post-acute care of the older patient rehabilitation and transitions of care thomas price, md emory...

Post-Acute Care of the Older Patient

Rehabilitation and Transitions of Care

Thomas Price, MDEmory University School of Medicine

Department of Internal MedicineDivision of Geriatric Medicine

4/2006

Overview The (lack of) Data Barriers to Recovery Assessing the Patient Know Your Therapists Sample Cases

The (lack of) Data

Hazards of Hospitalization in Older Persons

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

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

SNF USE

Current Trends

HHSUSE

Home Health Services

Home Health Visits, Medicare

0

50000

100000

150000

200000

250000

300000

1997 1998 1999 2000 2001

Visits (1k)

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

And Quicker Health Services Discharges…

From National Center for Health Statistics database

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

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 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 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

Delirium

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

Delirium

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

Cognitive Impairment Landi et al. (Rome, Italy 2002) ↑ Cognitive scoring => ↑ ADL recovery

Adj. Odds Ratio (95% CI)

Improved (n=138)

Unch/Worse (n=106)

Mod-Sev Cog Imp 0.36 (0.14-0.92) 21 37

Delirium 0.59 (0.17-2.00) 6 9

Age >85 1.07 (0.35-3.30) 24 35

>3 active disease process

0.56 (0.21-1.47) 103 86

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

Cognitive dysfunction and prior functional

impairment are strong predictors of rehab

potential.

Assessing the Patient

Assessing the Patient The “Delta”

Change in function predicts rehabilitation prognosis

Smaller decline time = faster recovery

Longer time impaired = worse potential

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 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 Team

Holistic approach Multi-angle (POV) assessment Too many variables for one person!

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 Team

Physical Therapy Evaluate and restore mobility and endurance

Main benchmark is gait•Feet walked•Assist needed•Device used

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 Team

Speech Therapy Evaluate and restore cognitive, speech, and swallowing function

Treat aphasia, dysarthria, dysphagia

Bedside swallowing challenge

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 Team

Wound Care Evaluate and manage wounds

•Pressure ulcers, surgical sites, ostomy

Assess barriers to wound healing•Poor mobility•Nutritional status

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

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

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

Cases

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 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 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 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 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

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 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 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

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 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 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

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 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 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

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

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10

Rate per 1000

Residents Discharges

Nursing Home Residents and Discharges, USA (1985-1999)

198519971999

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