Not for reproduction or redistribution · 2019-08-20 · Not for reproduction or redistribution •...

Not for reproduction or redistribution


Missed Opportunities for Rehabilitation: Improving Care Transitions Between

Hospital and Community

Jason R. Falvey, PT, DPT, PhD


• Verbalize the relationship between physical function and hospital readmissions for older adults

• Evaluate how changes in physical function early after hospitalization impact future healthcare outcomes

• Assess common breakdowns related to rehabilitation needs in communication that occur during care transitions

• Identify potential strategies for engaging patients in care transitions across the continuum of care

Objectives


Chapter One

Physical Function and Hospital Readmissions


“At the time of discharge, physiological systems are impaired, reserves are depleted, and the body cannot effectively defend against health threats.”

Harlan M. Krumholz, M.D. N Engl J Med 2013; 368:100-102

The Post Hospital Syndrome


The Headlines


Physical function is a stronger predictor of hospital readmission than comorbidity indices

Shih et al, 2015

Predictor of Hospital Readmission


• Multiple studies have shown the beneficial impact of rehabilitation services delivered within the hospital setting

• Older adults recovering from a ischemic stroke are less likely to get readmitted when the participate in rehabilitation within the hospital stay– 10-14% less likely depending on dose of therapy received

• Those recovering from pneumonia are less likely to get readmitted when they receive more in-hospital rehabilitation

• Exercise delivered to even very frail older adults improves function during hospital stay

• Yet many administrative policies at the hospital level impact rehabilitation delivery to the patients who need it most

Kumar 2018; Kim 2015; Martínez-Velilla 2019

Targeting Function During Hospitalization


• Staffing levels (common in ICU, especially in rural hospitals)

• Poor targeting of services (BID rehab for healthier, often more independent total joint replacements, at expense of other chronic conditions)

• Hospitals attempting to minimize rehabilitation minutes per discharge as a cost-cutting metric– And…

Barriers to Rehabilitation in the Hospital


Baseline levels of activities of daily living (ADL) are often used to guide treatment allocation

– However, using baseline levels alone can be highly misleading

Missed Opportunities: The Baseline Fallacy


• Declines in critical aspects of physical function, such as gait speed, muscle strength or aerobic capacity often precede declines in ADL function

• Community ambulatory ability and participation are also affected by hospitalization

• These are actionable, and independently linked with readmissions and mortality

Brown, 2016

Missed Opportunities: The Baseline Fallacy (cont.)


ADL function is not the only outcome of rehabilitation services

– For older adults recovering from critical illness or major surgery, mobility reduces the incidence of delirium and likelihood of pulmonary complications which prolong length of stay

– Participation in within-hospital rehabilitation may identify other concerns that would benefit from post-hospital rehabilitation (i.e. fall risk)



• Older adults often experience changes in community mobility after hospitalization

• Decreases in life-space mobility (metric of community ambulation) are linked with mortality, readmissions, and quality of life

• These decreases are often unaddressed during hospitalization



Dodson, 2019

Baseline Fallacy: Consequences


• More than 80% of acute care physical therapists feel that care coordination activities are not valued as productive time by their hospitals – Includes writing discharge summaries, calling therapists

at the next level of care, or communicating with patients after discharge (i.e. checking DME)

– Contributes to poor communication of functional information across care settings

• Yet, care communications are among the most important roles a therapists plays along with discharge planning

Falvey et al (2019)

Therapist Productivity Standards Hamper Delivery of Best Care


• 26% of hospital discharge summaries include measures of physical capacity for patients, despite being a recommended item by consensus panels and the Joint Commission

• Over 50% of hospital discharge summaries omit all of the physical therapy recommendations made for safety, assistance needed with mobility, DME status, and ADL needs– <1% of discharge summaries include all PT recommendations for

high-risk hip fracture or stroke patients• Physical therapists have poor confidence that their assessments,

notes, and recommendations are read by MDs, provided to therapists at the next level of care, or are used to guide future treatments

Falvey et al; Polnaszek et al; Horwitz et al

Movement of Functional Information Across Care Settings


When needs for ADL assistance go unmet after hospitalization

– 37% increase in readmission risk

– 43% increase in emergency department visits for injurious falls

– Trajectory of functional recovery in the early post-hospitalization period also prognosticates downstream outcomes

DePalma et al; Boyd et al

Lack of Knowledge About Function May Impact Future Outcomes


Volpato et al (2011) evaluated a cohort of older adults with Medicare Priority Diagnoses

– Aim of this study was to evaluate prognostic value of short physical performance battery scores

– Change in first 30 days was evaluated

Early Changes In Function are Valuable Health Indicators after Hospitalization


Gurnalik et al., 1995

Short Physical Performance Battery (SPPB)


Odds of hospital readmission increased 250% with any decline in SPPB score that occurred within 30 days after hospitalization

Volpato et al 2011

SPPB and Readmission


Fisher et al, 2012

Readmission by Early Step Counts


• After a stroke, Medicare beneficiaries who see an outpatient physical therapist within the first 30 days are less likely to be hospitalized

• Yet, only 10% of eligible patients see an outpatient therapist in this timeframe

• This mismatch between the high value of rehabilitation therapy and low utilization of services is pervasive across many diagnoses

Freburger, 2018

Rehabilitation After Hospitalization Reduces Risk for Readmission


Chapter One Summary

• Impaired physical function is a robust risk factor for readmission, and potentially modifiable! Use of rehabilitation during and after hospitalization has tremendous benefits for improving function and reducing readmissions

• Poor communication of function across settings is common, and may impact hospital quality metrics and patient satisfaction

• Changes in function that occur early after hospitalization are prognostic, but who measures and monitors?

• For more on these topics, see the 5-course series from Dr. Kyle Ridgeway and myself on hospital readmissions


Chapter Two

Enhancing the Role of Rehabilitation During Care Transitions


Burke, 2013

Bridging the Hospital to Outpatient Gap


Fragmentation of Post-Hospital Rehabilitation


Post-acute care quality metrics now include measures of readmission

– HHA: 30 day “return to community”

– SNF: 30 day readmissions (may span during and after SNF stay)

– IRF: 30-day “return to community”

Post-Acute Care Readmission Metrics


• Few older adults who go home from the hospital use home or community based rehab after stroke

• Attendance at follow-up outpatient clinics for adults recovering from critical illness is poor

• Other high-risk populations, such as older adults recovering from non-orthopedic surgery, are also perceived to be undertreated

• May be even worse for patients who use post-acute care first

Transitions to Home and Community Based Rehab Services are Poor


Reasons for non-attendance are unclear, but some evidence suggests modifiable factors are part of the reason

– Poor transportation

– Functional disability

– Fatigue/pain

– Dyspnea

– Fear of falling

Is Rehabilitation Non-Attendance Modifiable?


• Using the full complement of skills possessed by rehabilitation professionals may reduce hospital readmissions

• Administrators and clinic managers can lead substantial innovation in this area, and develop new care pathways or QI programs

Extending the Role of Rehabilitation Clinicians to Reduce Hospital Readmissions


Improving communication about physical function across the care continuum may impact readmission risk

– Specific recommended strategies• Have physical therapists in meetings with EMR and Health

IT to work on ways to automate inclusion of relevant PT and functional information into MD discharge summaries

• Support and encourage the writing of PT discharge summaries and ensure information is provided to next level in a timely manner

Improving Post-Discharge Communication


Unmet ADL needs and equipment needs are common after discharge

– Specific recommended strategies• Support productivity credit for in-hospital PTs who spend

time coordinating delivery and acquisition of DME for patients leaving the hospital

• Encourage follow-up phone calls to reduce unmet needs for ADL assistance

• Extend the role of acute care therapists to make a home visit for patients without other healthcare resources (i.e. undocumented immigrants or uninsured patients)

Extend Role of Acute Care PT/OT to Reduce Unmet Needs


Patients are trained on simple chronic disease monitoring upon hospital discharge (i.e. weight gain for CHF) but rarely engaged on monitoring functional decline

– Specific recommended strategies • Teach patients and caregivers simple methods to monitor

decline in function• Ensure patients know how to self-initiate rehabilitation

services after hospital discharge

Encourage Functional Self-management for Patients


Current Practices – Patient provided information on outpatient clinics, and

maybe? • Appointment made

– Patient, overwhelmed with all post-hospital info, does not follow-up or attend appointment

– No rehabilitation delivered, patient declines in function

– Patient at risk for hospitalization, fall, or other adverse event

Designing a Rehabilitation Program To Bridge Hospital to Outpatient


Evidence-informed practices – Rehab team in hospital (or post-acute care facility)

educates patient about outpatient therapy and importance

– Rehab team calls clinic to make appointment and ensures in-hospital info is provided

– Hospital Rehab team follows up to make sure patient has no barriers to attending

Designing a Rehabilitation Program To Bridge Hospital to Outpatient (cont.)


Evidence-Informed Practices – Outpatient therapists call patient to facilitate attendance– If patient has modifiable factors limiting attendance,

outpatient team delivers 1-2 visits at home to bridge gap for attendance, or refers for home health agency for treatment

• Monitor progress, work with HHA to effectively bridge gaps– Rehab team follows up with PCP to ensure communication

gaps closed and allow PCP to independently encourage attendance

– Consider extending PT role through telehealth interventions– Educational interventions should be standard, and could be

partnered with telemonitoring

Designing a Rehabilitation Program To Bridge Hospital to Outpatient (cont.)


• Orthopedic concerns, neurological populations, and balance/falls are the major populations seen in outpatient clinics

• General deconditioning and debility, however, is the rehab diagnosis most associated with hospital readmissions

• Hot topics also include rehabilitation for critical illness survivors and after surgery for older adults

Targeting Populations at Risk for Readmission May Tap New Revenue Opportunities for PT/OT


• Don’t feel stuck to historical roles and measures of therapist productivity in acute care settings

• Not allowing therapists to practice to the full extent of their ability may leave unaddressed risk factors for readmission

• Revamping rehabilitation roles in care transitions may both reduce hospital readmissions, and engage new patient populations in rehabilitation

• Diversifying revenue streams by finding patients likely to benefit from, and engage in, therapy is a win-win for business and population health

Chapter Two Summary


Question and Answer Session

Missed Opportunities for Rehabilitation: Improving Care Transitions Between Hospital and Community

1

Bibliography

MedBridge Missed Opportunities for Rehabilitation: Improving Care Transitions Between Hospital and Community

Jason R. Falvey, PT, DPT, PhD

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2. Boyd, C. M., Landefeld, C. S., Counsell, S. R., Palmer, R. M., Fortinsky, R. H., Kresevic, D., ... & Covinsky, K. E. (2008). Recovery of activities of daily living in older adults after hospitalization for acute medical illness. Journal of the American Geriatrics Society, 56(12), 2171-2179.

3. Brown, C. J., Foley, K. T., Lowman, J. D., MacLennan, P. A., Razjouyan, J., Najafi, B., ... & Allman, R. M. (2016). Comparison of posthospitalization function and community mobility in hospital mobility program and usual care patients: a randomized clinical trial. JAMA internal medicine, 176(7), 921-927.

4. Burke, R. E., Kripalani, S., Vasilevskis, E. E., & Schnipper, J. L. (2013). Moving beyond readmission penalties: creating an ideal process to improve transitional care. Journal of hospital medicine, 8(2), 102-109.

5. DePalma, G., Xu, H., Covinsky, K. E., Craig, B. A., Stallard, E., Thomas III, J., & Sands, L. P. (2012). Hospital readmission among older adults who return home with unmet need for ADL disability. The Gerontologist, 53(3), 454-461.

6. Falvey JR, Burke RE, Malone D, Ridgeway KJ, McManus BM, Stevens-Lapsley JE. Role of Physical Therapists in Reducing Hospital Readmissions: Optimizing Outcomes for Older Adults During Care Transitions From Hospital to Community. Phys Ther. 2016;96(8):1125–1134. doi:10.2522/ptj.20150526

7. Fisher, S. R., Kuo, Y. F., Sharma, G., Raji, M. A., Kumar, A., Goodwin, J. S., ... & Ottenbacher, K. J. (2012). Mobility after hospital discharge as a marker for 30-day readmission. Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences, 68(7), 805-810.

8. Freburger, J. K., Li, D., & Fraher, E. P. (2018). Community use of physical and occupational therapy after stroke and risk of hospital readmission. Archives of physical medicine and rehabilitation, 99(1), 26-34.

9. Galloway, R. V., Karmarkar, A. M., Graham, J. E., Tan, A., Raji, M., Granger, C. V., & Ottenbacher, K. J. (2016). Hospital readmission following discharge from inpatient rehabilitation for older adults with debility. Physical therapy, 96(2), 241-251.

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11. Horwitz, L. I., Jenq, G. Y., Brewster, U. C., Chen, C., Kanade, S., Van Ness, P. H., ... & Krumholz, H. M. (2013). Comprehensive quality of discharge summaries at an academic medical center. Journal of hospital medicine, 8(8), 436-443.

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12. Kim, S. J., Lee, J. H., Han, B., Lam, J., Bukowy, E., Rao, A., ... & Yoo, J. W. (2015). Effects of hospital-based physical therapy on hospital discharge outcomes among hospitalized older adults with community-acquired pneumonia and declining physical function. Aging and disease, 6(3), 174.

13. Krumholz, H. M. (2013). Post-hospital syndrome—an acquired, transient condition of generalized risk. New England Journal of Medicine, 368(2), 100-102.

14. Kumar, A., Resnik, L., Karmarkar, A., Freburger, J., Adhikari, D., Mor, V., & Gozalo, P. (2019). Use of Hospital-Based Rehabilitation Services and Hospital Readmission Following Ischemic Stroke in the United States. Archives of physical medicine and rehabilitation.

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