Work In Progress August 24, 2015

Transcription

1 Presenter Sarah Wilson MSOTR/L, CHT, CLT 4 th year PhD student at NOVA Southeastern University Practicing OT for 14 years Have worked for Washington Orthopedics and Sports Medicine for the last 8 years Specialize in rehabilitation of upper extremity orthopedic injuries Dissertation topic: Shoulder pathology after distal radius fractures and differences in functional outcomes

2 A Comparison of Discharge Functional Status after Rehabilitation in Skilled Nursing, Home Health, and Medical Rehabilitation Settings for Patients Following Stroke Work In Progress August 24, 2015

3 Funding Acknowledgements Rehabilitation Research and Training Center on Measuring Rehabilitation Outcomes and Effectiveness (H133B040032)

4 Post-Acute Care Rehabilitation Providers Inpatient Rehabilitation Facilities (IRFs) Skilled Nursing Facilities (SNFs) Home Health Agencies (HHAs) Long-Term Care Hospitals (LTCHs) Other providers outpatient comprehensive outpatient rehabilitation facilities day rehabilitation programs

5 Patients with Stroke: Post-Acute Care Use Among Medicare patients discharged from an acute care hospital in 2006 with the Diagnosis-Related Group of Specific Cerebrovascular Disorders, Except TIA 58.1% received post acute care Among those who received post acute care 35.6% were treated in a skilled nursing facility 34.4% were treated in an inpatient rehabilitation facility 19.7% received home health services 8.5% received outpatient services 1.8% were treated in a long-term care hospital 5 Gage et al. Examining Post Acute Care Relationships in an Integrated Hospital System. Available at:

6 Post-Acute Care: Functional Assessment Data Skilled Nursing Facility Home Health Care Inpatient Rehabilitation Facility Long-Term Care Hospital Minimum Data Set (MDS 2.0) 2010: MDS 3.0 Outcome and Assessment Information Set (OASIS-B) 2010: OASIS-C Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)/ FIM Instrument LTCH Continuity Assessment Records and Evaluation (CARE) data Set Started: 10/01/2012 6

7 Study Protocol: Inclusion Criteria 1. Primary diagnosis of stroke, hip fracture, or hip/knee replacement/revision 2. Aged 65 years of age or older 3. Traditional Medicare fee-for-service as primary payer* 4. Must be receiving rehabilitation services *Eventually revised to include Medicare managed care as several HHAs and SNFs experienced an increase in this population

8 Inclusion Criteria 5. Admitted directly from an acute care hospital** 6. Must receive post-acute care at IRF, SNF, or HHA within one day (IRF or SNF) or 2 weeks (HHA) of discharge from an acute inpatient hospital 7. English as the participants s primary language **Eventually revised for SNFs and HHAs to include subjects who had previously received rehabilitation in another post-acute care setting

9 Exclusion Criteria 1. Readmission to an acute care hospital > 48 hours during their PAC stay 2. Comatose

10 Data Collection and Instrumentation Study approved by each site s IRB Subject recruitment December 2005-December 2010 Patients who met study criteria were approached and consented by a study nurse Data collected within 48 hours of admission and 48 hours before discharge Data collection consisted of Interview Direct observation Medical chart review Correspondence with the patient s health care team

11 Data Elements Data elements collected at admission: Demographics Social support Other medical information including co-morbidities, vision, cognitive function, communication/hearing, pain, high risk factors bowel and bladder function Self-care and mobility measures Data elements collected on discharge: Discharge to Therapy days and minutes Info regarding barriers to discharge home Falls Devices/restraints used Pressure ulcers Mood/behavior / psychosocial well-being Self-care and mobility measures

12 Facility Locations Red=SNF, Green=IRF, Blue=HHA 12

13 Stroke Demographics and Comorbidities SNF IRF HHA TOTAL Stroke Female 24 (77) 43 (62) 26 (70) Age # comorbidities* Obesity* 6 (19) 7 (10) 13 (35) Vision* 7 (23) 33 (48) 8 (22) Bladder* 24 (77) 31 (45) 12 (32) Bowel* 11 (36) 10 (15) 4 (11) Short Term memory* 17 (55) 33 (48) 8 (22) Decision-making* 25 (81) 49 (71) 12 (32) Mood Disorder* 7 (23) 3 (4) 5 (14) 13

14 Service Utilization, Therapy Intensity and Discharge Location SNF IRF HHA Length of stay 48 (31.8) 19.5 (7.0) 32.4 (21.7) Overall therapy intensity (Total therapy min/los) Discharge home without therapy Discharge home with home health Discharge home with outpatient 82.5 (24.1) (28.9) 21.6 (14.4) 2 (7) 3 (4) 27 (73) 12 (39) 13 (19) 2 (5) 1 (3) 27 (39) 6 (16) Discharge to SNF 6 (19) 19 (28) - (-) 14

15 Self Care Function Unadjusted Comparisons Admission SNF IRF HHA Discharge

16 Mobility Function Unadjusted Comparisons Admission SNF IRF HHA Discharge

17 Regression Model - Self-Care Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 IRF 3.35* 3.56* HHA 11.09* 11.27* Adjusted R Change in R

18 Final Regression Model- Self-Care Setting alone, without adjustments for covariates, explains 26% of the variance with both IRF and HHA settings associated with significantly better self-care at discharge. However, after controlling for self-care scores at admission, IRF and HHA settings were no longer associated with significantly better self-care scores at discharge. Vision problems and bladder incontinence are associated with lower self-care scores at discharge Time from onset, prior PAC use, and length of stay did not explain additional variance in the final model (After controlling for length of stay IRF patients have slightly worse self-care scores at discharge).

19 Regression Model - Mobility Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 IRF 3.13* 3.28* HHA 9.87* 10.07* Adjusted R Change in R

20 Final Regression Model- Mobility Setting alone, without adjustments for covariates, explains 19% of the variance with both IRF and HHA settings associated with significantly better mobility at discharge. After controlling for mobility scores at admission, IRF and HHA settings were no longer associated with significantly better mobility scores at discharge. Diabetes was associated with lower mobility scores at discharge. Time from onset, prior PAC use, and length of stay did not explain additional variance in the final model (After controlling for length of stay IRF patients have slightly worse mobility scores at discharge).

21 Summary of Findings Although patients in IRFs have shorter lengths of stay and higher overall therapy intensity, 28% of these patients are discharged to SNFs after their IRF stay, and 39% are discharged with outpatient therapy. IRFs have significantly higher proportions of patients with vision impairments and vision is associated with lower self-care discharge scores. IRFs may need to provide more rehabilitation in this area. Patients with diabetes had significantly lower mobility scores which may be indicative of the need for more mobility training with this population.

22 Summary of Findings Home health patients are unique by being relatively high functioning relative to IRF and SNF patients. This setting does however have more patients who are obese. Many IRF and SNF patients span the same range of functional status. Both IRF and SNF patients have higher numbers of comorbidities including bladder incontinence. With bladder incontinence being associated with lower selfcare scores at discharge, more attention to this area would be beneficial to patients with stroke.

23 Conclusion Overall, after controlling for covariates, there is no significant difference in self-care and mobility outcomes with stroke patients in any of the three post-acute settings used in this study.

24 Questions?