Post acute care of the older patient rehabilitation and transitions of care
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Post-Acute Care of the Older Patient Rehabilitation and Transitions of Care. Thomas Price, MD Emory University School of Medicine Department of Internal Medicine Division of Geriatric Medicine 4/2006. Overview. The (lack of) Data Barriers to Recovery Assessing the Patient

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Post acute care of the older patient rehabilitation and transitions of care

Post-Acute Care of the Older PatientRehabilitation and Transitions of Care

Thomas Price, MD

Emory University School of Medicine

Department of Internal Medicine

Division of Geriatric Medicine

4/2006


Overview

Overview

  • The (lack of) Data

  • Barriers to Recovery

  • Assessing the Patient

  • Know Your Therapists

  • Sample Cases


The lack of data

The (lack of) Data


Post acute care of the older patient rehabilitation and transitions of care

Hazards of Hospitalization in Older Persons

Creditor, Ann Intern Med 1993;118:219-223


A bad situation

A Bad Situation

  • Older persons can show functional decline after only 24 hrs of bed-rest

  • Skilled Nursing Facility (SNF) care after acute hospitalization

    • 1989 = 600,000 admissions

    • 1996 = 1.1 million admissions

Johnson MF et al. JAGS 48, 2000


Current trends

HHS

USE

Current Trends

SNF

USE


Home health services

Home Health Services

Murtaugh CM et al. Health Affairs 22(5) 2003


And quicker health services discharges

And Quicker Health Services Discharges…

From National Center for Health Statistics database


A worse situation

A Worse Situation

  • Acute rehabilitation significantly limited in 2002 by Medicare

    • Stricter admissions criteria under PPS

    • Rapid rise of “subacute” SNF units

    • ↓ LOS = ↑ rehab efficiency

      … but led to increased mortality

Ottenhacber KJ et al. JAMA 292(14): 2004


Barriers to recovery

Barriers to Recovery


Functional independence measure fim

Functional Independence Measure (FIM)

  • ACRM/AAPMR

  • 18 Items

    • Motor skills (13), Cognitive (5)

    • Scale of 1 (total assist) to 7 (no assist)

    • Ranges 13-91 Motor, 5-35 Cognitive

    • Higher scores = Better function


Fim and rehab potential

FIM and Rehab Potential

  • Likourezos et al. (Mount Sinai NY 2002)

  • 164 pts, equivalent disease severity

  • SNF Rehab, avg LOS 40 days

  • Higher admission FIM Motor and Cognition score => better functional recovery

Likourezos A, Si M, Kim WO et al. Am J Phys Med Rehabil 2002;81:373-379


Delirium

Delirium

  • Marcantonio et al. (Harvard 2003)

  • 551 admissions to subacute rehab

  • Delirium associated with worse ADL and IADL recovery

Marcantonio ER et al. J Am Geriatr Soc 51:4-9, 2003


Delirium1

Delirium

Marcantonio ER et al. J Am Geriatr Soc 51:4-9, 2003


Delirium2

Delirium

Marcantonio ER et al. J Am Geriatr Soc 51:4-9, 2003


Cognitive impairment

Cognitive Impairment

  • Landi et al. (Rome, Italy 2002)

  • ↑ Cognitive scoring => ↑ ADL recovery

Landi F et al. J Am Geriatr Soc 50:679-684, 2002


Cognitive dysfunction and prior functional impairment are strong predictors of rehab potential

Cognitive dysfunction and prior functional impairment are strong predictors of rehab potential.


Assessing the patient

Assessing the Patient


Assessing the patient1

Assessing the Patient

  • The “Delta”

    • Change in function predicts rehabilitation prognosis

    • Smaller decline time = faster recovery

    • Longer time impaired = worse potential


Assessing the patient2

Assessing the Patient

  • History

    • Baseline functional level

      • IADL: Do you do your finances?

      • BADL: Do you need help to bathe?

    • Living situation and social support

    • Cognitive history


Assessing the patient3

Assessing the Patient

  • Exam identifies deficits and barriers

    • Musculoskeletal

      • Get up and go (Gait/LE proximal muscle)

      • Tone (spasticity)

    • Neurologic and Psychiatric

      • Focal findings (incl. dysarthria)

      • Cognitive (3 word recall or MMSE)

        • Delirium (Confusion Assessment Method)

      • Depression (SIG E CAPS or GDS)

    • Skin

      • Pressure ulcers


The interdisciplinary approach

The Interdisciplinary Approach


The interdisciplinary team

The Interdisciplinary Team

  • Holistic approach

  • Multi-angle (POV) assessment

  • Too many variables for one person!


The interdisciplinary team1

The Interdisciplinary Team

  • Social Services

    • Assess living situation and social support

    • Develop options for providing safe discharge pathway for patient

    • Enable supportive resources if available (home health, etc)


The interdisciplinary team2

The Interdisciplinary Team

  • Physical Therapy

    • Evaluate and restore mobility and endurance

    • Main benchmark is gait

      • Feet walked

      • Assist needed

      • Device used


The interdisciplinary team3

The Interdisciplinary Team

  • Occupational Therapy

    • Evaluate and restore ability to interact safely with the environment

    • Benchmarks are ADLs and IADLs

      • Manual dexterity

      • Activity independence


The interdisciplinary team4

The Interdisciplinary Team

  • Speech Therapy

    • Evaluate and restore cognitive, speech, and swallowing function

    • Treat aphasia, dysarthria, dysphagia

    • Bedside swallowing challenge


The interdisciplinary team5

The Interdisciplinary Team

  • Nursing

    • Assess patient’s pattern of behavior

    • Technical skills of IV therapy

  • Nutrition

    • Identify risk or presence of malnutrition

    • Provide options for care and correction


The interdisciplinary team6

The Interdisciplinary Team

  • Wound Care

    • Evaluate and manage wounds

      • Pressure ulcers, surgical sites, ostomy

    • Assess barriers to wound healing

      • Poor mobility

      • Nutritional status


Assessing the patient4

Assessing the Patient

  • What are skilled needs of the patient?

    • Nursing

      • IV therapy

      • Wound care

      • Enteral feeding (if new only)

    • Therapy

      • Physical therapy

      • Occupational therapy

      • Speech therapy


Interdisciplinary jargon

Interdisciplinary Jargon

  • Types of assistance

    • Max assist (1 person-2 person)

    • Mod assist (1 person)

    • Min assist

      • CGA: contact guard assist

      • HHA: hand hold assist

      • S: Supervision

      • Mod I: Modified independent

    • Independent

    • Ambulatory assist device


Devices

Devices


Cases

Cases

“Next, an example of the very same procedure when done correctly”


Case 1

Case 1

  • 89 y.o. female

    • Hypertension, past CVA with RHP (partial)

    • Fall with hip fracture (FNF s/p THR)

    • No significant delirium

    • Ambulates with walker

    • Husband is healthy, active and drives safely


Case 11

Case 1

  • OT assessment

    • Patient near baseline for IADLs

  • PT assessment

    • Patient ambulating 200-300’ with S/W

  • SW assessment

    • Home environment stable, social support adequate


Settings

Settings

  • Outpatient Therapy

    • Modalities: PT, OT, ST, MD

    • Requirements

      • Medicare B, Medicaid

      • Patient not “home bound”

    • Usual interval 2-8 wks, 2-3x weekly


Case 2

Case 2

  • 76 y.o. male

  • Mild-moderate Alzheimer’s Disease

  • Admitted for CHF exacerbation

  • Hospitalized x10 days

    • Bed rest for 3-4 days

  • Slow Get-Up and Go test

  • MMSE 20/30

  • Patient’s wife cannot drive (Macular Degeneration)


Case 21

Case 2

  • OT assessment

    • Below baseline for IADLs, ADLs

    • Unsafe to drive (endurance, cognition)

  • PT assessment

    • Ambulating 150-200’ with rolling walker

  • SW assessment

    • Safe home environment but no transport available to rehab center


Settings1

Settings

  • Home Health therapy

    • Modalities: PT, OT, ST, RN, SW

    • Requirements

      • Medicare A benefit, Medicaid

      • Safe environment

      • ADL/IADL independent or completely compensated at baseline

      • Patient must be “home-bound”

    • Usual interval: 90 day certification periods with recertification possible


Case 3

Case 3

  • 82 y.o. male with invasive pneumococcal pneumonia

  • History of COPD, HTN, CASHD, DM

  • Needs 1 more week of IV antibiotics

  • Was bedbound for 5 days

  • Lives alone in a senior hi-rise

  • Delirium present


Case 31

Case 3

  • OT assessment

    • Below baseline for IADL, ADL with fatigue

    • Mod-max assist for bathing, transfers

  • PT assessment

    • Walks 5-10’ with rolling walker

    • Needs CGA for ambulation

    • Frequent stops for endurance

  • SW assessment

    • Pt previously independent, can return home if meeting functional needs


Settings2

Settings

  • Subacute Rehabilitation

    • Modalities: PT, OT, ST, RN, SW, MD

    • Requirements

      • Medicare A or carrier covered benefit

      • Medicare 20/80 day split payment

      • Not available for Medicaid patients

      • Tolerate at least 90 minutes of therapy 5x/wk

    • Usual interval: 4-8 weeks


Case 4

Case 4

  • 68 y.o. post-CVA

  • Dense RHP, aphasia, dysphagia

  • Got thrombolytics

  • RHP and aphasia recovered by 50% in 3-4 days

  • Lives with wife


Case 41

Case 4

  • OT assessment

    • Improving, but 1-person assist for bathing, transfers

  • PT assessment

    • Walking 100’ x2 with CGA

    • Balance and safety concerns

    • Tolerates 2-3 sessions/day

  • SW assessment

    • Good social support, wife can help with short-term ADL and IADL dependence


Settings3

Settings

  • Acute Rehabilitation

    • Modalities: PT, OT, ST, RN, SW, MD

    • Requirements

      • Medicare A

      • Specific disease entities

      • High level of function potential

      • Require at least three hours of therapy 5x week or more

    • Usual interval 7-14 days


Case 5

Case 5

  • 87 y.o. post-pneumonia

  • 7 day hospitalization length with IV ABT

  • History of dementia x5 years

  • Family says “unable to take her back home”

  • Patient impoverished, Medicaid only

  • Cognitive impairment severe

  • Multiple pressure ulcers


Case 51

Case 5

  • OT assessment

    • Moderate to max assist for ADLs

    • Limited ability to follow commands

  • PT assessment

    • Baseline mobility poor

    • Unable to participate in PT sessions

  • SW assessment

    • Primary caregiver shows signs of fatigue, limited support from other family members


Settings4

Settings

  • Nursing Facility (Chronic Care)

    • Modalities: PT, OT, ST, RN, SW, MD

    • Requirements

      • Private pay, Medicaid (entry through skilled Medicare benefit possible)

      • Rehab provided a la “Part B” Medicare

    • “Short-stayers” starting to increase

    • “Respite stays” possible

    • Placement is going to be tough! Because…


The problem revealed

The Problem Revealed


Conclusions

Conclusions

  • Older patients are vulnerable to declines in functional status during acute illness

  • Discharge planning requires input from multiple team members

  • Transitions in care incorporate a number of settings and must be tailored to needs of every patient


The end

The End


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