Community Discharge Rates Research Articles

Beyond Discharge Disposition: A Scoping Review on Sociodemographic Disparities in Rehabilitation Use after Hip and Knee Arthroplasty.

The aims of this scoping review were to summarize the evidence regarding sex, racial, ethnic, geographic, and socioeconomic disparities in post-acute rehabilitation following total hip arthroplasty (THA) and knee arthroplasty (TKA). Literature searches were conducted in Ovid MEDLINE, EMBASE, CINAHL, Web of Science, and PEDro. Studies were included if they were original research articles published 1993 or later; used data from the US; included patients after THA and/or TKA; presented results according to relevant sociodemographic variables, including sex, race, ethnicity, geography, or socioeconomic status; and studied utilization of post-acute rehabilitation as an outcome. Twelve studies met the inclusion criteria. Five examined disparities in inpatient rehabilitation and found that Black patients and women experience longer lengths of stay after arthroplasty, and women are less likely than men to be discharged home after inpatient THA rehabilitation. Four studies examined data from skilled nursing facilities and found that insurance type and dual eligibility impact length of stay and rates of community discharge but found conflicting results regarding racial disparities in skilled nursing facility utilization after TKA. Five studies examined home health data and noted that rural agencies provide less care after TKA. Results regarding racial disparities in home health utilization after arthroplasty were conflicting. Six studies of outpatient rehabilitation noted geographic differences in timing of outpatient rehabilitation but mixed results regarding race differences in outpatient rehabilitation. Current evidence indicates that sex, race, ethnicity, geography, and socioeconomic status are associated with disparities in post-acute rehabilitation use after arthroplasty. Rehabilitation providers across the post-acute continuum should be aware of disparities in the population of patients after arthroplasty and regularly assess social determinants of health and other factors that may contribute to disparities. Customized care plans should ensure optimal timing and amount of rehabilitation is provided, and advocate for patients who need additional care to achieve the desired functional outcome.

Skilled Nursing Facility Changes in Ownership and Short-Stay Medicare Patient Outcomes

Skilled nursing facility (SNF) changes in ownership are receiving attention in the national conversation regarding health care quality and oversight. SNF ownership changes have been cited as possible ways for SNFs to obscure financial arrangements and shift funds away from patient care; however, it is unclear whether ownership changes are associated with quality outcomes, especially for short-stay patients. To determine which SNF characteristics are associated with changes in ownership and whether ownership changes were associated with differences in short-stay patient outcomes. This cohort study was a secondary analysis of 2016 to 2019 Medicare administrative data including SNFs in the United States with complete data. Data were analyzed from January 2016 through December 2019. SNF change in ownership. Outcomes of interest were facility-level risk-adjusted rates of hospital readmissions, emergency department visits, and community discharge for short-stay patients after admission to an SNF. Analyses were conducted using multivariable logistic regression and controlled interrupted time series. Of 11 004 SNFs, 1459 (13.26%) changed ownership between 2016 and 2019. Compared with for-profit SNFs, nonprofit and government SNFs had lower odds of changing ownership (nonprofit: odds ratio [OR], 0.40; 95% CI, 0.32-0.49; government: OR, 0.26; 95% CI, 0.17-0.41). Chain SNFs had higher odds of changing ownership than nonchain SNFs (OR, 1.38; 95% CI, 1.21-1.59). Urban SNFs with lower occupancy rates (OR per 10-percentage-point decrease, 1.19; 95% CI, 1.14-1.25), larger Medicaid populations (OR per 10-percentage-point increase, 1.17; 95% CI, 1.13-1.22), and lower staffing ratings (OR per 1-star increase on staffing rating, 1.18; 95% CI, 1.14-1.25) had higher odds of changing ownership. Descriptively, all 3 quality outcomes were worse throughout the study in SNFs undergoing ownership change compared with controls that did not change ownership. However, results of interrupted time series models found no associations between an ownership change and hospital readmissions or community discharge rates. Ownership change was associated with a short-term increase of 0.32 (95% CI, 0.03 to 0.62) percentage points in emergency department visits. In this cohort study of 11 004 SNFs in the US between 2016 and 2019, SNF characteristics historically associated with lower quality were more likely to change ownership; however, ownership changes were only associated with short-term increases in ED visits. These results suggest that SNF ownership changes may be a symptom, not a cause, of lower quality.

Association of Skilled Nursing Facility Participation in Voluntary Bundled Payments With Postacute Care Outcomes for Joint Replacement.

The Medicare Bundled Payments for Care Improvement (BPCI) model 3 of 2013 holds participating skilled nursing facilities (SNFs) responsible for all episode costs. There is limited evidence regarding SNF-specific outcomes associated with BPCI. To examine the association between SNF BPCI participation and patient outcomes and across-facility differences in these outcomes among Medicare beneficiaries undergoing lower extremity joint replacement (LEJR). Observational difference-in-differences (DID) study of 2013-2017 for 330 unique persistent-participating SNFs, 146 unique dropout SNFs, and 14,028 unique eligible nonparticipating SNFs. Rehospitalization within 30 and 90 days after SNF admission, and rate of successful discharge from the SNF to the community. Total 636,355 SNF admissions after LEJR procedures were identified for 582,766 Medicare patients [mean (SD) age, 76.81 (9.26) y; 424,076 (72.77%) women]. The DID analysis showed that for persistent-enrollment SNFs, no BPCI-related changes were found in readmission and successful community discharge rates overall, but were found for their subgroups. Specifically, under BPCI, the 30-day readmission rate decreased by 2.19 percentage-points for White-serving SNFs in the persistent-participating group relative to those in the nonparticipating group, and by 1.75 percentage-points for non-Medicaid-dependent SNFs in the persistent-participating group relative to those in the nonparticipating group; and the rate of successful community discharge increased by 4.44 percentage-points for White-serving SNFs in the persistent-participating group relative to those in the nonparticipating group, whereas such relationship was not detected among non-White-serving SNFs, leading to increased between-facility differences (differential DID=-7.62). BPCI was not associated with readmission or successful community discharge rates for dropout SNFs, overall, or in subgroup analyses. Among Medicare patients receiving LEJR, BPCI was associated with improved outcomes for White-serving/non-Medicaid-dependent SNFs but not for other SNFs, which did not help reduce or could even worsen the between-facility differences.

The implementation of a precision case management model in a Canadian inpatient rehabilitation center: The 12-months post-implementation findings of a quality improvement project.

Despite recommendations, few have reported on quality improvement initiatives to implement length of rehabilitation stay benchmarks, while actively monitoring functional outcomes. This article describes the development, implementation, and evaluation of a precision case management model across all inpatient rehabilitation client groups in a Canadian facility. To develop the length of rehabilitation-stay (LoRS) benchmarks, patient data was retrospectively analyzed. A severity specific method was used to stratify median length of stay. A target reduction on 8.6 days in LoRS was established. Functional discharge targets were also set and monitored at specific intervals via the Functional Independence Measure (FIM®). The implementation used an incremental quality improvement phased approach. Following 12-months, a statistically significant reduction in mean LoRS of 13.2 days was achieved, along with a small increase in FIM® change across all rehabilitation client groups. A similar pattern was seen across the three main client groups, where a LoRS reduction greater than the target was achieved, along with important improvements in LoRS efficiency. This study demonstrates how the implementation of a precision case management model can assist a facility in markedly reducing LoRS across inpatient groups, without compromising functional change or community discharge rates and begin its transformation to a value-based organization.

Impact of Hospital-Based Rehabilitation Services on Discharge to the Community by Value-Based Payment Programs After Joint Replacement Surgery.

The purpose of this study was to examine the impact of hospital-based rehabilitation services on community discharge rates after hip and knee replacement surgery according to hospital participation in value-based care models: bundled payments for care improvement (BPCI) and comprehensive care for joint replacement (CJR). The secondary objective was to determine whether community discharge rates after hip and knee replacement surgery differed by participation in these models. A secondary analysis of Medicare fee-for-service claims was conducted for beneficiaries 65years of age or older who underwent hip and knee replacement surgery from 2016 to 2017. Independent variables were hospital participation in value-based programs categorized as: (1) BPCI, (2) CJR, and (3) non-BPCI/CJR; and total minutes per day of hospital-based rehabilitation services categorized into tertiles. The primary outcome variable was discharged to the community versus discharged to institutional post-acute care settings. The association between rehabilitation amount and community discharge among BPCI, CJR, and non-BPCI/CJR hospitals was adjusted for patient-level clinical and hospital characteristics. Participation in BPCI or CJR was not associated with community discharge. This analysis found a dose-response relationship between the amount of rehabilitation services and odds of community discharge. Among those who received a hip replacement, this relationship was most pronounced in the BPCI group; compared with the low rehabilitation category, the medium category had odds ratio (OR) = 1.28 (95% CI = 1.17 to 1.41), and the high category had OR = 1.90 (95% CI = 1.71 to 2.11). For those who received a knee replacement, there was a dose-response relationship in the CJR group only; compared with the low rehabilitation category, the medium category had OR = 1.21 (95% CI = 1.15 to 1.28), and the high category had OR = 1.56 (95% CI = 1.46 to 1.66). Regardless of hospital participation in BPCI or CJR models, higher amounts of rehabilitation services delivered during acute hospitalization is associated with a higher likelihood of discharge to community following hip and knee replacement surgery. In the era of value-based care, frontloading of rehabilitation care is vital for improving patient-centered health outcomes in acute phases of lower extremity joint replacement.

For-Profit and Not-for-Profit Inpatient Rehabilitation in Traumatic Brain Injury: Analysis of Demographics and Outcomes

ObjectiveTo describe differences in characteristics and outcomes of patients with traumatic brain injury by inpatient rehabilitation facility (IRF) profit status. DesignRetrospective database review using the Uniform Data System for Medical Rehabilitation. SettingIRFs. ParticipantsIndividual discharges (N=53,630) from 877 distinct rehabilitation facilities for calendar years 2016 through 2018. InterventionNot applicable. Main Outcome MeasuresPatient demographic data (age, race, primary payer source), admission and discharge FIM, FIM gain, length of stay efficiency, acute hospital readmission from for-profit and not-for-profit IRFs within 30 days, and community discharges by facility profit status. ResultsPatients at for-profit facilities were significantly older (69.69 vs 64.12 years), with lower admission FIM scores (52 vs 57), shorter lengths of stay (13 vs 15 days), and higher discharge FIM scores (88 vs 86); for-profit facilities had higher rates of community discharges (76.8% vs 74.6%) but also had higher rates of readmission (10.3% vs 9.9%). ConclusionsThe finding that for-profit facilities admit older patients who are reportedly less functional on admission and more functional on discharge, with higher rates of community discharge but higher readmission rates than not-for-profit facilities is an unexpected and potentially anomalous finding. In general, older, less functional patients who stay for shorter periods of time would not necessarily be expected to make greater functional gains. These differences should be further studied to determine if differences in patient selection, coding and/or billing, or other unreported factors underlie these differences.

Recovery from Coronavirus Disease 2019 among Older Adults in Post-Acute Skilled Nursing Facilities

ObjectivesTo examine functional outcomes of post-acute care for coronavirus disease 2019 (COVID-19) in skilled nursing facilities (SNFs). DesignRetrospective cohort. Setting and ParticipantsSeventy-three community-dwelling adults ≥65 years of age admitted for post-acute care from 2 SNFs from March 15, 2020, to May 30, 2020. Measure(s)COVID-19 status was determined from chart review. Frailty was measured with a deficit accumulation frailty index (FI), categorized into nonfrail, mild frailty, and moderate-to-severe frailty. The primary outcome was community discharge. Secondary outcomes included change in functional status from SNF admission to discharge, based on modified Barthel index (mBI) and continuous functional scale scored by physical (PT) and occupational therapists (OT). ResultsAmong 73 admissions (31 COVID-19 negative, 42 COVID-19 positive), mean [standard deviation (SD)] age was 83.5 (8.8) and 42 (57.5%) were female, with mean FI of 0.31 (0.01) with no differences by COVID-19 status. The mean length of SNF stay for rehabilitation was 21.2 days (SD 11.1) for COVID-19 negative with 20 (64.5%) patients discharged to community, compared to 23.0 (SD 12.2) and 31 (73.8%) among patients who tested positive for COVID-19. Among those discharged to the community, all groups improved in mBI, PT, and OT score. Those with moderate-to-severe frailty (FI >0.35) had lower mBI scores on discharge [92.0 (6.7) not frail, 81.0 (15.4) mild frailty, 48.6 (20.4) moderate-to-severe frailty; P = .002], lower PT scores on discharge [54.2 (3.9) nonfrail, 51.5 (8.0) mild frailty, 37.1 (9.7) moderate-to-severe frailty; P = .002], and lower OT score on discharge [52.9 (3.2) nonfrail, 45.8 (9.4) mild frailty, 32.4 (7.4) moderate or worse frailty; P = .001]. Conclusions and ImplicationsOlder adults admitted to a SNF for post-acute care with COVID-19 had community discharge rates and functional improvement comparable to a COVID-19 negative group. However, those who are frailer at admission tended to have lower function at discharge.

Rural/urban differences in discharge from rehabilitation in older adults with traumatic brain injury.

Rates of traumatic brain injury (TBI) among older adults and treatment of this population in nursing homes are increasing. The objective of this study is to examine differences in the quality of care and outcomes of older adults with TBI in rural and urban settings by (1) comparing the rates of successful community discharge; and (2) reasons for not achieving successful discharge among patients in rural and urban environments. Retrospective national cohort study of skilled nursing facility (SNF) patients using Medicare inpatient claims linked with Minimum Data Set assessments. Demographic, health, and facility characteristics were compared between rural and urban settings using descriptive statistics. Logistic regression with state random effects was used to identify characteristics that predicted successful discharge. U.S. skilled nursing facilities (n=11,771). Medicare beneficiaries aged 66 and older discharged to a SNF following hospitalization for TBI between 2011 and 2015 (n=61,021). Successful community discharge defined as discharge from SNF within 100 days of admission and remaining in the community for ≥30 days without dying or admission to an inpatient healthcare facility. Unadjusted rates of successful discharge were significantly lower for patients in rural settings compared with patients in urban settings (52.1% vs 58.5%, p < 0.01). Patients in rural settings had lower adjusted odds (odds ratio 0.84, 95% confidence interval=0.80-0.89) of successful discharge. Reasons for not discharging successfully differed between rural and urban settings with rural patients less likely to discharge from SNF within 100 days though also less likely to be rehospitalized within 30 days of SNF discharge. Given the low overall rate of successful community discharge and worse outcomes among rural patients, further research to explore interventions to improve SNF care and discharge planning in this population is warranted.

How We Assess Spatial Neglect Matters: Prevalence of Spatial Neglect as Measured by the Catherine Bergego Scale and Impact on Rehabilitation Outcomes.

The aim of this study was to determine the prevalence and functional impact of unilateral spatial neglect on right hemisphere stroke patients in an inpatient rehabilitation facility using a multidimensional, functionally based behavioral measure (Catherine Bergego Scale [CBS]). This was a retrospective cohort study of 742 consecutive admissions of patients with right hemispheric stroke to an inpatient rehabilitation facility. Spatial neglect was assessed using the CBS. Functional impact of neglect was measured by hospital length of stay, Functional Independence Measure change per day, discharge destination, and number of falls. As measured by the CBS, 86% of the right hemisphere stroke patients had symptoms of spatial neglect. Moderate and severe neglect was associated with less Functional Independence Measure change per day and lower rates of community discharge. The presence of neglect was not significantly associated with fall rate or length of hospital stay after controlling for admission Functional Independence Measure scores and age. The "difficulty looking left" CBS item had the strongest relationship with total CBS scores and effectively predicted Functional Independence Measure change per day and discharge destination. Using a sensitive measure, the CBS, rates of spatial neglect are extremely high in right hemisphere stroke patients entering inpatient rehabilitation. Both identification and determination of neglect severity are extremely important given their significant relationship to rehabilitation outcomes and discharge destinations. Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. Upon completion of this article, the reader should be able to (1) describe why carefully assessing spatial neglect in right hemisphere stroke patients is important; (2) identify multiple dimensions of spatial neglect assessed by the Catherine Bergego Scale and how this approach differs from traditional paper and pencil assessment methods; and (3) describe the relationship between spatial neglect as measured by the Catherine Bergego Scale and functional outcomes of right hemisphere stroke patients in inpatient rehabilitation settings. Advanced. The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Rehabilitation Intensity and Patient Outcomes in Skilled Nursing Facilities in the United States: A Systematic Review.

Exponential increases in rehabilitation intensity in skilled nursing facilities (SNFs) motivated recent changes in Medicare reimbursement policies, which remove financial incentives for providing more minutes of physical therapy, occupational therapy, and speech therapy. Yet, there is concern that SNFs will reduce therapy provision and patients will experience worse outcomes. The purpose of this systematic review was to synthesize current evidence on the relationship between therapy intensity and patient outcomes in SNFs. PubMed, Medline, Scopus, Embase, CINAHL, PEDro, and COCHRANE databases were searched. English-language studies published in the United States between 1998 and February 14, 2020, examining the relationship between therapy intensity and community discharge, hospital readmission, length of stay (LOS), and functional improvement for short-stay SNF patients were considered. Data extraction and risk of bias were performed using the American Academy of Neurology Classification of Evidence scale for causation questions. American Academy of Neurology criteria were used to assess confidence in the evidence for each outcome. Eight observational studies met inclusion criteria. There was moderate evidence that higher intensity therapy was associated with higher rates of community discharge and shorter LOS. One study provided very low-level evidence of associations between higher intensity therapy and lower hospital readmissions after total hip and knee replacement. There was low-level evidence indicating higher intensity therapy is associated with improvements in function. This systematic review concludes with moderate confidence that higher intensity therapy in SNFs leads to higher community discharge rates and shorter LOS. Future research should improve quality of evidence on functional improvement and hospital readmissions. This systematic review demonstrates that patients in SNFs may benefit from higher intensity therapy. Because new policies no longer incentivize intensive therapy, patient outcomes should be closely monitored to ensure patients in SNFs receive high-quality care.

Association of Social Behaviors With Community Discharge in Patients with Total Hip and Knee Replacement

ObjectivesUnderstand the association between social determinants of health and community discharge after elective total joint arthroplasty. DesignRetrospective cohort design using Optum de-identified electronic health record dataset. Setting and ParticipantsA total of 38 hospital networks and 18 non-network hospitals in the United States; 79,725 patients with total hip arthroplasty and 136,070 patients with total knee arthroplasty between 2011 and 2018. MethodsLogistic regression models were used to examine the association among pain, weight status, smoking status, alcohol use, substance disorder, and postsurgical community discharge, adjusted for patient demographics. ResultsMean ages for patients with hip and knee arthroplasty were 64.5 (SD 11.3) and 65.9 (SD 9.6) years; most patients were women (53.6%, 60.2%), respectively. The unadjusted community discharge rate was 82.8% after hip and 81.1% after knee arthroplasty. After adjusting for demographics, clinical factors, and behavioral factors, we found obesity [hip: odds ratio (OR) 0.81, 95% confidence interval (CI) 0.76–0.85; knee: OR 0.73, 95% CI 0.69–0.77], current smoking (hip: OR 0.82, 95% CI 0.77–0.88; knee: OR 0.90, 95% CI 0.85–0.95), and history of substance use disorder (hip: OR 0.55, 95% CI 0.50–0.60; knee: OR 0.57, 95% CI 0.53–0.62) were associated with lower odds of community discharge after hip and knee arthroplasty, respectively. Conclusions and ImplicationsSocial determinants of health are associated with odds of community discharge after total hip and knee joint arthroplasty. Our findings demonstrate the value of using electronic health record data to analyze more granular patient factors associated with patient discharge location after total joint arthroplasty. Although bundled payment is increasing community discharge rates, post-acute care facilities must be prepared to manage more complex patients because odds of community discharge are diminished in those who are obese, smoking, or have a history of substance use disorder.

Skilled Nursing Facility Characteristics Associated With Financially Motivated Therapy and Relation to Quality

ObjectivesIn October 2019, the Centers for Medicare & Medicaid Services (CMS) implemented a new payment model for skilled nursing facilities (SNFs) that eliminated financial incentives to provide high-intensity therapy. Yet high-intensity therapy in SNFs has been linked to better quality outcomes, potentially putting patients at risk if clinically indicated therapy is reduced under the new payment model. A metric to help differentiate between financially motivated vs clinically indicated therapy in SNFs is thresholding: the percentage of patients receiving therapy within 10 minutes of reimbursement thresholds. This study examined which SNF characteristics are associated with thresholding and how thresholding relates to quality outcomes. DesignSecondary analysis of 2016 CMS administrative data. Setting and Participants14,162 SNFs. MethodsSNF Public Use Files, Nursing Home Compare, and Provider of Services files were linked. We used linear regression models to (1) identify SNF characteristics associated with thresholding and (2) determine associations between thresholding and quality outcomes, controlling for SNF and patient characteristics. ResultsThresholding was 6.4 percentage points [95% confidence interval (CI) 5.4, 7.4] higher in SNFs with all contractor therapy staff vs all in-house staff. Compared with nonprofit SNFs, thresholding was 2.5 (95% CI 0.1, 2.9) and 1.6 (95% CI 0.4, 2.9) percentage points higher in governmental and for-profit SNFs, respectively. For each additional therapist per 1000 patient-days, SNFs had 2.9 (95% CI –3.4, −2.4) percentage points lower thresholding. Higher thresholding was significantly associated with worse quality outcomes, including lower rates of functional improvement and community discharge and higher rates of 30-day admissions, but magnitudes were small. Conclusions and ImplicationsSNFs with higher thresholding behavior may respond to changes in financial incentives under the new payment model by reducing clinically indicated therapy and should be monitored to ensure access to necessary therapy is maintained. Although thresholding behavior may indicate cost-intensive therapy practice, it may not have clinically significant implications for patients.

Assessing the impact of Minnesota's return to community initiative for newly admitted nursing home residents.

To evaluate Minnesota's Return to Community Initiative's (RTCI) impact on community discharges from nursing homes. Secondary data were from the Minimum Data Set and RTCI staff (April 2014 - December 2016). The sample consisted of 18444 non-Medicaid nursing home admissions in Minnesota remaining for at least 45days, with high predicted probability of community discharge. The RTCI facilitates community discharge for non-Medicaid nursing home residents by assisting with discharge planning, transitioning to the community, and postdischarge follow-up. A key evaluation question is how many of those transitions were directly attributable to the program. Return to Community Initiative was implemented statewide without a control group. Program impact was measured using regression discontinuity, a quasi-experimental design approach that leverages the programs targeting model. Return to Community Initiative increased community discharge rates by an estimated 11 percent (P<0.05) for the targeted population. The program effect was robust to time and increased with level of facility participation in RTCI. The RTCI had a modest yet significant impact on the community discharge rates for its targeted population. Findings have been applied in strengthening the RTCI's targeting approach and transitioning process.

Facility and Geographic Variation in Rates of Successful Community Discharge After Inpatient Rehabilitation Among Medicare Fee-for-Service Beneficiaries

The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 mandated a quality measure of successful community discharge for postacute care services. Examining variation in performance nationally can help identify opportunities for improving patient-centered quality of care. To examine US facility-level and geographic variation in rates of successful community discharges after inpatient rehabilitation. This retrospective cohort study of Medicare claims data from December 31, 2013, through October 1, 2015, included 1154 inpatient rehabilitation facilities submitting claims to the Centers for Medicare & Medicaid Services and a total of 487 862 Medicare fee-for-service beneficiaries discharged from inpatient rehabilitation facilities. Analyses were performed from December 8, 2017, through September 11, 2018. Successful community discharge as defined for the Discharge to Community-Post-Acute Care Inpatient Rehabilitation Facility Quality Reporting Program measure. To be considered a successful community discharge, patients had to discharge from the inpatient rehabilitation facility to the community (ie, home or self-care) and remain there without experiencing an unplanned rehospitalization or dying within the following 31 days. Centers for Medicare & Medicaid Services specifications were followed to identify the cohort, define the outcome, and calculate risk-standardized facility and state rates. Among the 487 862 patients included in the cohort, mean (SD) age was 76.4 (10.8) years, and 56.9% were female. The overall rate of successful community discharge after inpatient rehabilitation was 63.7% (95% CI, 63.6%-63.8%). Risk-standardized rates ranged from 42.9% to 83.6% across inpatient rehabilitation facilities. Two hundred sixteen facilities (18.7%) performed significantly better than the mean national rate and 203 (17.6%) performed significantly worse (P < .05). Risk-standardized state rates ranged from 55.9% to 73.3%. Rates were lowest in the Northeast (Massachusetts, 55.9%; New Hampshire, 57.0%) and highest in the West (Oregon, 70.3%; Hawaii, 73.3%). The observed variation suggests opportunities exist for improving this important, patient-centered national quality measure. Future research is needed to identify the aspects of care delivery and the community services and supports that facilitate successful community discharge. These findings can be used to guide care improvement efforts and further improve the consistency and quality of postacute care.

Home health agency work environments and hospitalizations.

An important goal of home health care is to assist patients to remain in community living arrangements. Yet home care often fails to prevent hospitalizations and to facilitate discharges to community living, thus putting patients at risk of additional health challenges and increasing care costs. To determine the relationship between home health agency work environments and agency-level rates of acute hospitalization and discharges to community living. Analysis of linked Center for Medicare and Medicaid Services Home Health Compare data and nurse survey data from 118 home health agencies. Robust regression models were used to estimate the effect of work environment ratings on between-agency variation in rates of acute hospitalization and community discharge. Home health agencies with good work environments had lower rates of acute hospitalizations and higher rates of patient discharges to community living arrangements compared with home health agencies with poor work environments. Improved work environments in home health agencies hold promise for optimizing patient outcomes and reducing use of expensive hospital and institutional care.

Toward Spanning the Quality Chasm: An Examination of Team Functioning Measures

ObjectiveTo examine the effect of 5 measures of team functioning on patient outcomes. DesignObservational, exploratory, measurement. Team functioning surveys and patient outcomes collected 1 year apart in a clinical trial were analyzed. The findings are discussed in context of the domains of team functioning, team effectiveness, and quality improvement. Setting27 Veterans Affairs medical centers. ParticipantsStaff (t1: N=356; t2: N=273) on inpatient teams and patients (t1: N=4266; t2: N=3213) treated by the teams. InterventionsNot applicable. Main Outcome MeasuresFive measures of team functioning (Physician Engagement, Shared Leadership, Supervisor Team Support, Teamness, and Team Effectiveness scales) and 3 measures of patient outcomes (functional improvement, discharge destination, and length of stay) were assessed at 2 time points with hierarchical generalized linear models to evaluate the association between team functioning measures and changes in patient outcomes. ResultsAssociations (P<.05) between team functioning measures and patient outcomes were found for 3 of the 15 analyses over the study period. Higher Physician Engagement scale score was associated with lower length of stay (P=.017), and increased scores on Teamness and Team Effectiveness scales correlated with higher rates of community discharge (P=.044 and .049, respectively). ConclusionsThis exploratory analysis revealed trends that team functioning corresponds with patient outcomes in clinically relevant patterns. An increase in community discharge and a decrease in length of stay were associated with higher scores of team functioning. Here, we find evidence that modifiable attributes of team functioning have a measurable effect on patient outcomes. Such findings are promising and support the need for further research on team effectiveness.

Facility and Market Factors Affecting Transitions From Nursing Home to Community

Research into nursing home transitions has given limited attention to the facility or community contexts. To identify facility and market factors affecting transitions of nursing home residents back to the community. Multilevel models were used to estimate effects of facility and market factors on facility-level community discharge rates after controlling for resident demographic, health, and functional conditions. Facility discharge rates were adjusted using Empirical Bayes estimation. Annual cohort of first-time admissions (N=24,648) to 378 Minnesota nursing facilities in 75 nursing home markets from July 2005 to June 2006. Community discharge within 90 days of admission; facility occupancy, payer mix, ownership, case-mix acuity, size, admissions from hospitals, nurse staffing level, and proportion of admissions preferring or having support to return to the community; and nursing market population size, average occupancy, market concentration, and availability of home and community-based services. Rates of community discharge (Empirical Bayes residual) were highest in facilities with more residents preferring community discharge, more Medicare days, higher nurse staffing levels, and higher occupancy. In addition, facilities had higher community discharge rates if they were located in markets with a greater ratio of home and community-based services recipients to nursing home residents and with larger populations. State Medicaid programs should undertake system-level interventions that encourage nursing facilities to reduce unused bed capacity, balance the mix of payers, invest in nurse staffing, and take other steps to promote community discharges. In addition, states should increase home and community-based services, particularly in markets with low community discharge rates.

Team Training and Stroke Rehabilitation Outcomes: A Cluster Randomized Trial

Strasser DC, Falconer JA, Stevens AB, Uomoto JM, Herrin J, Bowen SE, Burridge AB. Team training and stroke rehabilitation outcomes: a cluster randomized trial. ObjectiveTo test whether a team training intervention in stroke rehabilitation is associated with improved patient outcomes. DesignA cluster randomized trial of 31 rehabilitation units comparing stroke outcomes between intervention and control groups. SettingThirty-one Veterans Affairs medical centers. ParticipantsA total of 237 clinical staff on 16 control teams and 227 staff on 15 intervention teams. Stroke patients (N=487) treated by these teams before and after the intervention. InterventionThe intervention consisted of a multiphase, staff training program delivered over 6 months, including: an off-site workshop emphasizing team dynamics, problem solving, and the use of performance feedback data; and action plans for process improvement; and telephone and videoconference consultations. Control and intervention teams received site-specific team performance profiles with recommendations to use this information to modify team process. Main Outcome MeasuresThree patient outcomes: functional improvement as measured by the change in motor items of the FIM instrument, community discharge, and length of stay (LOS). ResultsFor both the primary (stroke only) and secondary analyses (all patients), there was a significant difference in improvement of functional outcome between the 2 groups, with the percentage of stroke patients gaining more than a median FIM gain of 23 points increasing significantly more in the intervention group (difference in increase, 13.6%; P=.032). There was no significant difference in LOS or rates of community discharge. ConclusionsStroke patients treated by staff who participated in a team training program were more likely to make functional gains than those treated by staff receiving information only. Team based clinicians are encouraged to examine their own team. (ClinicalTrials.gov identifier NCT00237757).

Poster 79: Community Discharge Rates: A Comparison of Severe Stroke Patients and Nonsevere Stroke Patients

Objective: To compare the community discharge rates of severe stroke patients to nonsevere stroke patients in the Uniform Data System for Medical Rehabilitation database. Design: Retrospective cohort study. Setting: 882 inpatient rehabilitation facilities (IRFs). Participants: 87,361 stroke patients discharged during calendar year 2005. Severe stroke patients were defined as having met criteria for classification into case-mix group 0110 (N=24,609) and were compared with nonsevere stroke patients in the database (N=62,752).

Are We Selecting the Right Patients for Stroke Rehabilitation in Nursing Homes?

Murray PK, Dawson NV, Thomas CL, Cebul RD. Are we selecting the right patients for stroke rehabilitation in nursing homes? Objective To examine the effect of stroke rehabilitation in the nursing home on community discharge rates and functional status among patients stratified by propensity to receive rehabilitation. Design Retrospective cohort. Setting Medicaid-certified nursing homes (N=945) in Ohio. Participants Patients with stroke (N=2013) admitted to an Ohio nursing home. Intervention Rehabilitation therapy services. Main outcome measures The propensity to receive rehabilitation, used to adjust for selection bias, was calculated for each patient by using a logistic regression model. Community discharge and change in functional status, measured by using a crosswalk to the FIM instrument, were determined 3 months after admission. Results By 3 months after admission, 36.9% of the patients were discharged to the community, 16.6% had died, and 46.5% remained in the nursing home. The overall effect of rehabilitation on community discharge (relative risk [RR]=1.58; 95% confidence interval [CI], 1.33–1.85) was not homogeneous across subgroups stratified by propensity to receive rehabilitation. Patients less likely to receive rehabilitation, as measured by a lower propensity score, had a significant benefit in terms of community discharge (RR=1.65; 95% CI, 1.35–1.97), but those more likely to receive services did not (RR=1.21; 95% CI, 0.87–1.56). Among long-term nursing home residents, rehabilitation services were not associated with improved functional status. Conclusions With respect to community discharge, patients who were less likely to receive rehabilitation therapy appear to receive greater benefit from rehabilitation services than those who were more likely to receive rehabilitation. This finding raises concerns about current selection practices for rehabilitation services. Research is needed to identify the patients most likely to benefit, especially in the present fiscally constrained reimbursement environment.