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Post-Acute Care of the Older Patient Rehabilitation and Transitions of Care

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

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  1. 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

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

  3. The (lack of) Data

  4. Hazards of Hospitalization in Older Persons Creditor, Ann Intern Med 1993;118:219-223

  5. 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

  6. HHS USE Current Trends SNF USE

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

  8. And Quicker Health Services Discharges… From National Center for Health Statistics database

  9. 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

  10. Barriers to Recovery

  11. 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

  12. 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

  13. 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

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

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

  16. Cognitive Impairment • Landi et al. (Rome, Italy 2002) • ↑ Cognitive scoring => ↑ ADL recovery Landi F et al. J Am Geriatr Soc 50:679-684, 2002

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

  18. Assessing the Patient

  19. Assessing the Patient • The “Delta” • Change in function predicts rehabilitation prognosis • Smaller decline time = faster recovery • Longer time impaired = worse potential

  20. 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

  21. 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

  22. The Interdisciplinary Approach

  23. The Interdisciplinary Team • Holistic approach • Multi-angle (POV) assessment • Too many variables for one person!

  24. 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)

  25. The Interdisciplinary Team • Physical Therapy • Evaluate and restore mobility and endurance • Main benchmark is gait • Feet walked • Assist needed • Device used

  26. The Interdisciplinary Team • Occupational Therapy • Evaluate and restore ability to interact safely with the environment • Benchmarks are ADLs and IADLs • Manual dexterity • Activity independence

  27. The Interdisciplinary Team • Speech Therapy • Evaluate and restore cognitive, speech, and swallowing function • Treat aphasia, dysarthria, dysphagia • Bedside swallowing challenge

  28. 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

  29. The Interdisciplinary Team • Wound Care • Evaluate and manage wounds • Pressure ulcers, surgical sites, ostomy • Assess barriers to wound healing • Poor mobility • Nutritional status

  30. 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

  31. 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

  32. Devices

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

  34. 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

  35. 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

  36. Settings • Outpatient Therapy • Modalities: PT, OT, ST, MD • Requirements • Medicare B, Medicaid • Patient not “home bound” • Usual interval 2-8 wks, 2-3x weekly

  37. 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)

  38. 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

  39. 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

  40. 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

  41. 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

  42. 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

  43. 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

  44. 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

  45. 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

  46. 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

  47. 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

  48. 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…

  49. The Problem Revealed

  50. 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

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