Inpatient Rehabilitation Facility Discharge Research Articles

Differences in Daily Activity Performance Between Inpatient Rehabilitation Facility and Home Among Stroke Survivors.

Stroke survivors are one of the largest consumer groups of rehabilitation services. Despite improvement in daily activities while in inpatient rehabilitation, many have difficulty performing daily activities at home after discharge. The difference in performance between a standard clinical context and at home is poorly understood. To better understand differences in activity performance during transition from inpatient rehabilitation facility (IRF) to home, we examined daily activity performance scores from 2 different environments (IRF and home) at the same time point (discharge). This was a cross-sectional analysis using baseline data from a randomized controlled trial. Participants were stroke survivors aged ≥50 who planned to discharge home from the IRF. The Functional Independence Measure and Section GG codes (both converted to International Classification of Functioning, Disability, and Health scores) were conducted per protocol first at home and then in the IRF at discharge (≤3 days apart, order not randomized). Among 57 participants, activity scores at home were significantly worse than scores at IRF discharge. Over 40% of participants had discharge scores indicating no-to-mild impairment for shower/tub transfer, walking, and going up/down stairs, while home visit scores indicated moderate-to-complete impairment for those activities. The greatest differences in scores were for shower/tub transfer (median difference 1.5, 95% CI 1.00-2.00) and going up/down stairs (median difference 1.50, 95% CI 1.00-2.00). The environment plays an important role in stroke survivors' functioning at home. Future studies should further examine how the environment impacts activity performance upon returning home following stroke.

Healthy Days at Home Among Older Medicare Beneficiaries With Traumatic Brain Injury Requiring Inpatient Rehabilitation.

The objectives of this study were to characterize and identify correlates of healthy days at home (HDaH) before and after TBI requiring inpatient rehabilitation. Setting: Inpatient hospital, nursing home, and home health services. Average of n=631 community-dwelling fee-for-service age 66+ Medicare beneficiaries across 30 replicate samples who were hospitalized for traumatic brain injury (TBI) between 2012 and 2014 and admitted to an inpatient rehabilitation facility (IRF) within 72hours of hospital discharge. Retrospective study using data from Medicare claims supplemented with data from the National Trauma Databank. The primary outcome, HDaH, was calculated as time alive not using inpatient hospital, nursing home, and home health services in the year before TBI hospitalization and after IRF discharge. We found HDaH declined from 93.2% in the year before TBI hospitalization to 65.3% in the year after IRF discharge (73.6% among survivors only). Most variability in HDaH was: (1) in the first 3months after discharge and (2) by discharge disposition, with persons discharged from IRF to another acute hospital having the worst prognosis for utilization and death. In negative binomial regression models, the strongest predictors of HDaH in the year after discharge were rehabilitation Functional Independence Measure mobility score (β=0.03; 95% CI, 0.002-0.06) and inpatient Charlson Comorbidity Index score (β=-0.06; 95% CI, -0.13 to 0.001). Dual Medicaid eligible was associated with less HDaH among survivors (β=-0.37; 95% CI, -0.66 to -0.07). In this study, among community-dwelling older adults with TBI, we found a notable decrease in the proportion of time spent alive at home without higher-level care after IRF discharge compared to before TBI. The finding that physical disability and comorbidities were the biggest drivers of healthy days alive in this population suggests that a chronic disease management model is required for older adults with TBI to manage their complex health care needs.

Abstract TP80: Differences in Access to Post Acute Care Services Between Traditional Medicare and Medicare Advantage Beneficiaries in Michigan

Introduction: In recent years, Medicare Advantage (MA) enrollment in the US has increased dramatically relative to traditional Medicare (TM). There is evidence to suggest that MA stroke patients are less likely to receive inpatient rehabilitation facility (IRF) based care in favor of home health. To evaluate potential gaps in quality of care, we compared post-acute care use patterns following hospitalization for acute stroke between TM and MA populations. Methods: We probabilistically linked data from Michigan’s Get With The Guidelines-Stroke registry and Michigan Value Collaborative multipayer claims data registry for 16,231 TM and MA beneficiaries discharged alive following acute stroke (ICD-10 I61-I63) between 2016-2020. We used discharge claims to identify the initial discharge destination classified as home, home health, IRF, skilled nursing facility (SNF) or other. Unadjusted differences in proportions and time trends between TM and MA populations were assessed using chi square statistical tests. Results: TM and MA-insured patients constituted 75.1% and 24.9% of the 16,231 stroke discharges, respectively. Compared with TM, MA beneficiaries were older (77.4 vs 75.8, P <0.001), less likely to be female (50.3% vs 55.3%, P <0.001), and more likely to be white (87.0% vs 82.4%, P <0.001). Over the study period, the proportion of MA patients increased from 21.2% in 2016 to 32.4% in 2020 ( P <0.001) (Table). Overall, significant differences in discharge destination were due to more MA patients discharged to home and home health ( P <0.001). Despite significant differences between MA and TM populations, there were no consistent time trends in discharge patterns. However, the exception was in 2020 where increased utilization of home health was accompanied by decreases in IRF and SNF discharge. Conclusions: We did not find clinically meaningful differences in discharge patterns between TM and MA populations. Changes in 2020 were likely attributed to COVID-19.

Utility of the AM-PAC "6 Clicks" Basic Mobility and Daily Activity Short Forms to Determine Discharge Destination in an Acute Stroke Population.

The American Heart Association and American Stroke Association recommend early identification of level of rehabilitative care as a priority after stroke. To evaluate the utility of the Activity Measure for Post-Acute Care (AM-PAC) "6 Clicks" Daily Activity and Basic Mobility forms to determine the next level of rehabilitation after hospitalization for adults with stroke. Retrospective cohort design using medical records from 2015 to 2016. Major urban hospital. Patients admitted to the stroke service, with a confirmed stroke, who were seen by a physical or occupational therapist; who had a 6 Clicks Basic Mobility or Daily Activity score at initial evaluation; and who were discharged to home, an acute inpatient rehabilitation facility (IRF), or a subacute skilled nursing facility (SNF). Length of stay and discharge destination. Seven hundred four participants (M age = 68.28 yr; 51.21% female) were included. Analysis of variance and receiver operating characteristic curves were performed. Daily Activity scores were highest for home discharge, lower for IRF discharge, and lowest for SNF discharge; Basic Mobility showed a similar pattern. Cutoff values distinguishing home from further inpatient rehabilitation were 44.50 for Basic Mobility and 39.40 for Daily Activity scores (area under the curve [AUC] = .82 for both forms), with scores of 34.59 (AUC = 0.64) and 31.32 (AUC = 0.67) separating IRF from SNF, respectively. Therapists should incorporate 6 Clicks scores into their discharge planning. What This Article Adds: This research demonstrates the utility of an outcome measure in the acute care setting that assists in planning discharge destination for patients with stroke.

Abstract WP63: The Effect Of Inpatient Rehabilitation Facility Treatment On 90 Day Outcomes: A Shift Analysis Of Modified Rankin Scale Score In Ischemic Stroke Patients

Introduction: Several AHA Guidelines recommend inpatient rehabilitation facility (IRF) care to enhance post-stroke recovery. We evaluated the IRF treatment effect on modified Rankin scale (mRS) score change at 90 days in ischemic stroke (IS) patients. Methods: Using prospectively collected data from Get With the Guidelines-Stroke, the Uniformed Data System for Medical Rehabilitation registry and the electronic medical record, we identified IS patients with discharge disposition of home or IRF between 1/1/2018-12/31/2020. Sociodemographics, clinical variables and IS treatment rates were summarized. IRF outcomes, including length of stay (LOS), improvement in mobility and self-care scores and discharge disposition were compared in thrombectomy vs no thrombectomy groups. mRS at IRF discharge was calculated with a Cronbach interrater score of 0.88; shift analyses of mRS at hospital discharge and 90 days were completed for IS patients in the Home and IRF care groups. Results: Among 738 patients, 499 went home, 239 went to IRF. IRF patients were more likely to have Medicare insurance (49.2 vs 28.9%), undergo thrombectomy (16.3 vs 4.6%) have increased LOS (12.7 vs 4.8 days) and stroke severity (mean NIHSS 7.8 vs 4.8; mean mRS 3.1 vs 1.7) compared to Home (Table 1). At IRF, 39 patients previously underwent thrombectomy, 200 did not. Both groups had a IRF LOS >14 days and considerable recovery in the self-care and mobility domains (Table 2). Shift analysis of mRS at hospital discharge compared to 90 days yielded significant improvements in mRS of 0-2 and lower mortality in the IRF group compared to home group (Figure). Conclusion: In ischemic stroke patients with higher disease severity, IRF treatment is a catalyst for improved functional recovery.

Abstract TP70: Preliminary Associations Between Quality Indicators, Motor Status, And Self-efficacy In Early Stroke Rehabilitation

Introduction: Recent changes in reimbursement policies for inpatient rehabilitation facility (IRF) providers prompted the adoption of Quality Indicators (QI) on the IRF Patient Assessment Instrument leading to the discontinuation of the Functional Independence Measure (FIM). Given that the FIM has shown associations with motor assessments and self-efficacy measures during early stroke recovery, the purpose of this study was to confirm if similar associations exist with QI. Methods: Participants with acute ischemic and hemorrhagic stroke completed a battery of assessments at the time of IRF admission and discharge: Total QI (summation of self-care and mobility items), Upper Extremity Fugl-Meyer (UEFM), Action Research Arm Test (ARAT), and Stroke Self-Efficacy Questionnaire (SSEQ). We determined associations between QI and these measures by computing correlation coefficients with an alpha value=.01 denoting significance following a Bonferroni correction. Results: Fourteen individuals (7 females, age=65.9±9.0 years, 8.1±3.5 days post-stroke) with moderate-severe motor deficit completed study procedures. Table 1 summarizes admission and discharge scores and associations with QI. Conclusions: Significant associations between motor assessments and QI from this ongoing study parallel similar associations involving the FIM. The implementation of QI in IRFs necessitates additional work to validate our findings and to determine psychometric properties of QI to enhance clinical research in stroke rehabilitation.

Examining the accuracy of the AM-PAC “6-clicks” at predicting discharge disposition in traumatic brain injury

ABSTRACT Objective To assess the accuracy of the AM-PAC “6-Clicks” in predicting discharge dispositions among severely injured patients with an acute traumatic brain injury (TBI). Methods We performed a retrospective review of patients with a TBI who presented to our trauma center from 2016 through 2018 and received a “6-Clicks” assessment. Outcomes were hospital length of stay (LOS) and discharge disposition: home, inpatient rehabilitation facility (IRF), subacute location (SL), or death/hospice. Subgroup analyses evaluated patients with concomitant mobility-limiting injuries (CM-LI). Results There were 432 patients with a TBI; 42.6% (n = 184) had CM-LI. CM-LI patients had lower “6-Clicks” scores compared to patients with an isolated TBI (9 vs 14, p < .0001) and a longer hospital LOS (16.5 d vs 9 d, p < .0001). Increasing “6-Clicks” scores were associated with a home discharge (OR 1.21, 95% CI 1.15–1.28, p < .0001) while decreasing scores were predictive of an IRF or SL discharge or death/hospice. Increasing scores correlated with decreasing hospital LOS for the cohort (β − 8.93, 95% CI −10.24 – −7.62, p < .0001). Conclusion Among patients with an acute TBI, increasing “6 Clicks” scores were associated with a shorter hospital LOS and greater likelihood of home discharge. Decreasing mobility scores correlated with discharge to an IRF, SL, and death/hospice.

Age- and sex-specific predictors of inpatient rehabilitation facility discharge destination for adult patients with traumatic brain injury

ABSTRACT Objective : To determine age- and sex-specific predictors of discharge destination among patients with traumatic brain injury (TBI) receiving inpatient rehabilitation facility (IRF) care. Design : Secondary analysis of Uniform Data System for Medical Rehabilitation data. Methods : Logistic regression of patients (N = 221,961) age ≥18, TBI diagnosis, admitted to IRF between 2002 and 2018. Outcome : Discharge destination (subacute vs. home/community settings) Results : Approximately 16% were discharged to subacute vs. 84% home. Younger versus older adults had lower odds of subacute discharge [OR = 0.72; 95% CI: 0.69, 0.76]. Younger females had lower odds of subacute discharge (vs. home) than older females [OR = 0.68; 95% CI: 0.63, 0.74]; younger males had lower odds of subacute discharge (vs. home) than older males [OR = 0.74; 95% CI: 0.70, 0.78]. Younger females versus younger males had lower odds of subacute discharge (vs. home) [OR = 0.83; 95% CI: 0.79, 0.87]. Older females versus older males had lower odds of subacute discharge (vs. home) [OR = 0.93; 95% CI: 0.90, 0.97]. Predictors of discharge destination for age- and sex-stratified groups varied. Conclusions : Younger (vs. older) and female (vs. male) patients had lower odds of subacute discharge vs. home.

Inpatient rehabilitation facility discharge destination among younger adults with traumatic brain injury: differences by race and ethnicity

ABSTRACT Objective : To determine the association of race and ethnicity with discharge destination among patients with traumatic brain injury (TBI) receiving inpatient rehabilitation facility (IRF) care. Design Secondary analysis using Uniform Data System for Medical Rehabilitation data. Methods : Patients (N = 99,614) diagnosed with TBI, age 18–64, admitted for IRF care between 2002 and 2018. Logistic regression was used to analyze data. Outcome : Discharge destination (home/community vs. subacute settings). Results : Most younger adults (age 18–64) with TBI were discharged home (89.24%) after IRF care vs. subacute (10.76%). Of those discharged home, 63.16% were white, 10.42% Black, 8.94% Hispanic/Latino, and 6.72% other races/ethnicities. After adjusting for covariates, patients who were Hispanic/Latino [OR = 1.26; 95% CI: 1.15, 1.37] and other race/ethnicities [OR = 1.10; 95% CI: 1.00, 1.21] (vs. White) had higher odds of discharge home vs. subacute. There was no difference in discharge destination for Black patients (vs. white). Predictors of discharge destination for groups stratified by race/ethnicity varied. Conclusions : Younger patients with TBI who were Hispanic/Latino or other races/ethnicities (vs. white) were more likely to go home vs. subacute. Findings can be used to inform IRF planning, resource allocation, and transitional care planning.

Association Between 2010 Medicare Reforms and Utilization of Postacute Inpatient Rehabilitation in Ischemic Stroke.

The aim of the study was to investigate whether the elimination of trial admissions and the initiation of documentation requirements, via the 2010 Centers for Medicare and Medicaid Services Inpatient Rehabilitation Facility Prospective Payment System Rule, limited inpatient rehabilitation facility access while increasing skilled nursing facility utilization compared with home discharge in ischemic stroke patients. This is a retrospective observational study using Get with the Guidelines - Stroke hospital data between January 1, 2008 and December 31, 2015 (N = 1,643,553). Between January 1, 2008 and December 31, 2009, 54.1% of patients went home, 25.4% to inpatient rehabilitation facility and 20.5% to skilled nursing facility. Between January 1, 2010 and December 31, 2015, there was a 1.4% absolute increase in home discharge, a 1.1% inpatient rehabilitation facility decline and a 0.3% skilled nursing facility decline.Within the 1.1% absolute decline in inpatient rehabilitation facility discharge, the adjusted odds of inpatient rehabilitation facility versus home discharge decreased 12% after 2010 Rule (adjusted odds ratio = 0.88, 95% confidence interval = 0.87-0.89, P < 0.0001). There was no statistically significant change in skilled nursing facility versus home discharge.Lower adjusted odds of inpatient rehabilitation facility discharge versus home discharge were identical across age groups and were present in all geographic regions. In populations with ischemic stroke, the Centers for Medicare and Medicaid Services 2010 Inpatient Rehabilitation Facility Prospective Payment System Rule was associated with a 1.1% absolute decrease in inpatient rehabilitation facility discharge, with a concomitant increase in home discharge rather than to skilled nursing facility.

Intrinsic patient factors predictive of inpatient rehabilitation facility discharge following primary total knee arthroplasty: a systematic review and meta-analysis

BackgroundTotal Knee Arthroplasty (TKA) reduces pain and improves function in those suffering from severe osteoarthritis. A significant cost of TKA is post-acute care, however, current evidence suggests that discharge to an Inpatient Rehabilitation Facility (IRF) has inferior outcomes to home discharge, with no greater benefit in physical function. Only individual studies have investigated TKA patient characteristics predictive of discharge destination, therefore, the aim is to systematically review the literature and meta-analyse intrinsic patient factors predictive of IRF discharge. If predictive factors are known, then early discharge planning and intervention strategies could be implemented.MethodsDatabases PubMed, CINAHL, Embase, Cochrane, and Pedro were searched up to October 2019 for all studies investigating pre-operative intrinsic patient factors predictive of IRF discharge. For assessing the methodological quality of included studies, the Quality In Prognosis Studies (QUIPS) tool was used. Statistical analysis and graphical reporting were conducted in R statistical software. To assess the effect of predictors of discharge destination, odds ratios with the corresponding 95%CI were extracted from the results of univariate and multivariable analyses.ResultsA total of 9 articles published between 2011 to 2018 with 218,151 TKA patients were included. Of the 13 intrinsic patient factors reported, 6 met the criteria for synthesised review: age, obesity, comorbidity, gender, SF-12/VR-12 survey, and smoking. Due to the heterogeneity of statistical analysis and reporting 2 variables could undergo meta-analysis, gender and smoking. Female gender increased the likelihood of IRF discharge by 78% (OR = 1.78; 95%CI = 1.43–2.20; I2 = 33.3%), however, the relationship between smoking status and discharge destination was less certain (OR = 0.80; 95%CI = 0.42–1.50; I2 = 68.5%).ConclusionIn this systematic literature review and meta-analysis female gender was shown to be predictive of IRF discharge after total knee arthroplasty. There was also a trend for those of older age and increased comorbidity, as measured by the Charlson Comorbidity Index, or the severely obese to have an increased likelihood of IRF discharge. The marked heterogeneity of statistical methods and reporting in existing literature made pooled analysis challenging for intrinsic patient factors predictive of IRF discharge after TKA. Further, high quality studies of prospective design on predictive factors are warranted, to enable early discharge planning and optimise resource allocation on post-acute care following TKA.Trial registrationThis review was registered with PROSPERO (CRD42019134422).

Is Referral to Home Health Rehabilitation After Inpatient Rehabilitation Facility Associated With 90-Day Hospital Readmission for Adult Patients With Stroke?

We examined the association between home health rehabilitation referral and 90-day risk-adjusted hospital readmission after discharge from inpatient rehabilitation facilities among adult patients recovering from stroke (N = 1219). A secondary data analysis of the 2005-2006 Stroke Recovery in Underserved Population database. A logistic regression model, multilevel model, and the propensity score inverse probability weighting model were used to evaluate the risk of 90-day rehospitalization between patients with stroke who received a referral for home health rehabilitation and those who did not receive a home health rehabilitation referral at inpatient rehabilitation facility discharge. The regression, multilevel, and propensity score inverse probability weighting models indicated that inpatient rehabilitation facility patients with stroke who received home health rehabilitation referral had substantially lower odds of 90-day rehospitalization after inpatient rehabilitation facility discharge compared with those who were not referred to home health (odds ratio = 0.325, 95% confidence interval = 0.138-0.764; odds ratio = 0.340, 95% confidence interval = 0.139-0.832; odds ratio = 0.407, 95% confidence interval = 0.183-0.906, respectively). Our findings suggest the importance of continuation of care (home health) after hospitalization and intense inpatient rehabilitation for stroke. Additional research is needed to establish appropriate use criteria and explore potential underuse of home health services as well as the benefits for follow-up outpatient services for those who do not qualify for home health at inpatient rehabilitation facility discharge.

Dysphagia Associated with Risk of Depressive Symptoms among Stroke Survivors after Discharge from a Cluster of Inpatient Rehabilitation Facilities.

To examine the association of stroke-induced dysphagia during an inpatient rehabilitation facility (IRF) stay and depressive symptoms at a 3-month follow-up. A retrospective cross-sectional design using the Stroke Recovery in Underserved Populations 2005-2006 study database. Hierarchical logistic regression models were utilized to examine if stroke-induced dysphagia is a significant predictor for depressive symptoms at 3-month follow-up across the stepwise introduction of the demographics and clinical characteristics at the IRF discharge and 3-month follow-up. Multiple imputations with Markov-chain Monte Carlo method was used to address the covariates with missing observations. In a total of 1,045 stroke survivors, 335 (32.1%) stroke survivors had dysphagia and 710 (67.9%) stroke survivors did not have dysphagia during the IRF stay. The adjusted logistic regression model and multiple imputation method revealed that stroke survivors with dysphagia are more likely to have depressive symptoms at 3-month follow-up (Odds ratio [OR] 3.169, 95% confidence interval [CI] 1.379-7.283; OR 1.746, 95% CI 1.153-2.642, respectively). A high level of functional and cognitive status, functional support, and community participation at the 3-month follow-up was inversely associated with depressive symptoms (OR 0.973, 95% CI 0.951- 0.995; OR 0.884, 95% CI 0.829-0.942; OR 0.793, 95% CI 0.714-0.882). Stroke survivors experiencing dysphagia during the IRF stay had a higher risk of developing depressive symptoms compared to those without dysphagia at 3-month follow-up. Healthcare providers should pay attention to dysphagia care in IRFs which might prevent the development of depressive symptoms when the stroke survivors are discharged and back in their communities.

Abstract TMP42: Coherent Neural Oscillations Inform Early Stroke Motor Recovery

Introduction: Neural oscillations may contain valuable information for stroke rehabilitation. The objective of this study was to examine the predictive performance of neural oscillations in early stroke motor recovery using dense array electroencephalography (EEG). Since past work theorizes that neural oscillations underlie behavior, we hypothesized that coherent oscillations with ipsilesional primary motor cortex (M1) across a 1-30 Hz band would significantly predict early motor recovery post-stroke. Methods: Individuals with stroke admitted to an inpatient rehabilitation facility (IRF) completed a three-minute resting EEG recording and structural MRI around the time of IRF admission and motor testing (Functional Independence Measurement motor subscale (FIM-motor)) at IRF admission and discharge. We examined how well FIM-Motor change was predicted using EEG power and coherence with ipsilesional M1 across delta (1-3 Hz), theta (4-7 Hz), alpha (8-12 Hz), low beta (13-19 Hz), and high beta (20-30 Hz) frequency bands, along with corticospinal tract (CST) injury, in a lasso regression with K-fold cross-validation for deviance estimation. Results: Twenty-seven subjects (20 males, 58.3±14.6 years, 8-17 days post-stroke) with predominantly mild-moderate motor impairment participated. EEG ipsilesional M1 coherence with 16 leads overlying both hemispheres predicted 61.8% of FIM-motor change from IRF admission to discharge, with higher frequencies (alpha, high beta) positively relating to motor recovery. Lower frequencies overlying contralesional parietal (theta) and frontal (delta) regions inversely and positively related to motor recovery respectively. Coherence outperformed EEG power and CST injury measurements. Ipsilesional M1 coherence also predicted 55.2% of the variance in residuals derived from a predictive model containing only CST injury, suggesting that EEG coherence and CST injury contain unique information for motor recovery prediction. Conclusions: Early after stroke, coherence of neural oscillations with ipsilesional M1 across the entire brain through a wide frequency spectrum is best at predicting functional gains from inpatient rehabilitation and may be feasible as a bedside biomarker of motor recovery.

Associations of Self‐Reported History of Depression and Antidepressant Use Before Stroke Onset With Poststroke Post–Acute Rehabilitation Care—An Exploratory Study: The BASIC (Brain Attack Surveillance in Corpus Christi) Project

BackgroundPrestroke depression status and post–acute rehabilitation care (PARC) are determinants of poststroke depression and function. However, little is known on how prestroke depression status affects PARC placement, a possible pathway for upstream intervention. We examined how prestroke depression status affects PARC in a population‐based study.Methods and ResultsIncident ischemic stroke cases were from the BASIC (Brain Attack Surveillance in Corpus Christi) Project from 2008 to 2012. Prestroke depression status was self‐reported and categorized as (1) never depressed, (2) history of depression without antidepressant use before stroke onset, or (3) antidepressant use before stroke onset. PARC included home, a skilled nursing facility, or an inpatient rehabilitation facility. Confounder‐adjusted multinomial regression models were used to examine the association between prestroke depression status and PARC. Adjustment for stroke severity was deferred in the main analyses because it may lie on the causal pathway. There were 548 stroke survivors (mean age 65.3 years, 48.3% female, 62.6% Mexican‐American). The adjusted odds ratios comparing home discharge to a skilled nursing facility were 1.88 (95% CI: 0.86‐4.11) for those with a history of depression and 2.55 (95% CI: 1.11‐5.83) for those using an antidepressant at stroke onset, relative to those never depressed. The adjusted odds ratios comparing an inpatient rehabilitation facility to a skilled nursing facility were 1.17 (95% CI 0.40‐3.42) and 3.28 (95% CI 1.24‐8.67) for those with a history of depression and those using an antidepressant at stroke onset, respectively, relative to those never depressed.ConclusionsAntidepressant use before stroke onset may increase odds of home and inpatient rehabilitation facility discharge compared with skilled nursing facility discharge.

Responsiveness of the activity measure for post-acute care (AM-PAC) from discharge from inpatient stroke rehabilitation to six month follow-up

Functional stroke scales must detect significant change over time, but defining “significant” is difficult. The activity measure for post-acute care (AM-PAC) measures activity limitations in 3 domains: basic mobility (BM), daily activity (DA), and applied cognitive (AC). This study assesses the ability of the AM-PAC to detect change from inpatient rehabilitation facility (IRF) discharge (DC) to an outpatient setting 6 months (6 M) later. We analyzed data from a observational database for stroke patients treated at our academic IRF. We assessed AM-PAC domains at IRF DC and again by phone 6 M later. Change between DC and 6 M was calculated by: – standardized response mean (SRM, 0–0.4–0.6 = moderate effect); – proportion achieving the minimal clinically important difference (MCID, estimated as 0.5SD of baseline scores after Norman et al., 2003) with our data; – the published, mixed population minimal detectable change (MDC). Of 273 patients at DC, 139 (51%) had both AM-PAC scores and were included. Those included were not demographically different but were better on physical and cognitive measures at IRF admission. The mean age = 67.1 ± 14.8 y, NIHSS = 7.9 ± 7.5, discharge FIM = 84.1 ± 19.1, FIM Gain = 20.2 ± 10.6, and rehabilitation length of stay = 14.8 ± 7.6d. The mean DC/6 M scores for BM were 51.7 ± 11.2/56.0 + 12.1, DA = 44.4 ± 9.9/49.2 + 14.5 and AC = 40.0 ± 9.8/44.7 + 9.2. Change metrics for the 3 AM-PAC domains are given in Table 1 . Between 40%–50% of stroke patients were classified as “significantly” improved, depending on measure, suggesting the AM-PAC is able to capture “real life” change. The sample experienced change at the lower end of “moderate improvement” by SRM. Estimated MCID and the MDC were similar for DA and AC, not BM. Further research should explore factors, which predict functional success or failure.

Development of a Risk-adjustment Model for the Inpatient Rehabilitation Facility Discharge Self-care Functional Status Quality Measure.

Functional status measures are important patient-centered indicators of inpatient rehabilitation facility (IRF) quality of care. We developed a risk-adjusted self-care functional status measure for the IRF Quality Reporting Program. This paper describes the development and performance of the measure's risk-adjustment model. Our sample included IRF Medicare fee-for-service patients from the Centers for Medicare & Medicaid Services' 2008-2010 Post-Acute Care Payment Reform Demonstration. Data sources included the Continuity Assessment Record and Evaluation Item Set, IRF-Patient Assessment Instrument, and Medicare claims. Self-care scores were based on 7 Continuity Assessment Record and Evaluation items. The model was developed using discharge self-care score as the dependent variable, and generalized linear modeling with generalized estimation equation to account for patient characteristics and clustering within IRFs. Patient demographics, clinical characteristics at IRF admission, and clinical characteristics related to the recent hospitalization were tested as risk adjusters. A total of 4769 patient stays from 38 IRFs were included. Approximately 57% of the sample was female; 38.4%, 75-84 years; and 31.0%, 65-74 years. The final model, containing 77 risk adjusters, explained 53.7% of variance in discharge self-care scores (P<0.0001). Admission self-care function was the strongest predictor, followed by admission cognitive function and IRF primary diagnosis group. The range of expected and observed scores overlapped very well, with little bias across the range of predicted self-care functioning. Our risk-adjustment model demonstrated strong validity for predicting discharge self-care scores. Although the model needs validation with national data, it represents an important first step in evaluation of IRF functional outcomes.

Effects of Postacute Settings on Readmission Rates and Reasons for Readmission Following Total Knee Arthroplasty

ObjectivesExamine the effects of postacute discharge setting on unplanned hospital readmissions following total knee arthroplasty (TKA) in older adults. DesignSecondary analyses of 100% Medicare (inpatient) claims files. SettingAcute hospitals across the United States. ParticipantsMedicare fee-for-service beneficiaries ≥66 years of age who were discharged from an acute hospital following TKA in 2009-2011 (n = 608,031). MeasurementsThe outcome measure was unplanned readmissions at 30, 60, and 90 days. The independent variable of interest was postacute discharge setting: inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), or community. Covariates included demographic, clinical, and facility-level factors. The top 10 reasons for readmission were tabulated for each discharge setting across the 3 consecutive 30-day time periods. ResultsA total of 32,226 patients (5.3%) were re-admitted within 30 days. Compared with community discharge, patients discharged to IRF and SNF had 44% and 40% higher odds of 30-day readmission, respectively. IRF and SNF discharge settings were also associated with 48% and 45% higher odds of 90-day readmission, respectively, compared with community discharge. The largest increase in readmission rates occurred within the first 30 days of hospital discharge for each discharge setting. From 1 to 30 days, postoperative and post-traumatic infections were among the top causes for readmission in all 3 discharge settings. From 31 to 60 days, postoperative or traumatic infections remained in the top 5-7 reasons for readmission in all settings, but they were not in the top 10 at 61 to 90 days. ConclusionsPatients discharged to either SNF or IRF, in comparison with those discharged to the community, had greater likelihood of readmission within 30 and 90 days. The reasons for readmission were relatively consistent across discharge settings and time periods. These findings provide new information relevant to the delivery of postacute care to older adults following TKA.

Comprehensive Overview of Nursing and Interdisciplinary Rehabilitation Care of the Stroke Patient

In the United States, the incidence rate of new or recurrent stroke is approximately 795 000 per year, and stroke prevalence for individuals over the age of 20 years is estimated at 6.5 million.1 Mortality rates in the first 30 days after stroke have decreased because of advances in emergency medicine and acute stroke care. In addition, there is strong evidence that organized postacute, inpatient stroke care delivered within the first 4 weeks by an interdisciplinary healthcare team results in an absolute reduction in the number of deaths.2,3 Despite these positive achievements, stroke continues to represent the leading cause of long-term disability in Americans: An estimated 50 million stroke survivors worldwide currently cope with significant physical, cognitive, and emotional deficits, and 25% to 74% of these survivors require some assistance or are fully dependent on caregivers for activities of daily living (ADLs).4,5 Notwithstanding the substantial progress in acute stroke care over the past 15 years, the focus of stroke medical advances and healthcare resources has been on acute and subacute recovery phases, which has resulted in substantial health disparities in later phases of stroke care. Additionally, healthcare providers (HCPs) are often unaware of not only patients’ potential for improvement during more chronic recovery phases but also common issues that stroke survivors and their caregivers experience. Furthermore, even with evidence that documents neuroplasticity potential regardless of age and time after stroke,6 the mean lifetime cost of ischemic stroke (which accounts for 87% of all strokes) in the United States is an estimated $140 000 (for inpatient, rehabilitation, and follow-up costs), with 70% of first-year stroke costs attributed to acute inpatient hospital care1; therefore, fewer financial resources appear to be dedicated to providing optimal care during the later phases of stroke recovery. Because there remains a …

Projecting Function of Stroke Patients in Rehabilitation Using the AlphaFIM Instrument in Acute Care

(1) To establish the reliability and validity of the AlphaFIM instrument; (2) To examine the hypotheses that the 6-item AlphaFIM instrument administered in acute care would closely approximate the full 18-item FIM instrument rating administered at admission to an inpatient rehabilitation facility (IRF); (3) to determine whether the acute AlphaFIM projected rating could predict the full FIM instrument ratings at discharge from the IRF; (4) to test whether the acute AlphaFIM projected rating could predict length of stay (LOS) in the IRF; (5) to determine if the acute AlphaFIM projected rating could predict the likelihood of patients being discharged from the IRF to the community. A prospective cohort study of 144 stroke patients in an acute care stroke unit with subsequent transfer to an IRF. None. IRF admission FIM rating, IRF discharge FIM ratings, LOS, and likelihood of discharge to community. The AlphaFIM instrument displayed adequate reliability and validity. Results of a linear regression showed the acute AlphaFIM instrument ratings were significant in predicting IRF admission FIM instrument ratings, IRF discharge FIM instrument ratings, and IRF LOS. Results of a logistic regression indicated the ability of the acute AlphaFIM instrument ratings to predict the likelihood of patients being discharged from the IRF to the community was statistically significant but did not account for a great deal of the variance in the model. The AlphaFIM instrument, used in acute care, has utility in projecting FIM instrument ratings of stroke patients' function at admission to and discharge from the IRF.