Postacute Care Rehabilitation Research Articles

The design elements of outpatient geriatric rehabilitation from patient, healthcare professional, and organizational perspective; a qualitative study

Purpose To gain a rich understanding of the experiences and opinions of patients, healthcare professionals, and policymakers regarding the design of OGR with structure, process, environment, and outcome components. Methods Qualitative research based on the constructive grounded theory approach is performed. Semi-structured interviews were conducted with patients who received OGR (n = 13), two focus groups with healthcare professionals (n = 13), and one focus group with policymakers (n = 4). The Post-acute Care Rehabilitation quality framework was used as a theoretical background in all research steps. Results The data analysis of all perspectives resulted in seven themes: the outcome of OGR focuses on the patient’s independence and regaining control over their functioning at home. Essential process elements are a patient-oriented network, a well-coordinated dedicated team at home, and blended eHealth applications. Additionally, closer cooperation in integrated care and refinement regarding financial, time-management, and technological challenges is needed with implementation into a permanent structure. All steps should be influenced by the stimulating aspect of the physical and social rehabilitation environment. Conclusion The three perspectives generally complement each other to regain patients’ quality of life and autonomy. This study demonstrates an overview of the building blocks that can be used in developing and designing an OGR trajectory.

The cutoff values of functional independence measure scores for predicting discharge destination in the early stroke phase.

This study aimed to determine cutoff values of functional independence measure (FIM) scores to predict the discharge destinations of patients with acute stroke. The sample included 318 patients with acute stroke (mean age, 72.0 years; women, 39%). The discharge destination was categorized into three groups: home, postacute rehabilitation (hospital with convalescent rehabilitation wards), and postacute care (institution without convalescent rehabilitation wards). We assessed FIM after lifting bed restriction. Multinomial logistic regression analyses were used to estimate odds ratios (OR) and 95% confidence intervals (CI) of the FIM scores for predicting discharge destinations, with postacute rehabilitation as a reference. Cutoff values of motor and cognitive FIM scores for distinguishing home from postacute rehabilitation and postacute care from postacute rehabilitation were determined using receiver operating characteristic curves. The proportion of home, postacute rehabilitation, and postacute care were 34.6%, 41.8%, and 23.6%, respectively. After adjustments for clinical variables, the ORs (95% CIs) for motor and cognitive FIM scores for home versus postacute rehabilitation were 1.08 (1.04-1.11) and 1.05 (0.98-1.12). Furthermore, those for postacute care versus postacute rehabilitation were 1.01 (0.98-1.04) and 0.92 (0.87-0.98). The cutoff values of the motor and cognitive FIM scores for distinguishing home from postacute rehabilitation were 37.5 (sensitivity: 0.92; specificity: 0.64) and 23.5 (sensitivity: 0.78; specificity: 0.67). Furthermore, those for distinguishing postacute care from postacute rehabilitation were 15.5 (sensitivity, 0.81; specificity, 0.51) and 12.5 (sensitivity, 0.74; specificity, 0.64). The identified cutoff values may serve as early indicators for predicting discharge destinations from acute stroke care.

Does post acute care reduce the mortality of octogenarian and nonagenarian patients undergoing hip fracture surgery?

With the increasing number of elderly individuals worldwide, a greater number of people aged 80years and older sustain fragility fracture due to osteopenia and osteoporosis. This retrospective study included 158 older adults, with a median age of 85 (range: 80-99) years, who sustained hip fragility fracture and who underwent surgery. The patients were divided into two groups, one including patients who joined the post-acute care (PAC) program after surgery and another comprising patients who did not. The mortality, complication, comorbidity, re-fracture, secondary fracture, and readmission rates and functional status (based on the Barthel index score, numerical rating scale score, and Harris Hip Scale score) between the two groups were compared. The patients who presented with fragility hip fracture and who joined the PAC rehabilitation program after the surgery had a lower rate of mortality, readmission rate, fracture (re-fracture and secondary fracture), and complications associated with fragility fracture, such as urinary tract infection, cerebrovascular accident, and pneumonia (acute coronary syndrome, out-of-hospital cardiac arrest, or in-hospital cardiac arrest. PAC is associated with a lower rate of mortality and complications such as urinary tract infection, bed sore, and pneumonia in octogenarian and nonagenarian patients with hip fragility fracture.

Abstract TP118: Development and Integration of a Dedicated Neurorehabilitation Space Within a Hospital-Based Stroke Unit

Background: It is well documented that rehabilitation post-stroke is associated with better functional outcomes, however, in the United States access to post-acute care rehabilitation is becoming increasingly limited. The Office of the Inspector General recently reported that 13% of Medicare beneficiaries were denied access by some Medicare Advantage Organizations to medically necessary care, including admission to inpatient rehabilitation facilities (IRF). Further, the Centers for Medicare and Medicaid Services have initiated the Review Choice Demonstration (RCD) for IRF Services in several states which is anticipated to further reduce access to post-acute care rehabilitation. In response, when our institution began planning for a new neuroscience unit, the decision was made to build a dedicated neurorehabilitation space. The purpose of this project was to design a space that would increase patient access to high quality, intensive neurorehabilitation in the hospital setting. Methods: To maximize utilization and effectiveness of the space, the neurorehabilitation staff were involved in the design of the layout and the selection of appropriate equipment, and participated in several training sessions. One year after opening, the neurorehabilitation staff were surveyed about their access to necessary equipment, and their perception of the effects different features of the space had on the quality of their treatment sessions. Results: Of the 20 surveys completed, the percentage of staff who reported they had the necessary equipment increased from 35% to 100%, and 90% of the space’s features had a favorable effect on the quality of the treatment sessions. Additionally, 95% of staff reported that the overall time spent with each patient increased and overall job satisfaction improved from 60% to 85%. Conclusion: A dedicated rehabilitation space was developed to better meet the needs of the neurorehabilitation staff, and to improve patient access to neurorehabilitation in the hospital setting. Survey results suggested that job satisfaction and staff’s perception of therapy quality improved after opening the new space.

SYSTEMATIC REVIEW OF REHABILITATION IN SKILLED NURSING FACILITIES FOR PERSONS LIVING WITH DEMENTIA

Abstract We conducted a systematic review of published literature though April 2023 to identify the experiences and outcomes of persons living with dementia (PLWD) undergoing post-acute care rehabilitation in skilled nursing facilities (SNF). A systematic search for studies published in English was carried out in eight databases including PubMed, Scopus, Google Scholar, Embase, PsycINFO, CINAHL, Cochrane Library, and Web of Science. Two reviewers independently screened articles and conducted a quality appraisal of selected studies. Forty-one articles met inclusion criteria. There was heterogeneity of study designs with most articles (n=33) being observational and cross-sectional, while randomized clinical trials (n=3) and qualitative studies (n=5) were less represented. Certain themes emerged from the results regarding patient outcomes and experiences. Measured outcomes demonstrated increased health service utilization, varied functional outcomes, and suboptimal patient care. Patient experiences included significant challenges with health care transitions, gaps in healthcare worker and caregiver knowledge & education, emphasis on alternate models of care, and importance of goal alignment. Overall, this systematic review provides a comprehensive understanding of the outcomes and experiences of post-acute care rehabilitation in SNFs for PLWD. The findings highlight the need for alternative care pathways, improved healthcare transitions, tailored rehabilitation approaches, enhanced dementia training for healthcare professionals, and person-centered goal setting. By addressing these critical aspects, future interventions can be developed to improve the delivery of post-acute care for PLWD and enhance their health outcomes.

Development and Evaluation of Rehabilitation Service Areas for the United States

BackgroundGeographic areas have been developed for many healthcare sectors including acute and primary care. These areas aid in understanding health care supply, use, and outcomes. However, little attention has been given to developing similar geographic tools for understanding rehabilitation in post-acute care. The purpose of this study was to develop and characterize post-acute care Rehabilitation Service Areas (RSAs) in the United States (US) that reflect rehabilitation use by Medicare beneficiaries.MethodsA patient origin study was conducted to cluster beneficiary ZIP (Zone Improvement Plan) code tabulation areas (ZCTAs) with providers who service those areas using Ward’s clustering method. We used US national Medicare claims data for 2013 to 2015 for beneficiaries discharged from an acute care hospital to an inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), long-term care hospital (LTCH), or home health agency (HHA). Medicare is a US health insurance program primarily for older adults. The study population included patient records across all diagnostic groups. We used IRF, SNF, LTCH and HHA services to create the RSAs. We used 2013 and 2014 data (n = 2,730,366) to develop the RSAs and 2015 data (n = 1,118,936) to evaluate stability. We described the RSAs by provider type availability, population, and traveling patterns among beneficiaries.ResultsThe method resulted in 1,711 discrete RSAs. 38.7% of these RSAs had IRFs, 16.1% had LTCHs, and 99.7% had SNFs. The number of RSAs varied across states; some had fewer than 10 while others had greater than 70. Overall, 21.9% of beneficiaries traveled from the RSA where they resided to another RSA for care.ConclusionsRehabilitation Service Areas are a new tool for the measurement and understanding of post-acute care utilization, resources, quality, and outcomes. These areas provide policy makers, researchers, and administrators with small-area boundaries to assess access, supply, demand, and understanding of financing to improve practice and policy for post-acute care in the US.

Medical Leadership in Inpatient Rehabilitation Facilities in the United States.

Inpatient rehabilitation facilities treat patients with extensive postacute care rehabilitation needs. Physiatrists are uniquely trained in the complexities of such patients; however, not all inpatient rehabilitation facilities use physiatrists as medical leadership. This study identifies the training background and credentials of medical directors in all inpatient rehabilitation facilities within the United States. Using Internet search, e-mail, and telephone communication, the following data were collected: medical director credential and specialty information, board certification rates and years of practice experience, as well as bed numbers for each inpatient rehabilitation facilities listed on The Centers for Medicare and Medicaid Services Website. Data were collected between November 2019 and November 2020. Of the 1114 open facilities, 85% have medical directors with a doctor of medicine degree, while 13% have a doctor of osteopathic medicine degree. Two percent reported no physician medical director. Physiatry is the most common specialty (80%), followed by internal medicine, family medicine, neurology, orthopedic surgery, general surgery, and medicine/pediatrics. The mean number of beds per facility is 35.6 (median, 24; range, 4-350). There is an average of 11.4 inpatient rehabilitation facility beds per 100,000 people nationally. Physiatry is the predominant specialty to fulfill medical leadership at inpatient rehabilitation facilities, although there remains room for growth. In addition, doctor of medicine degrees greatly outnumber doctor of osteopathic medicine degrees in medical leadership.

Association of Social Determinants of Health Measures and Successful Community Discharge Across Rehabilitation Service Areas

<h3>Research Objectives</h3> Evaluate: 1) variation in successful community discharge across Rehabilitation Service Areas (RSAs) nationally, and 2) the relationship between social determinants of health (SDH) variables/indices and successful community discharge across RSAs. <h3>Design</h3> Retrospective cross-sectional analysis of Centers for Medicare & Medicaid Services (CMS) and AHRQ SDH dataset. We performed maximum likelihood factor analysis with varimax rotation and principled mean analysis to identify how many factors to extract from the AHRQ-SDH dataset and calculated a rehabilitation-specific SDH measure (SDH-R) based on these factors and variables. Next, we calculated the Social Deprivation Index (SDI) and the SDH-R for a random sample of 800 RSAs and examined the association between SDI and SDH-R and successful community discharge. <h3>Setting</h3> We examined discharges following post-acute care from long-term care hospitals, home health agencies, and skilled nursing and inpatient rehabilitation facilities. <h3>Participants</h3> The population included 2013–2015 Medicare records from fee-for-service beneficiaries >65 years. The cohort included 2,287,210 records across all diagnostic groups. <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> Successful community discharge across the 1711 RSAs nationally using CMS quality measure specifications. <h3>Results</h3> The national average for successful community discharge across RSAs was 55.1%. The pattern of successful community discharge indicates the majority of RSAs(1239, 72.4%) perform at the national average for successful community discharge with 253 RSAs (14.8%) significantly below and 219(12.8%) significantly above the national average. Factor analysis with AHRQ-SDH variables identified five factors with eigenvalues >1.0. The resultant model explained 23.1% of the variation in successful community discharge. The SDH-R model performed significantly better than the SDI (RMSE:SDH-R=0.88 vs SDI=0.99). <h3>Conclusions</h3> Successful community discharge varied across RSAs nationally. We identified SDH variables related to successful community discharge following rehabilitation. More research is needed to understand how SDH impacts community discharge across high- and low-performing RSAs and explore disparities and equity issues related to successful community discharge following post-acute care rehabilitation. <h3>Author(s) Disclosures</h3> This work was supported by the Agency for Healthcare Research and Quality (AHRQ) R01-HS024711 (TR,JP,AH,YK,KE), T32-HS026133 (YK,JD). All authors declare no conflicts.

What Determinants Affect Inpatient Satisfaction in a Post-Acute Care Rehabilitation Hospital?

ObjectiveTo examine how specific hospital service domains (personal issues domain, discharge domain, rehabilitation doctor domain, nursing domain, physical therapist domain, occupational therapist domain, and food domain) influence final patient satisfaction scores, the overall quality of care, and willingness to recommend the hospital to others among patients in an inpatient rehabilitation hospital. DesignLongitudinal study. SettingPatient-level data from electronic medical records were joined with Press Ganey (www.pressganey.com) satisfaction data for a single post-acute care inpatient rehabilitation facility in northeast Florida. ParticipantsPatients who participated in the inpatient rehabilitation survey (N=4,785). InterventionsNot applicable. Main Outcome MeasuresMain outcome measures included final patient satisfaction scores, overall rating of care during the stay, and willingness to recommend the hospital to others. ResultsThis study found the personal issues domain to be the most important factor in determining the final patient satisfaction score, overall rating of care, and likelihood to recommend the hospital to others, followed by the physical therapist, nurse, discharge, and food domains (P<.0001). Within the personal issues domain score, staff promptness and explanation upon arrival were areas identified as opportunities to make improvements that would result in the greatest positive effect. ConclusionsThis work represents novel findings by investigating the major determinants of positive patient experience in a rehabilitation hospital setting. These findings provide actionable information to improve patient experience as well as where to focus improvement efforts using limited resources.

A multicenter study to compare the effectiveness of the inpatient post acute care program versus traditional rehabilitation for stroke survivors

There is insufficient evidence to prove the effect of the Post-acute Care (PAC) program on post-stroke recovery. This study aimed to determine the effectiveness of the PAC versus traditional inpatient rehabilitation (non-PAC) for middle- and old-aged stroke survivors. This multicenter cohort study enrolled 334 stroke patients admitted for post-stroke rehabilitation. The outcome variables included the Barthel Index (BI), Functional Oral Intake Scale (FOIS), Mini Nutritional Assessment-Short Form (MNA-SF), EuroQoL-5D (EQ-5D), Lawton–Brody Instrumental Activities of Daily Living (ADL) Scale, and Mini-Mental State Examination (MMSE). The inverse-probability-of-treatment-weighting method was used to analyze the differences in outcomes between the PAC and non-PAC groups. The PAC group showed better improvements in BI, MNA-SF, EQ-5D, Instrumental ADL, and MMSE compared to the non-PAC group, with differences in effect sizes of 0.54 (95% confidence interval [CI] 0.38–0.71), 0.26 (95% CI 0.10–0.42), 0.50 (95% CI 0.33–0.66), 0.44 (95% CI 0.28–0.60) and 0.34 (95% CI 0.17–0.50), respectively. The PAC project showed more improvement in basic and instrumental ADL and status of swallowing, nutrition, and cognition than those of non-PAC, which had less length of stay restricted by the National Health Insurance. More studies are warranted to investigate the influence of hospital stay and duration from stroke onset on the PAC’s effectiveness.

Recovery of walking ability in stroke patients through postacute care rehabilitation

BackgroundWalking entails orchestration of the sensory, motor, balance, and coordination systems, and walking disability is a critical concern after stroke. How and to what extent these systems influence walking disability after stroke and recovery have not been comprehensively studied. MethodsWe retrospectively analyzed patients with stroke in the Post-acute care-Cerebrovascular Diseases (PAC-CVD) program. We compared the characteristics of patient groups stratified by their ability to complete the 5-m walk test across various time points of rehabilitation. We then used stepwise linear regression to examine the degree to which each stroke characteristic and functional ability could predict patient gait performance. ResultsFive hundred seventy-three patients were recruited, and their recovery of walking ability was defined by the timing of recovery in a 5-m walk test. The proportion of patients who could complete the 5-m walk test at admission, at 3 weeks of rehabilitation, at 6 weeks of rehabilitation, between 7 and 12 weeks of rehabilitation, and who could not complete the 5-m walk test after rehabilitation was 52.2%, 21.8%, 8.7%, 8.7%, and 8.6%, respectively. At postacute care discharge, patients who regained walking ability earlier had a higher chance of achieving higher levels of walking activity. Stepwise linear regression showed that Berg Balance Scale (BBS) (β: 0.011, p < .001), age (β: −0.005, p = .001), National Institutes of Health Stroke Scale (NIHSS) (6a + 6b; β: −0.042, p = .018), Mini-Nutritional assessment (MNA) (β: −0.007, p < .027), and Fugl–Meyer upper extremity assessment (FuglUE) (β: 0.002, p = .047) scores predicted patient's gait speed at discharge. ConclusionBalance, age, leg strength, nutritional status, and upper limb function before postacute care rehabilitation are predictors of walking performance after stroke.

Abstract TP121: Examination Of Initial NIHSS And Discharge Disposition In Patients Hospitalized With Acute Ischemic Stroke

Introduction: Acute ischemic stroke (AIS) patients require post-acute care (PAC) rehabilitation that is consistent with degree of stroke deficit. Appropriate PAC disposition for AIS patients varies widely. We examine the relationship between initial National Institutes of Health Stroke Scale (NIHSS) and discharge disposition to determine if stroke severity is associated with disposition. Methods: In our IRB-approved database, consecutive Emergency Department stroke code activations with confirmed diagnosis of AIS were retrospectively analyzed from January 2004-May 2021 at UC San Diego. Patients were grouped into mild (NIHSS 0-5), moderate (NIHSS 6-14), and severe (NIHSS &gt;14) stroke. Outcome variables were PAC disposition: Home, Inpatient Rehab Facility (IRF), Skilled Nursing Facility (SNF), Expired, and Other. Chi-squared and Kruskal-Wallis followed by pairwise proportion tests were used for analysis. Analyses were adjusted for age, sex, baseline modified Rankin score (mRS), and acute stroke treatment. Results: Total 2316 patients were included for analysis. There was a difference between initial stroke severity and discharge disposition overall (p&lt;0.001). (Table 1). Mild stroke patients had less discharges to IRF, SNF, Expired, or Other compared to moderate (p&lt;0.001) and severe (p&lt;0.001) strokes. There was no difference between moderate and severe stroke patients discharged to IRF (p=0.44) or SNF (p=0.48). Age, baseline mRS, and receiving acute stroke treatment were independent predictors for discharge to home, IRF, and SNF. Baseline mRS was an independent predictor for Expired patients. Conclusion: Patients with mild strokes are discharged home more than moderate and severe strokes, but there was no difference between moderate and severe stroke patients discharged to either IRF or SNF. This suggests PAC disposition is not consistent with stroke severity and further studies are needed to investigate other factors related to final disposition.

26 A COLLABORATIVE QUALITY IMPROVEMENT PROJECT BETWEEN AN NHS TRUST AND INDEPENDENT PROVIDER TO DEVELOP A CARE-HOME SPECIFIC ELECTRONIC NURSING HANDOVER

BackgroundThe COVID19 pandemic highlighted deficiencies in information exchange in nursing handover in an intermediate care unit, based in a 30 bed independent care home, into which the hospital organisation assigns a multidisciplinary team to provide post-acute care rehabilitation for adults. Mean length of stay is 20 days and > 75% return home. Weekly bed turnover is approximately 15%. A revised electronic template was developed to complement an Intermediate Care Framework already in use, based on National Audit of Intermediate Care quality indicators.MethodsSemi-structured interviews with nursing leaders and a weighted questionnaire for the whole nursing team were used to determine baseline levels of confidence around aspects of nursing handover.An Ishikawa diagram analysed factors contributing to poor documentation and communication. The ‘Chain Of Care’ vision for care home environments incorporated the need for microsystem-tailored, standardised, integrated nursing handover. Four iterations occurred. A post-implementation weighted questionnaire collated qualitative information on confidence change.ResultsAreas of greatest ‘swing’ towards INCREASED or SLIGHTLY INCREASED confidence around...: 70%, addressing questions from residents or relatives; 70%, responding to change in a resident’s health status; 70%, giving handover to ambulance crew or doctor or fellow nurse.ConclusionCategorical selections across multiple information domains enabled increased/slightly increased confidence in the nursing team in the quality of the information exchanged in nursing handover in an intermediate care rehabilitation care-home setting. Focussed, free-text options permit narrative if required.A shared electronic template facilitated accessibility and live-time editing in an environment with relatively higher bed-turnover and frequently changing functional mobility and care needs of residents.Tailoring the nursing handover to the intermediate care environment with mitigation of variation of information provision/accessibility/language were considered in the iterations. Versions are reposited for inspectors.

28 A COLLABORATIVE QUALITY IMPROVEMENT PROJECT BETWEEN AN NHS TRUST AND INDEPENDENT PROVIDER TO DEVELOP A CARE-HOME SPECIFIC MULTIDISCIPLINARY SAFETY BRIEF

BackgroundThe COVID19 pandemic highlighted deficiencies in interdisciplinary risk-communication in an intermediate care unit, based in a 30 bed independent care home, into which the hospital organisation assigns medical, pharmacy, physiotherapy, occupational therapy and social work teams to provide post-acute care rehabilitation for adults. Mean length of stay is 20 days and > 75% return home. Weekly bed turnover is approximately 15%.MethodsSemi-structured interviews with nursing leaders and a weighted questionnaire for multidisciplinary team were used to determine baseline levels of confidence around environmental and resident-specific risk awareness.An Ishikawa diagram analysed factors contributing to risk-communication. The ‘Chain Of Care’ vision for care home environments incorporated a Multidisciplinary Safety Brief. Five iterations occurred before reaching standardisation. A post-implementation weighted questionnaire collated qualitative information on confidence change.The Safety Brief supplements intra-professional group handover processes. Duration ranged 90-120 seconds, occurring at shift commencement and 12.00 h daily. Retained documentation is available for inspectors.ResultsThe Safety Brief as a communication tool: 86% of the team found it useful; 71% found that it had the ‘right amount’ of detail; and 62% found that it was of the ‘right duration’.Areas of greatest ‘swing’ towards INCREASED or SLIGHTLY INCREASED confidence in awareness of...: 72%, deaths in last 24 hours; 68%, planned discharges today; 67%, residents at risk of falling/had fallen within 48 hours; 67%, residents with same name; 66%, bed-availability; 63%, infection risks; 62%, experiencing delirium; 62%, living with dementia; 59%, scheduled appointments today; and 52%, those receiving palliative care.ConclusionA Multidisciplinary Safety Brief increased/slightly increased multidisciplinary team confidence in environmental and resident-specific risks in a care home environment. Risk-communication in any environment is complex especially if subject to frequent change. Communication tools need to be tailored to microsystem, systematic, comprehensive, yet brief and intuitive. Generalisability to non-intermediate care, non-geriatrician supported care home environments was considered iteratively.

Use of an iPad App (Aid for Decision-making in Occupational Choice) for Collaborative Goal Setting in Interprofessional Rehabilitation: Qualitative Descriptive Study.

BackgroundGoal setting is a key part of the rehabilitation process. The use of technology and electronic tools such as smartphone apps and websites has been suggested as a way of improving the engagement of users in meaningful goal setting and facilitating shared decision-making between patients and health professionals.ObjectiveThis study aims to describe experiences of health professionals and patients in the use of the English language version of the iPad app Aid for Decision-making in Occupational Choice (ADOC) to facilitate collaborative goal setting in rehabilitation.MethodsWe recruited participants from 3 acute and postacute care rehabilitation wards in both public and private organizations in New Zealand. Participants were registered allied health professionals, including physiotherapists, occupational therapists, and speech-language therapists, who engage in goal setting as part of their normal work, and their adult patients. We collected data via semistructured interviews to gather information about the experiences of the participants in the use of ADOC for goal setting. Data were analyzed with thematic analysis.ResultsA total of 8 health professionals and 8 patients participated in the study. Six main themes emerged from the data: changing patients’ perspective on what is possible, changing health professionals’ perspective on what is important, facilitating shared decision-making, lack of guides for users, logistic and organizational barriers, and app-related and technical issues.ConclusionsHealth professionals and patients found ADOC to be a valuable tool when setting shared rehabilitation goals. The use of ADOC promoted a patient-centered approach that empowered patients to engage in collaborative goal setting. The technological limitations of the app that negatively impacted experiences can be addressed in the future implementation of ADOC in rehabilitation settings.

27 A COLLABORATIVE QUALITY IMPROVEMENT PROJECT BETWEEN AN NHS TRUST AND INDEPENDENT PROVIDER TO DEVELOP A CARE-HOME SPECIFIC TREATMENT ESCALATION PLAN

BackgroundThe COVID19 pandemic highlighted deficiencies in information exchange around treatment escalation plans (TEP) in an intermediate care unit, based in a 30 bed independent care home, into which the hospital organisation assigns medical, pharmacy, physiotherapy, occupational therapy and social work teams to provide post-acute care rehabilitation for adults. Mean length of stay is 20 days and > 75% return home. Weekly bed turnover is approximately 15%.TEP documentation is a component of RESTORE2 use, as recommended in the British Geriatric Society Good Practice Guide for Managing COVID19 in Care Homes.MethodsSemi-structured interviews with nursing leaders and a weighted questionnaire for the whole nursing team were used to determine baseline levels of confidence around aspects of TEP.An Ishikawa diagram analysed factors contributing to poor documentation and communication. The ‘Chain Of Care’ vision for care home environments incorporated the need for a TEP. Three iterations occurred. A post-implementation weighted questionnaire collated qualitative information on confidence change.ResultsAreas of greatest ‘swing’ towards INCREASED or SLIGHTLY INCREASED confidence around...: 90%, Cardiopulmonary Resuscitation (CPR) status clarity; 90%, treatment ‘ceiling of care’ e.g. ‘conveyance to the Emergency Department in any situation that the clinical team deem necessary’; 40%, conversations with out-of-hours services/external clinicians around appropriate actions; 30%, conversations with nominated persons around appropriate actions.ConclusionThe TEP incorporates more than just CPR status and contributed to increased nursing team confidence in responding to the acutely deteriorating adult appropriately in a care home environment. Clear documentation of: capacity assessment; patient prioritisation (using ReSPECT principles); and agreed treatment escalation and limitation, enabled information exchange. Standardisation of language, and cross-fertilisation with Nursing Handover, facilitated conversations with external clinicians and nominated persons.Tailoring the TEP to the care-home environment and rendering it generalisable to non-intermediate care, non-geriatrician supported care home microsystems was considered in the iterations.

Psychometric evaluation of the Hopkins Rehabilitation Engagement Rating Scale in postacute physical therapy services.

Evaluate the reliability and validity of the Hopkins Rehabilitation Engagement Scale (HRERS) in a postacute rehabilitation sample. We hypothesized that HRERS items would comprise a single factor, and would demonstrate adequate internal consistency and temporal stability, and significant relationships with key constructs. Research Method and Design: Retrospective medical record review between 2016 and 2017 of older veterans (N = 107) admitted to a community living center postacute care (CLC-PAC) rehabilitation hospital unit to address targeted physical therapy rehabilitation goals. Inclusion criteria included availability of two HRERS administrations at Time 1 (admission) and Time 2 (approximately one-month follow-up or physical therapist/CLC-PAC discharge). Across timepoints, HRERS items reflect a single factor of engagement, and the scale has good internal consistency at admission (Time 1, α = .759) and follow-up (Time 2, α = .877). The temporal stability of HRERS across ratings was r = .56 (p < .001). Increased pain rating (r = -.309, p < .01) and depressive symptoms (-.287, p < .01) at admission correlates with subsequent physical therapist (PT) engagement (HRERS Time 2). Low admission PT engagement correlates with less frequent PT attendance (r = -.242, p < .01) and greater number of consults placed during the CLC stay (r = -.222, p < .05). HRERS is a reliable and valid measure of PT engagement in older CLC-PAC Veterans. Findings support the administration of the HRERS at more than one timepoint during rehabilitation to inform interventions targeting select behavioral health factors such as pain and depression. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Role of ADL Independence in Postacute-Care Rehabilitation Service Needs in the Elderly Abdominal Surgery Population

Abstract Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations. More than half of all surgical patients are age 65 and older, and research suggests that a majority of these patients will require postacute-care (PAC) rehabilitation services. Despite the growing costs, characteristics related to requiring PAC in the elderly abdominal surgery population are not well studied. This project aims to describe discharge trends, as well as factors related to requiring placement at a skilled-nursing facility in the elderly abdominal surgery population. Primary Author and Speaker: Erika Dobson Contributing Authors: Rebecca Julian, Hailey Zanette

Occupational Therapy in Postacute Care for Survivors of COVID-19: Research Gaps We Need to Fill.

This column discusses issues in the delivery of postacute care (PAC) rehabilitation services for coronavirus disease 2019 (COVID-19) survivors and gaps in the current research. Occupational therapy practitioners must not only better understand factors that influence the type of PAC rehabilitation a COVID-19 survivor will receive but also comprehend how wide variations in delivery of PAC occupational therapy have affected important outcomes for survivors. The COVID-19 Rehabilitation Research Framework, developed by Cochrane Rehabilitation and the World Health Organization Rehabilitation Program, offers a guide for occupational therapy research priorities that may fill two important gaps: (1) the need for high-quality PAC rehabilitation studies and (2) the need for research on activity and participation assessments and outcomes for COVID-19 survivors. Using electronic health records and other data sources, occupational therapy practitioners and researchers can help build the evidence base to support and guide PAC rehabilitation for survivors of COVID-19 and, perhaps, future pandemics.

Identifying patients at risk for nonroutine discharge after surgery for cervical myelopathy: an analysis from the Quality Outcomes Database.

Optimizing patient discharge after surgery has been shown to impact patient recovery and hospital/physician workflow and to reduce healthcare costs. In the current study, the authors sought to identify risk factors for nonroutine discharge after surgery for cervical myelopathy by using a national spine registry. The Quality Outcomes Database cervical module was queried for patients who had undergone surgery for cervical myelopathy between 2016 and 2018. Nonroutine discharge was defined as discharge to postacute care (rehabilitation), nonacute care, or another acute care hospital. A multivariable logistic regression predictive model was created using an array of demographic, clinical, operative, and patient-reported outcome characteristics. Of the 1114 patients identified, 11.2% (n = 125) had a nonroutine discharge. On univariate analysis, patients with a nonroutine discharge were more likely to be older (age ≥ 65 years, 70.4% vs 35.8%, p < 0.001), African American (24.8% vs 13.9%, p = 0.007), and on Medicare (75.2% vs 35.1%, p < 0.001). Among the patients younger than 65 years of age, those who had a nonroutine discharge were more likely to be unemployed (70.3% vs 36.9%, p < 0.001). Overall, patients with a nonroutine discharge were more likely to present with a motor deficit (73.6% vs 58.7%, p = 0.001) and more likely to have nonindependent ambulation (50.4% vs 14.0%, p < 0.001) at presentation. On multivariable logistic regression, factors associated with higher odds of a nonroutine discharge included African American race (vs White, OR 2.76, 95% CI 1.38-5.51, p = 0.004), Medicare coverage (vs private insurance, OR 2.14, 95% CI 1.00-4.65, p = 0.04), nonindependent ambulation at presentation (OR 2.17, 95% CI 1.17-4.02, p = 0.01), baseline modified Japanese Orthopaedic Association severe myelopathy score (0-11 vs moderate 12-14, OR 2, 95% CI 1.07-3.73, p = 0.01), and posterior surgical approach (OR 11.6, 95% CI 2.12-48, p = 0.004). Factors associated with lower odds of a nonroutine discharge included fewer operated levels (1 vs 2-3 levels, OR 0.3, 95% CI 0.1-0.96, p = 0.009) and a higher quality of life at baseline (EQ-5D score, OR 0.43, 95% CI 0.25-0.73, p = 0.001). On predictor importance analysis, baseline quality of life (EQ-5D score) was identified as the most important predictor (Wald χ2 = 9.8, p = 0.001) of a nonroutine discharge; however, after grouping variables into distinct categories, socioeconomic and demographic characteristics (age, race, gender, insurance status, employment status) were identified as the most significant drivers of nonroutine discharge (28.4% of total predictor importance). The study results indicate that socioeconomic and demographic characteristics including age, race, gender, insurance, and employment may be the most significant drivers of a nonroutine discharge after surgery for cervical myelopathy.