post-acute care of the older patient rehabilitation and transitions of care thomas price, md emory...
TRANSCRIPT
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
0123456789
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