Community Discharge Rates Research Articles

Initial home health outcomes under prospective payment.

To assess initial changes in home health patient outcomes under Medicare's home health Prospective Payment System (PPS), implemented by the Centers for Medicare and Medicaid Services (CMS) in October 2000. Pre-PPS and early PPS data were obtained from CMS Outcome and Assessment Information Set (OASIS) and Medicare claims files. Regression analysis was applied to national random samples (n=164,810) to estimate pre-PPS/PPS outcome and visit-per-episode changes. Outcome episodes were constructed from OASIS data and linked with Medicare claims data on visits. Outcome changes (risk adjusted) were mixed and generally modest. Favorable changes included higher improvement rates under PPS for functioning and dyspnea, higher community discharge rates, and lower hospitalization and emergent care rates. Most stabilization (nonworsening) outcome rates also increased. However, improvement rates were lower under PPS for wounds, incontinence, and cognitive and emotional/behavioral outcomes. Total visits per episode (case-mix adjusted) declined 16.6 percent although therapy visits increased by 8.4 percent. The outcome and visit results suggest improved system efficiency under PPS (fewer visits, similar outcomes). However, declines in several improvement rates merit ongoing monitoring, as do subsequent (posthome health) hospitalization and emergent care use. Since only the early PPS period was examined, longer-term analyses are needed.

Outcomes of rehabilitation services for nursing home residents

Murray PK, Singer M, Dawson NV, Thomas CL, Cebul RD. Outcomes of rehabilitation services for nursing home residents. Arch Phys Med Rehabil 2003;84:1129–36. Objective: To examine survival and community discharge outcomes related to rehabilitation services among patients admitted to nursing homes before the implementation of the Balanced Budget Amendment of 1997. Design: Retrospective cohort. Setting: A total of 945 Medicaid-certified nursing homes in Ohio. Participants: A total of 11,150 patients admitted for the first time to a nursing home from 1994 to 1996. Interventions: Not applicable. Main Outcome Measures: Community discharge and survival rates among patients who did or did not receive rehabilitation services, using multivariable techniques to adjust for patients’ propensity to receive rehabilitation and for other potential confounders. In secondary analyses, we also examined dose-response effects and analyzed the effects of rehabilitation when patients were divided into 5 diagnostic groups (stroke, hip fracture, congestive heart failure, chronic lung disease, other). Results: Rehabilitation was provided to 58% of the patients and was associated with higher community discharge rates (relative risk=1.48; 95% confidence interval [CI], 1.40–1.57) and a lower hazard of death (hazard ratio=.81; 95% CI, .75–.88). Dose-response effects were observed for both outcomes ( P<.001) among patients receiving rehabilitation. Rehabilitation was associated with improved community discharge rates in each of the 5 diagnostic groups. Conclusions: New reimbursement policies that discourage the provision of rehabilitation services may have adverse effects on patients, their families, and societal costs of care.

Prospective payment for nursing homes increased therapy provision without improving community discharge rates.

To determine the impact of the prospective payment system (PPS) for skilled nursing facilities (SNFs) on therapy use and community discharge rates. Quasi-experimental study examining the predemonstration (1994) to demonstration (1997) change in amount of therapy provided, and in community discharge rates at PPS participating and nonparticipating facilities. Eighteen PPS participating and 17 nonparticipating SNFs in five states. Two thousand sixty-seven admissions to 18 PPS participating and 17 nonparticipating SNFs in five states. We compared changes in number of physical and occupational therapy visits per stay for patients receiving therapy and likelihood of being located in the community 60 days after admission between 1994 and 1997. Analyses were stratified by functional category and risk adjusted using multivariate methods. Demographics and percentage of patients in each stratum were similar in participating and nonparticipating sites and between 1994 and 1997. Amount of therapy received by the highest-functioning patients increased in participating sites (19.3 to 26.5 visits per stay, P = .005), but not in nonparticipating sites (23.3 to 18.2, P = .98). After adjusting for covariates, likelihood of community discharge for the highest-functioning patients did not change between participating and nonparticipating sites. The highest-functioning patients treated under the SNF PPS demonstration experienced great increases in therapy, without any improvement in rate of community discharge.

Functional task benchmarks for stroke rehabilitation

Objective: To determine typical outcome “benchmarks” for 18 functional tasks in patients undergoing stroke rehabilitation. The benchmarks are intended to serve as points of reference to which the outcomes of patients with similar impairments and degrees of disability can be compared. Subjects: Records from 26,339 stroke patients discharged from 252 inpatient facilities across the United States that submitted 1992 data to the Uniform Data System for Medical Rehabilitation. Methods: Stroke impairment was detailed as the presence or absence of hemiparesis resulting from stroke and the side(s) of involvement. Within each of five stroke impairment categories, patients were further classified by the Functional Independence Measure-Function-Related Groups (FIM-FRGs) into nine syndromes by degree of disability (admission motor and cognitive FIM scores) and by age. Outcomes were determined for each stroke syndrome at patients' discharge from medical rehabilitation. Main Outcome Measures: Patients' median performance levels on each of the 18 items making up the FIM, length of stay, and community discharge rates. Results: The majority of patients whose admission motor FIM scores were above 37 were able to eat, groom, dress the upper body, and manage bladder and bowel functions independently by discharge. In addition to these tasks, most of those whose motor FIM scores were above 55 were able to dress the lower body, bathe, and transfer onto a chair/bed or toilet. The majority of patients whose initial motor FIM scores were above 62 points and whose cognitive FIM scores were above 30 gained independence in most tasks, including stair climbing and tub transfers. Community discharge rates ranged from 51.6% for the group of patients with the most severe disabilities to 99.2% for the group with the least severe disabilities. Conclusion: The clinician can apply these benchmarks to guideline development and quality improvement, and in establishing patient goals.

Discharge outcome after stroke rehabilitation.

The purpose of this study was to examine the relations between host characteristics (age and side of body affected) and program variables (lengths of stay in acute care and rehabilitation, levels of functional ability at admission and discharge, and rates of community discharge). A sample of 7,905 patients was drawn from medical rehabilitation facilities enrolled in the Uniform Data System for Medical Rehabilitation who were admitted and discharged for the first time between January 1988 and June 1989. Data were analyzed using either chi 2 tests or z normal tests of proportions, and analyses of variance (ANOVA) and/or t tests. Significance was set at p less than 0.05, and statistically significant F ratios were examined using Student-Newman-Keuls tests. The average age of patients was 70.7 years (24% less than 65 years, 53% 65-79 years, and 23% greater than 79 years). Lengths of stay in acute care and rehabilitation, admission and discharge functional independence ratings, and rates of community discharge were generally inversely related to patient age. Patients with bilateral paresis had lower rates of community discharge than those with unilateral paresis, although this distinction was not evident in the older group. Results showed that older age and bilateral paresis are negatively associated with levels of independence at admission and discharge and with rates of community discharge.