Changes in Rehabilitation for the Orthopedic Patient

1. Changes in Rehabilitation for the Orthopedic Patient Dorianne Feldman MD, MSPT Assistant Professor and Medical Director Comprehensive Inpatient Rehabilitation Program Department of Physical Medicine and Rehabilitation Johns Hopkins University School of Medicine March 22, 2013

2. Disclosures • Consultant for American International Group.

3. Objectives To better understand changes in orthopedic rehabilitation and the impact on functional outcomes.

4. Outline 1) Overview of health care trends on orthopedic rehabilitation 2) Impact of trends on post-acute discharge planning 3) Definition of inpatient rehabilitation levels of care 4) Criteria for inpatient rehabilitation admission 5) Differences in rehabilitation outcomes for the orthopedic patient 6) Summary

5. Future of Healthcare • Aging Population • More Older People • 2010-2050: ~2x age 65-75, ~3x age 75-85, ~4x over age 85 – More persons with multiple medical problems at risk of hospitalization – More persons dying: facing potential expensive end of life care More persons who may qualify for expensive life sustaining therapy (inpatient or outpatient) • Medical • Rehabilitation

6. Healthcare Implications Technological Advances Evidence based therapies that prolong longevity or quality of life • Cancer chemotherapy and radiotherapy • Cardiac procedures (angioplasty, stents, endovascular AVR) • Orthopedic procedures: arthroplasty • Medications • Dialysis • Organ Transplantation • Antibiotics

7. Hip Fractures: The “Breaking” Facts • 1990: around 1.66 million hip fractures worldwide. (Kannus, P., et al. Bone 18.1 (1996): S57-S63). • 2050: projected rise in hip fractures to 6.26 million worldwide. (Kannus, P., et al. Bone 18.1 (1996): S57-S63). • 2005: 735,064 in the US received hip or knee replacement with 76.5% requiring post-acute care. (DeJong, G et al. Archives Phys Med RehabilVol 90, Aug 2009)

8. Hip Fractures: The “Breaking” Facts • Significant public health concern: • annual US hospital admissions to increase to 700,000 by 2050. • annual spending to exceed $15 billion shortly. • 1 year mortality around 36% . (Macaulay, William, et al. Journal of the American Academy of Orthopaedic Surgeons 14.5 (2006): 287-293).

9. Challenges • Discharge to home not possible for many • Disability • Medical comorbidities • Psychiatric disease (Munin et al. Archives Phys Med Rehabil, Vol 86, March 2005) • Approximately 1/3 return to prior living situation (Macaulay, William, et al. Journal of the American Academy of Orthopaedic Surgeons 14.5 (2006): 287-293). • No specific guidelines for intervention in rehabilitation setting. (Munin et al. Archives Phys Med Rehabil, Vol 86, March 2005)

10. Case • 75 year old female slips on icy driveway and sustains hip fracture. She undergoes surgery and is medically stable. She has been seen by PT and OT and determined unsafe for discharge to home.

11. How do we best manage this patient?

12. Inpatient Rehabilitation Settings • Inpatient rehabilitation facilities (IRF): • Hospital based or freestanding rehabilitation hospitals (Acute Inpatient Rehabilitation) • Skilled Nursing Facilities (SNF): • Hospital based or freestanding

13. Enduring Clinical Conundrum Subacute vs. Acute Rehabilitation • In the US but not in other countries • Canada and Australia do not have subacute care

14. Inpatient Rehabilitation Facility (IRF) • Provide interdisciplinary rehabilitation • Must be able to tolerate 3 hours of therapy daily 5-7 days/week • Must have goals for two therapy disciplines • Physician supervision daily

15. Skilled Nursing Facilities (SNF) • Nursing homes that U.S. Centers for Medicare and Medicaid Services (CMS) have authorized to render skilled nursing and rehabilitation services. • Includes non-freestanding units often called subacute or transitional care. • Receive therapies ranging from 45 minutes over 3 days to 720 minutes over 5 days. • Can have goals for only 1 therapy discipline.

16. Case #1 75 year old female slips on icy driveway and sustains hip fracture. She undergoes hip arthroplasty?

17. Does Patient Qualify For Inpatient Rehabilitation? If BMI >50? If post-operative period complicated by myocardial infarction? If bilateral arthroplasty versus single?

18. Case #2 75 year old female slips on icy driveway and sustains hip fracture.

19. Does Patient Qualify For Inpatient Rehabilitation? • What if undergoes ORIF? • Does weight bearing status matter? • How about social support system?

20. Rehabilitation Assessment Considerable variation exists in selection of patients for different levels of rehabilitation care

21. CMS Criteria for IRF Admission 1. Stroke 2. Spinal cord injury 3. Congenital deformity 4. Amputation 5. Major multiple trauma 6. Fracture of femur (hip fracture) 7. Brain injury 8. Polyarthritis, including rheumatoid arthritis 9. Neurological disorders, including multiple sclerosis, motor neuron diseases, polyneuropathy, muscular dystrophy, and Parkinson’s disease 10. Burns 11. Knee or hip joint replacement must meet one or more of the following specific criteria: • bilateral knee or bilateral hip joint replacement surgery • Body Mass Index of at least 50 at upon admission to IRF. • 85 or older at the time of admission to IRF.

22. IRF Designation: 60% Rule • Medicare requires 60% of patients receive at least 3 hours of therapy daily and meet a list of 13 medical conditions over a 12 month period. • 40% of IRF admissions can fall completely outside the specified diagnostic categories and still qualify for IRF admission.

23. Medical Necessity and Appropriateness for IRF • Condition must require 24-hour physician care by rehabilitation trained physician and involvement required is more than SNF • 24-hour rehabilitation nursing is needed • Requires and must participate in 3 hours of physical, occupational, speech-language pathology, or prosthetics-orthotics services per day • Inter-disciplinary team approach required • Expectation for significantimprovement in reasonable time (2 weeks) • Realistic goal for modified independence in activities of daily living so individual can return home, home with family or other community setting such as an assisted living facility; not institution • Length of rehab program monitored by team conferences and discharge planning begins on admission www.emoryhealthcare.org/senior-health-center/.../acute-rehab-criteria.pdf

24. IRF vs. SNF: Why is this so important? • IRF care is more costly • IRF care may lead to better outcomes • Variability in utilization of these services • Aim of CMS and private payors is post-acute care cost reduction • No clear standards to help clinicians determine which type of care is best • Where would you want your family member to receive rehabilitation?

26. SNF vs. IRF: Munin Study • 42 hip fracture subjects treated at IRF • 34 hip fracture subjects treated at SNF • IRF duration: 12.8 days (average) • SNF duration: 36.2 days (average) • Therapy participation similar between groups • No significant difference based on site if sicker • IRF subjects with better functional outcome at 12 weeks (controlling for baseline group differences) • IRF more likely to regain 95% premorbid status. • IRF with higher discharge to home rates. Munin et al. Arch Phys Med RehabilVol 86, March 2005

27. SNF vs. IRF: DeJong Study • IRF advantage not huge • Compared functional outcomes SNF vs. IRF for knee (N=1401) and hip replacement (N=751) • 11 IRF’s, 8 freestanding SNF; 1 hospital SNF • Freestanding SNF entered higher function and left with higher function than IRF • IRF achieved greater motor gains in shorter time • Overall effect of motor gains after controlling patient differences and onset days not big • Greatest motor gains seen between medium volume IRF and low volume freestanding SNF • SNF’s with longest stay duration and least amount therapy had less favorable outcomes • Early rehabilitation better functional outcome (Day 3 vs. Day 7) DeJong, G et al. Arch Phys Med Rehabil. Vol 90. August 2009

28. SNF vs. IRF: Kramer Study • Examined both stroke (n=485) and hip fracture (n=518) outcomes for Medicare patients, SNF vs. IRF from 1991-1994 • Outcomes adjusted for premorbid residence, caregiver availability, comorbidities, admission ADL ability, mobility, depression and cognition. • Stroke patients (but not Hip Fracture) were more likely to return to the community after IRF care (Unadjusted 75% vs. 51%*; Adjusted OR 1.3). • Better ADL outcomes in stroke patients. • Medicare costs more IRF than SNF and SNF than “Traditional SNF.” • * Percentages omit patients admitted to “Traditional SNF”, and include only “Subacute SNF” Kramer AM, et al. JAMA. 277:396-404, 1997 .

29. Rehabilitation Content: IRF vs. SNF • Compared 6 freestanding SNFs and 11 IRFs. • 218 patients with hip hemiarthroplasty or THA. • No difference in time to rehabilitation start of care and equal comorbidity between groups. • Total rehabilitation hours(PT/OT): 1.2 in SNF and 2 in IRF. • Weekday hours (PT/OT): 1.6 in SNF and 2.6 in IRF. • IRF: more gait and exercise and lower body ADL training through day #8. Munin et al. Am. J Phys Med Rehabil. Vol 89. No. 7, july 2010

30. Assessment Dichotomy • Which patients do better in IRF? • Which patients do better in SNF? • Are there some patients where level of care doesn’t matter?

31. Are Postacute Care Decisions Impacted by Availability? • Nationwide retrospective study of all Medicare patients with stroke, hip fracture or LE Joint replacements in 1999 • Administrative data set • Clinical factors important in choice of IRF/ SNF. • Selection of IRF vs. SNF influenced most by geography; distance to closest facility and number of facilities in area. Buntin MB, et al. Health Services Research 40:413-434, 200

32. Post Rehabilitation: Disposition Factors • Less chance for discharge to home: • Higher burden of care • Lower function • Cognitive impairment • Weight bearing status Munin et al. Arch Phys Med Rehab Vol 86, March 2005

33. Outcomes: Weight Bearing Status • 224 patients with hip arthroplasty in SNF or IRF with different weight bearing status. • Follow-up phone call 8 months post-rehabilitation (N=84). • Unrestricted weight bearing (WBAT) 2.583 higher likelihood of home discharge than those with restricted weight bearing • Study controlled for maximum severity, age, and admission cognition. Siebens, H. et al. American Academy of Phys Med and Rehab. Vol 4. 548-555. August 2012

34. Breaking the Bank: Post-Hip Fx Costs Predictors of cost: • Older age • premorbid institutionalization • male gender • poor pre-operative walking capacity • Impaired activities of daily living pre-operatively • multiple comorbidities • dementia or cognitive impairment • diabetes, cancer, and cardiac disease Hu, F et al. Injury2012 Jun;43(6):676-85.

35. Breaking the Bank: Post-Hip Fx Costs • 1991: Medicare costs estimated at $2.9 billion. Centers for Disease Control and Prevention. Incidence and costs to Medicare of fractures among Medicare beneficiaries aged >65years—United States, July 1991–June 1992. MMWR 1996;45(41):877–83. • 40% of added costs occur first three months post-hospital discharge. Haentjens, P et al. J Bone Joint Surg AM. 2001 Apr;83-A(4):493-500. • SNF longer length of stay may negate cost savings. Munin et al. Arch Phys Med Rehab Vol 86, March 2005

36. Medicare Spending: IRF vs. SNF • Hip fracture patients admitted to IRF more expensive, but with decreased mortality. • IRF lowered institutionalization rates for hip fracture patients. • SNF admission also decreased mortality for hip fracture patients. • IRF better in “marginal patients.” Buntin, M. et al. Medical Care. Vol 48. No.9, September 2010.

37. Cost Savings: Dollars and Cents • Higher cost for those not institutionalized pre-morbidly • Less expense for those already institutionalized Haentjens, P et al. J Bone Joint Surg AM. 2001 Apr;83-A(4):493-500.

38. Bottom Line… • Fracture prevention • Post-fracture rehabilitation • Avoid institutionalization Haentjens, P et al. J Bone Joint Surg AM. 2001 Apr;83-A(4):493-500.

39. Summary • Expected rise in hip fractures with aging population. • Rehabilitation is key to reduction in post hip fracture mortality, achievement of pre-fracture functional status, and may reduce institutionalization. • Rehabilitation level of care determination (setting and intensity) remains challenging.

40. Summary Continued… • No standardized guidelines exist. • IRF may lead to better functional outcomes; although more expensive. • Need to identify attributes of successful rehabilitation to optimize care given reimbursement changes and increased healthcare costs.

41. Questions?