy. Most patients receive some combination of OT, PT, and/or speech therapy. 

For example, a patient might receive 1.5 hours of PT and 1.5 hours of OT, or 1 hour of PT, 1 hour of OT, and 1 hour of speech therapy. 

Now technically, Medicare says the 3-hours of therapy shouldn’t be used as a “rule of thumb” and there can be exceptions, such as providing more therapy one day and less another due to fluctuations in energy. CMS mentions a few times in the benefit policy manual that it could also be 15 hours of therapy during a 7-day week, but most IRFs follow the 3-hour rule pretty strictly. 

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What does occupational therapy look like in IRF?

IRFs run on a pretty tight schedule. So, if you’re an occupational therapy practitioner working in inpatient rehab, chances are your day will be structured down to the minute. 

A big upside for many practitioners in IRF is the amount of time you get to spend with a patient. This allows you to do some more intensive and innovative interventions that you wouldn’t otherwise be able to do in acute care or home health. 

Often, occupational therapy’s role in IRF focuses primarily on helping a patient discharge safely to home by addressing function with activities of daily living, instrumental activities of daily living, functional cognition, and mental health. 

The majority of sessions will be 1:1 with the patient. However, group therapy is occasionally done in the IRF, and some practitioners will also complete home visits before discharge. OT has an important role in IRF by assisting in scoring the functional assessment called Section GG or the CARE tool on the IRF-PAI, reducing hospital readmissions, and helping patients achieve their ideal outcomes.

How can I learn more?

Want to learn more about IRFs, the continuum of care, and how to master discharge planning? Join the Amplify OT Membership to become an OT Amplifier!

In the membership, you’ll get access to my Mastering OT Policy and Medicare Course for free, where we take a deep dive into the continuum of care, reimbursement, and how to use this information to AMPLIFY occupational therapy and the value you bring to your job. 

You can also use our quick reference guide, the Adult Rehab Guide, to have information like this about IRF and other settings right at your fingertips. Check it out HERE

Become an OT Amplifier! you should feel good about what you do. Emerge a confident clinician who knows their value. Join the Amplify OT Membership Today. Image shows 5 screens with previews of the Amplify OT membership courses and groups.


Special thanks to Lindsay Bright, OTD/S, for her contributions to this article.

Clarice standing in a light room smiling wearing black pants and a light green puff sleeve shirt

hi there,

I’m  Clarice

Occupational therapist & medicare specialist helping practitioners understand policy, engage in advocacy, and own their value!

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