Post-acute care and geriatric

rehabilitation

Intermediate Care as an added value for Integrated Care

Dr. Marco Inzitari

Director of Healthcare, Research and Teaching, Parc Sanitari Père Virgili

Associate Professor of Medicine, Universitat Autònoma de Barcelona

Barcelona

minzitari@perevirgili.catsalut.net marcoinzi

Outline

Needs, services and

principles

Evidence on post-acute care across

different resources

Integrated care

Post-acute provision in

Catalonia: a lab for integration

New directions and goals

Outcomes and evaluation

Introduction

Long term and catastrophic disability, associated with the

progression of chronic disabling conditions or acute diseases,

has an impact on quality of life of older adults and their

caregivers, and increases costs for healthcare systems

Patients often require a diverse array of services to treat major

health episodes, manage chronic disease and pursue

independent, healthy living

…when you’ve seen one post-

acute geriatric unit, you’ve seen

only one post-acute geriatric unit

Post-acute care: paradigm of heterogeneity Between and within systems

The USA system

Principal profiles admitted in in-patient units %

IRF

• Stroke 20,6

• Fracture lower extremity 15,5

SNF

• Major Joint and Limb Reattachment of Lower Extremity 5,5

• Simple Pneumonia and Pleurisy 3,7

LTACH (Long Term Care)

• Respiratory System Diagnosis with Ventilator (support 96+ Hours) 11,5

• Pulmonary Edema and Respiratory Failure 6,7 Ma

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Department of Health Intermediate Care – Halfway Home; Updated Guidance for the

NHS and Local Authorities, 2009

Post-acute care: paradigm of heterogeneity Between and within systems

The UK system

Heterogeneity: threat or

opportunity?

Intermediate care: concepts and classification

1. They are targeted at people who would otherwise face:

unnecessarily prolonged acute hospital stays (goal 1: “Early discharge”)

inappropriate admission to acute inpatient care (goal 2: “Admission

avoidance”)

long term residential care or continuing in-patient care (goal 3: “Delay

institutionalization”)

2. They have a planned outcome of maximizing independence and typically enabling

patients and service users to resume living at home

3. Based on:

comprehensive assessment and structured individual care that involves

active therapy, treatment or opportunity for recovery.

cross-professional working, with a single assessment framework, single

professional records and shared protocols

4. Time limited, <6 weeks (aften 1-2 weeks)

Department of Health Intermediate Care – Halfway Home; Updated Guidance for the

NHS and Local Authorities, 2009

Clinical and non-clinical factors help determine

the best PAC setting for a given patient

Ma

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Evidence on “Early discharge” as a goal

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Bed-based

Day hospital

Home-based

Source of admission to intermediate care services Goals of Intermediate Care resources:

•Early discharge (post-acute)

•Admission Avoidance

•Delay institutionalization

“Bed-based” models (in-patients units)

Hutchinson T, et al, Clinical Medicine 2011, Vol 11, No 2: 146–9

Which evidence?

• Community Hospitals better than acute hospitals for

rehabilitation of older adults after an acute event

• Costs are similar

Available RCTs:

•RCT, Trondheim, Norway

•RCT, Leeds/Bradford, UK

National Pilot Audit on Intermediate Care, 2011

Bed-based

Day hospital

Home-based

“Early discharge”: Trondheim experience

RCT, intermediate care in community h (int.) Vs general h. (control)

N=72

Total stay=31 dies

N=70

Total stay=29.8 dies

N=142 randomized (mean age=80,9 years, 65% women)

Intervention Control

Garasen H, et al, BMC Public Health 2007

6 months follow-up

“Early discharge”: Leeds/Bradford experience

RCT, community h (int.) Vs geriatric department of general h (control)

N=141

LOS*=15 (9-25) days

N=79

LOS*=15 (9-24) days

N=103 N=57

N=220 randomized (mean age=85 years, 75% women)

6 months

*Mean from randomization (IQR)

Intervention Control

Main outcome

•IADL, Nottingham ADL (0-66 points, less-more disability)

•Between groups difference (mean[95% CI])=5.30 [0.64- 9.96] favor intervention

Green J, et al, BMJ 2005

“Early discharge”: costs

O’Reilly J, et al, BMJ 2006

Intervention

(Community H.)

Control

(Geriatric Acute)

Cost/day, £ 148 146

Cost of the process

(6 months*),

mean(SD), £

7233 (5031) 7351 (6229)

*Includes home services, home-based treatments, readmissions etc.

RCT, community h (int.) Vs geriatric department of general h (control)

The sooner the better

Early discharge (<2 days, N=54) Vs delayed (>2 days, N=37) Vs controls (N=54)

Time from randomisation to community hospital transfer (days)

14121086420-2

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fro

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ine

to 6

mo

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s

60

40

20

0

-20

-40

-60

Correlation coefficient (Pearson)

r = −0.239; P = 0.023

ANCOVA of the difference in NEADL between baseline and 6 months (P = 0.030).

Ch

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in

NE

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line

-6 m

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ths

Time from randomization to discharge

Young J, et al, Age Aging 2007

Adjusted by age, gender, previous

institutionalization and baseline

Barthel Index

Evidence of inpatients geriatric rhb

Bachmann S, et al, BMJ 2010

•Inpatient rehabilitation for geriatric patients

improves functional status and reduces

nursing-home placement and mortality

•Hospital stay might be decreased or

increased, depending on type and concept of

the program

•Reduction in admission to nursing homes

might reduce costs or offset additional costs of

the initial inpatient rehabilitation

Impact on function

Building a better picture of provision

NHS Scotland, Community Hospital Strategy Refresh, 2012

Adapted from Small et al., Disability and Rehabilitation 2009

Geriatric rehabilitation in day hospital (1)

Emerging issues from the ‘90ies:

1. Debate on type of intervention, if short and intensive, or long-term

2. A report by National Audit Office revealed a widespread view of DH as

an expensive resource, promoting the direction of funding towards

other resources (i.e. acute geriatric units)

3. Different competitive resources in geriatric rehabilitation (home-based)

4. Evidence was not consolidated

Bed-based

Day hospital

Home-based

50ies – 90ies

expansion to 400 structures in UK

Relevant for consolidation of geriatric

interdisciplinary care

Geriatric rehabilitation in day hospital (2)

Evidence

Superior to usual care but not to other models of CGA (Forster A, et al., BMJ 1999)

Different RCT compared day hospital to home-based geriatric rehab, for mixed or

stroke patients (Forster A, Cochrane Database Syst Rev 2000, Roderick P, Age

Ageing 2001)

No differences in functional outcomes

DH patients had higher risk of hospital admission (possibly for the location inside acute

hospitals) – (Crotty M, et al, Age Ageing 2008)

No differences in costs (high heterogeneity in models of home-based care) – (Parker SG,

et al., Health Technol Assess 2009)

Newer tendencies in DH:

• Geriatric syndromes or other processes (falls, cognitive imp, Parkinson)

• More evaluation or intervention, different intensities of treatment

• “New” admission avoidance goals

Bed-

based Day

hospital Home-based

Community-based care after discharge

Beswick AD, et al, Lancet 2008

Bed-based

Day hospital

Home-based

Home-based rehabilitation for stroke

Mas MA, Inzitari M, Int J Stroke 2012

Bed-based

Day hospital

Home-based

1. Positive impact on: Functional status, dependency, institutionalization, death, lenght

of hospital stay, satisfaction

2. Specific recommendations for implementation:

3. Discussion:

•Evidence limited to northern Europe

•Cost savings are not clear, and

probably rely on the specific type of

model

Dealing with heterogeneity and fragmentation

Integrated care:

“Integrated healthcare management and

provision between levels of care as well

as between healthcare and social

services, has demonstrated benefits for

older adults with complex needs”

Three levels:

› macro: reference area (Kaiser Permanente

Veterans Health Administration etc.)

› meso: population group (PACE, SIPA etc.)

Ham C, Integrated care, The King’s Fund 2011

› micro: institutions provide integrated care for individual users through different

coordination tools (coordination and continuity of care, care planning, person

centered care, case management, ICT solutions: shared electronic health records,

telemedicine etc.)

Outline

Needs, services and

principles

Evidence on post-acute care across

different resources

Integrated care

Post-acute provision in

Catalonia: a lab for integration

New directions and goals

Outcomes and evaluation

ALT PIRINEU-ARAN

GIRONA

LLEIDA

CENTRAL

BARCELONA

TARRAGONA

TERRES DE L'EBRE

Garr igues

Alt Empordà

BaixEmpordà

Maresme

Val lèsOriental

Va l lèsOccidental

BarcelonèsBaix

Llobregat

Cerdanya

Solsonès

Bages

Berguedà

Ripol lès

Osona

Selva

Pla del ’Estany

Garrotxa

Garraf

Segr ià

Concade Barberà

Segarra

Noguera

Pr iorat

Pal larsSobirà

Pal larsJussà

Gironès

Alt Penedès

Anoia

TarragonèsBaix

Camp

Urgel l

Alt Urgel l

AltCamp

Baix Ebre

AltaRibagorça

BaixPenedès

Montsià

Riberad ’Ebre

TerraAl ta

Plad ’Urgel l

Val d ’Aran

LL. E. 72

M.E. 38

H. Dia 30

EAIA 2

PADES 3

LL. E. 405

M.E. 185

H. Dia 168

EAIA 7

PADES 6

UFISS 6

LL. E. 529

M.E. 240

H. Dia 193

EAIA 9

PADES 7

UFISS 5

LL.E. 3.780

M.E. 1.531

H. Dia 1.060

EAIA 33

PADES 44

UFISS 40

LL. E. 286

M.E. 84

H. Dia 64

EAIA 3

PADES 5

UFISS 2

LL. E. 177

M.E. 111

H. Dia 30

EAIA 2

PADES 3

UFISS 1

LL. E. 554

M.E. 182

H. Dia 214

EAIA 5

PADES 7

UFISS 4

Font: Servei Català de la Salut . Àrea Serveis i

Qualitat. 2004

Total resources (2005)

Consulting teams in acute care: 58

Intermediate care: 2.486

Long term care: 5.803

Day h.: 1.759

Geriatric/Dementia outpatients: 88

Home care teams: 75

The SocioSanitari geriatric network of Catalonia

Created in 1986-1988, and expanded until 2000

Chronic care and integration plans

An opportunity for geriatric post-acute care

Top-down approach

Bodenheimer T. Follow the money. NEJM 2009

Parc Sanitari Pere Virgili: a lab for integration

ALT PIRINEU-ARAN

GIRONA

LLEIDA

CENTRAL

BARCELONA

TARRAGONA

TERRES DE L'EBRE

Garr igues

Alt Empordà

BaixEmpordà

Maresme

Val lèsOriental

Va l lèsOccidental

BarcelonèsBaix

Llobregat

Cerdanya

Solsonès

Bages

Berguedà

Ripol lès

Osona

Selva

Pla del ’Estany

Garrotxa

Garraf

Segr ià

Concade Barberà

Segarra

Noguera

Pr iorat

Pal larsSobirà

Pal larsJussà

Gironès

Alt Penedès

Anoia

TarragonèsBaix

Camp

Urgel l

Alt Urgel l

AltCamp

Baix Ebre

AltaRibagorça

BaixPenedès

Montsià

Riberad ’Ebre

TerraAl ta

Plad ’Urgel l

Val d ’Aran

Public institution with private management rules

Linked with the two main University Hospitals of Catalonia

Healthcare resources

Main needs and users’ profile

Units Capacity Geriatrics End of life care

Alzheimer disease

and other

dementias

Other

neurodegenerative

diseases

Bed-based

Subacutes 16 beds O

Convalescence and rehab 290 beds O

Palliative care 14 beds O

Long term care 25 beds O O

Ambulatory and home

Day hospital 27 chairs O O

Geriatric outpatients 100 visits O

Dementia outpatients 200 visits O

Follow-up visits 360 visits O O

Home care teams 2 teams O O O O

Disability evaluation

SEVAD 2 teams O O O

EVO 2 teams O O

Nursing home

Intermediate care Early discharge

Integrated care & transitions models

Acute

Hospital

Primary

care

Interm.

care

PSPV: a Lab for Intermediate & Integrated Care

Diagnostics at admission in our hospital

Patients profile at admission (average of 2010-2012)

Stroke

Hip fracture

CHF

Knee replacement

COPD

Vascular surgery

Other neurological

Other surgical

Other orthopedic

surgery

Hip replacement

Skin wound

Vertebral surgery

Cranial trauma

Bone infections

Frail with severe

comorbidity

%

Catalan stroke rehabilitation pathway

Intensive

rehabilitation

program (PRI)

Special

programs

< 60 yo

> 75 yo*

* Independents with

adequate social support

Geriatric post-acute

rehabilitation units Hospital-at-home

Long term care

No limits

Where?

Catalan MasterPlan for Cerebrovascular disease, Ministry of Health

Rehabilitation phenotypes in stroke

1) Previously impaired (PI,N=96):

• impaired pre-stroke function (Barthel I. 60)

• higher comorbidity (Charlson I.)

• moderate-severe stroke (NIHSS)

2) Moderately impaired (MI,N=160):

• high pre-stroke function (Barthel I. >90)

• lower comorbidity (Charlson I.)

• mild-moderate stroke (NIHSS)

determining moderate post-stroke functional and

mild cognitive impairment

3) Severely impaired (SI,N=127):

• high pre-stroke function (Bartehl I. >90)

• lower comorbidity (Charlson I.)

• severe stroke (NIHSS)

determining severe functional and moderate

cognitive impairment

•384 patients (mean age 79.06 ±

7.9 years, 50.8 % women, 81%

ischemic stroke),

•9 intermediate care hospitals in

Catalonia

Pérez LM, et al, EUGMS conference 2014, oral communication

Goals:

•To identify characteristics associated with the rehabilitation process

•To develop tailored rehabilitation programs

Hierarchical cluster analysis

Rehabilitation phenotypes in stroke

Pérez LM, et al, EUGMS conference 2014, oral communication

Functional change

(Barthel discharge-

admission)

Barthel at discharge

Lenght of stay (days)

PI MI SI PI MI SI

PI MI SI

Nursing home

Intermediate care

Response to crises and

Admission Avoidance:

Exacerbated chronic

diseases+functional decline

Integrated care & transitions models

Acute

Hospital

Primary

care

Interm.

care

PSPV: a Lab for Intermediate & Integrated Care

Colprim D, et al. JAMDA: 2013

ID

IH

N=33 N=32

Direct admission from primary care

15-20% of total admissions to PSPV

come from home/primary care

Quasi-experimental study

Sample:

•Exacerbated chronic

diseases+functional decline

•Same primary care areas

•Same baseline characteristics

•Admitted in 2010 for

convalescence+rehabilitation:

• DIRECT: from home by home care

unit (n:32)

Vs

• POST-ACUTE: from acute hospital

(n:33)

Nursing home

Intermediate care

Response to crises

and Admission

Avoidance:

Short stays for exacerbated

chronic diseases

Integrated care & transitions models

Acute

Hospital

Primary

care

Interm.

care

PSPV: a Lab for Intermediate & Integrated Care

New lines: “Admissions avoidance” strategies

Unnecessary hospitalizations:

•Harm for the patients: risk of geriatric

syndromes and negative outcomes

•Burden for the system

•Accumulating evidence on CGA and

geriatric interventions to the

Emergency Department

•BGS 2003 encourages the use of

intermediate care resources to avoid

unnecessary hospitalizations Hutchinson, et al., National Pilot Audit on Intermediate Care

Intermediate care for “Admissions avoidance”

Patient at A&I (ER) with exacerbated

chronic condition or minor event

decompensating complex situation.

Consider home discharge (treatment

needs + caregiving + available home-

based resources):

• Impossible Quick admission to CGA

bed (<24 h)

• Possible Geriatric hospital-at-home

Subacute care: direct admission from the

Emergency Department or primary care

Gual N, et al., Age&Ageing 2013, e-letter

•N=120 patients (mean age+SD=85.2+7.6 years, 63% women) transferred in 6 months

•Aprox. 95% came from ER/A&E of University General Hospitals

•72% admitted for respiratory problems and 27% for heart failure; 52% with associated

cognitive impairment/dementia

•72.5%(N=87) discharged at home and 71.7%(N=86) still at home during the first month.

•Mean Length Of Stay+SD=14.3+8.93 days (10,6 in 2014)

p-value OR 95% CI

Inferior Superior

Outcome: placement at discharge (variables associated with discharge destination other than usual

place of living)

ISAR 0,003 2,148 1,302 3,545

ISAR=Identification of Seniors At Risk scale

Multivariable analysis, adjusted for demographics, clinical and functional variables

ISAR is the best predictor, although AUC ranges from 0,6 to 0,7

Refining candidate selection: predictors of discharge destination

Geriatric expertise,

prevention, management

and inter-disciplinary care

Nursing home

Intermediate care

Care transitions

at discharge

Integrated care & transitions models

Acute

Hospital

Primary

care

Interm.

care

PSPV: a Lab for Intermediate & Integrated Care

Care transitions: a critical point

1. Transition coach (e.g. Univ. Colorado). Primary care coordinator (physician,

nurse or social worker), ensures smooth transitions

• Address medication management

• Electronic data transfer

• Follow-up care and clinical warning signs

• Home or site visits after discharge

2. Care Navigation. Inpatient care manager

• Collects relevant clinical information from the patient’s PCP.

• Collects information about inpatient stay

• Passes information to the next setting

Different models of support to care transitions:

Maximizing the Value of Post-acute Care, American Hospital Association 2010

Standard classic pre-discharge alert and information to primary

care >48 h before discharge

Medication reconciliation and electronic prescription

Early supported discharge for complex and stroke patients: in-

hospital meeting with primary care and patient/family (still

unstructured process)

Formal discharge planning within HCCC ICT platform (working

group at Dept. Health)

Potential added values of specialist follow-up and telemedicine

connection for high risk patients

Discharge and continuity of care at PSPV

Care transitions: a critical point

1. Transition coach (e.g. Univ. Colorado). Primary care coordinator (physician,

nurse or social worker), ensures smooth transitions

• Address medication management

• Electronic data transfer

• Follow-up care and clinical warning signs

• Home or site visits after discharge

2. Care Navigation. Inpatient care manager

• Collects relevant clinical information from the patient’s PCP.

• Collects information about inpatient stay

• Passes information to the next setting

Different models of support to care transitions:

Maximizing the Value of Post-acute Care, American Hospital Association 2010

Unplanned care

transitions are

associated with negative

outcomes for the

patients and for the

system (Ouslander and Berenson

NEJM: 2011)

Living with a partner

Post general surgery

Post traumatologic surgery

≥8 drugs

Risk of pressure ulcers (Emina)

Women

Admission for respiratory problem

1.0 2.0 3.0

HR(95%CI)=1.35(1.01-1.81)

HR(95%CI)=1.88(1.21-2.94)

HR(95%CI)=0.91(0.66-1.26)

HR(95%CI)=1.98(1.37-2.86)

HR(95%CI)=1.34(0.96-1.87)

HR(95%CI)=1.30(0.96-1.75)

HR(95%CI)=1.40(0.87-2.25)

HR (95%CI)

Original

data

analysis

Review

of the

evidence

Design of a pilot complex intervention

N=1679 pacients, 14% ≥1 unplanned transfers (incidence=5.64/1000 days of stay)

Risk factors for acute hospital unplanned readmissions from intermediate care

Colprim D et al. 2014 JAMDA, in press

Acute re-tranfers from post-acute care

Based on 4 pillars

Early symptom

detection by nursing staff

Gaps in Knowledge /

Expert nurses

Advance care planning

Facility capacity /

Transfusions

Nursing home

Integrated care & transitions models

Acute

Hospital

Primary

care

Interm.

care

Early discharge

Response to crises and

Admission Avoidance

Care transitions at

discharge

Facilitating elements:

•Information and data sharing •Bundled payements

•Partnership to improve outcomes •Shared evidence-based quality metrics

Which relevant facilitating

element should promote

integration (system level)?

Inter-operable Health Electronic Records

Clinical Software (integrates the

MDS)

HC3

Coordination tools

Promoting integrated care actions in post-acute care

Affordable Care Act provisions that impact Acute and Post-Acute Care providers

Evaluation

Triple aim vision:

Efficiency (Results) Systems are evolving towards

coordination and integration (process outcomes: function

at home, readmissions etc)

Satisfaction Systems evolution towards improving

Patient Centered Care is urgent

Costs (sustainability) Need to incorporate VALUE based

measures (better health for € spent)

Summary and take home messages

Resources and organization

High heterogeneity: threat or opportunity?

Evidence exists: in-patient rehabilitation, home care…and day hospital

Questioning PAC? Key level for healthcare integration

New lines of development

Response to crisis and hospital admission avoidance: community-oriented

Development towards home care (but not all can be faced at home)

Need to promote integration (between levels of care and with social care)

Patients centered care and transitional care are key for competitiveness

Evaluation

Need for more research on models and complex interventions

Need to incorporate comprehensive approaches and value-based

outcomes

minzitari@perevirgili.catsalut.net marcoinzi