Case Management Society of America


Early Collaboration for Improved Patient and Family Outcomes

Moving Patients From Acute Care to Rehabilitation Following Catastrophic Injury


A catastrophic injury, such as a spinal cord injury or traumatic brain injury, is something most people don’t think about or plan for until it happens. When it does happen, patients and their families are often in a state of devastation and shock; their lives have been completely altered in a matter of minutes, and they are often struggling just to understand what has happened to their loved one. They can become overwhelmed with the machines, the process and number of medical personnel involved, medical terminology, and often aren’t sure whom they should ask the seemingly infinite number of unanswered questions in their minds.

This state of devastation and confusion can make it difficult for families to focus on anything beyond the patient’s current health state and the moment-to-moment ups and downs after a catastrophic injury. However, long-term care planning should be a key consideration almost immediately when a patient is admitted into the ICU. Lengths of stay in acute care prior to transfer to rehabilitation average three weeks, so efficient and effective decision-making is important.

The ICU/acute care social worker, whose role is complex, dynamic and fast-paced, is tasked with assessing the patient’s condition, the family’s needs and providing essential support to all involved in the patient’s treatment. Serving as a liaison between the patient/family and the medical staff, medical social workers address several important factors in the early stages of a catastrophic injury, such as initial family support, crisis counseling, coordination with insurance companies and public benefit specialists, education on advance directives and care planning, surrogate decision makers and guardianships. Families under extreme stress also have difficulty sustaining attention and remembering information provided to them, so repetition and journal-keeping are encouraged.

In the early days after a patient’s injury, a best practice for social workers is to participate in daily rounds with the patient and family/caregivers, to include the full medical team: physicians, nurses, pharmacists, chaplains, therapists and psychologists. Providing these resources to give updates and answer questions on a daily basis can help mitigate confusion among the patient and his or her family, as well as ease the anxiety of not knowing what is coming next in the journey of their loved one’s care.

While it’s important for the family to focus on daily needs and establish goals early in the patient’s recovery, this is also the ideal time for the social worker to work within the interdisciplinary team to bring in a specialist physician or physiatrist, to help assess the patient and determine the appropriate and necessary next level of care. The earlier in the process long-term care becomes a consideration — even within the first 24 to 48 hours after admission — the more successful the patient’s rehabilitation process will be.

For acute care social workers, it’s important to establish a network and build relationships with physicians from rehabilitation hospitals that specialize in catastrophic injuries, such as traumatic brain injury, spinal cord injury and others. Bringing these specialists in for consultation early on during the patient’s acute care stay is a critical step in the process to ensure patients have a seamless, successful transition to long-term care.

Physiatrists, also known as physicians who specialize in physical medicine and rehabilitation (PM&R), can help case managers with the following:

–   Assessing the patient’s injury and determining the most appropriate next level of care. Most patients with catastrophic injury do not discharge directly home from the acute care hospital. When determining the appropriate level of rehabilitation, multiple factors are taken into consideration, such as the patient’s diagnosis, severity of injury, prognosis, current medical condition, complications, age and medical history prior to the injury. For example, for one patient, a rigorous, specialized acute inpatient rehabilitation program may be medically necessary, while another patient may require a less intensive program at a subacute level of rehabilitation, such as at a long-term acute care hospital (LTACH) or skilled nursing facility (SNF). Physiatrists also help evaluate additional factors that can influence a patient’s long-term rehabilitation success, including family support, housing accessibility and return to work or school options.

Early involvement of a physiatrist is also beneficial to the acute care physicians who have worked hard to save these patients’ lives, as they are able to see their patients being steered toward the right level of care to help their patients achieve the highest level of functional independence and productivity following catastrophic injury.

Prior to beginning the next level of rehabilitation, the physiatrist also works closely with the acute care social worker, patient and family to discuss the discharge plan following inpatient rehabilitation. Ideally, we prefer the patient discharge back to a home setting with family or a caregiver, but sometimes this is limited by inaccessibility of a patient’s home or lack of a potential caregiver. If eventual discharge home is not an option, it is ideal to begin the discussion regarding other discharge options to optimize patient care.

Often, physiatrists will provide consultation on the specific injury and appropriate post-acute and long-term treatment for a patient, even if that patient is not well suited for their specific rehabilitation facility, and will see the patient through to his or her next level of care.

–   Avoiding common complications related to the injury that can impede recovery and rehabilitation. No matter which direction the path leads for the next step in a patient’s rehabilitation, when physiatrists are involved early in the patient’s care, they can help provide education to the patient and family about the injury, begin to discuss prognosis and the rehabilitation process and work with the acute care team to create a medical care plan to avoid potential medical complications. While some complications are not preventable, many are, and the physiatrist can provide education on how to prevent these from occurring. For example, when mobility and sensation are limited after spinal cord injury, patients are at a high risk for development of pressure ulcers. Having a proper turning schedule while in bed and getting the patient out of bed when appropriate, and with the appropriate equipment, can help prevent this complication.

When patients develop certain complications, these can impede their recovery and prevent the transition to the next phase of rehabilitation. This also increases the overall cost of the patient’s care by the potential need for further medical intervention, extending the length of time in the acute hospital and increasing the likelihood the patient could develop further complications down the road. Therefore, it is imperative to prevent these complications before
they occur.

During acute hospitalization, physiatrists can also help facilitate the patient’s acute care rehabilitation plan with an eye toward rehabilitation, consulting with nursing on issues such as bowel and bladder management and padding for skin protection, and with therapists for proper transfer techniques and bracing to keep the patient safe prior to transfer to rehabilitation.

Following the acute care case management referral to the rehabilitation hospital, the rehabilitation hospital will frequently send a clinical liaison to evaluate the patient, discuss the patient’s situation with the acute care facility, and align expectations with the families as to next steps of rehabilitation. Depending on the geographic location of the acute care hospital and rehabilitation facility, they will work closely with the clinical liaisons to establish a safe transition plan, including transportation, to the rehabilitation facility.


Insurance coverage is also is an important factor in the decision for post-acute care, and acute care social workers play a critical role in helping to assess what healthcare coverage is available, and to manage expectations among the family, medical providers and the insurance companies as to what the patient’s current and potential coverage can and cannot provide.

Knowing the course of care and necessary level of rehabilitation early in the process helps social workers effectively advocate and plan for the best coverage to meet the patient’s needs. The harsh reality is that the medical system itself is often not as responsive and supportive as family members in crisis need, and they depend on the social worker for care navigation and crisis intervention.

Typically, insurance companies assign nurse case managers to patients/families with catastrophic injuries. It is most helpful for acute care social workers and patients/families to establish relationships with the insurance case managers, and to align expectations for the post-acute treatment disposition and plan.

A cohesive post-acute plan that begins with establishing a relationship between the acute care social worker and the physiatrist can help patients get to the right rehabilitation program faster with fewer complications, which ultimately results in a better overall outcome for patients: getting them to be as independent and as productive as possible in the long term.

Morgan Brubaker, DO, joined the CNS Medical Group at Craig Hospital in 2016 after completing her fellowship in Spinal Cord Injury Medicine at Craig Hospital. She leads one of the inpatient spinal cord injury rehabilitation teams. Dr. Brubaker earned her medical degree at Midwestern University, Arizona College of Osteopathic Medicine. She completed her internship in internal medicine and residency in physical medicine and Rehabilitation (PM&R) at Mayo Clinic. She is board certified in physical medicine and rehabilitation and the subspecialty of Spinal Cord Injury Medicine.

Andrew Schaeffer, MSW, LCSW, works as a licensed clinical social worker in the Neuro-Trauma Intensive Care Unit, the Burn Intensive Care Unit and the Multi-trauma Unit at Swedish Medical Center in Englewood, Colorado. He received his bachelor’s degree in biochemistry from the College of Wooster in Ohio and his master’s degree in social worker from the University of Denver. Andrew has worked at Swedish Medical Center for the last ten years doing medical social work. He has 17 years of healthcare experience working at community mental health and addiction centers, transitional housing programs and homeless shelters. He also serves as the clinical supervisor for the MSW interns at Swedish Medical Center.