Post-acute Rehabilitation Facilities Research Articles

Trends and Factors Associated With Extremity Fractures and Post-Acute Care Utilization of Nevada Older Adults: Insights of Age-Friendly State Planning in U.S.

Along with the trend of a steady utilization decline in the U.S. nursing home beds, post-acute care (PAC) utilization at the skilled nursing facilities has declined. This study was a cross-sectional, retrospective review of hospital discharge-based claim data. We evaluate the factors associated with utilizing post-acute care at rehabilitation facilities among those with extremity fractures in the state of Nevada. All Nevada hospital discharges of aged ≥65 years with extremity fractures between 2018 and 2021 were divided to post-acute care locations by (1) rehabilitation facilities (skilled nursing facility and inpatient rehabilitation facility) and (2) homes (with and without services). PAC utilization at facilities declined from 55.1% in 2018 to 49.7% in 2021 (P < .001). In response, PAC utilization at homes continuously upwards, particularly, homes with services from 18.8% in 2018 to 24.5% in 2021 (P < .001). Older age, female, lower extremity fractures, comorbidities, and Medicare beneficiaries were associated with higher probabilities of utilizing post-acute rehabilitation facilities. Racial minorities, COVID-19 pandemic, upper extremities, Medicaid beneficiaries, rural hospitals, and prolonged hospital length of stay were associated with lower probabilities of PAC utilization at facilities. Caregiver burdens and workforce training is urgently warranted to respond to this utilization shift. Effective geriatrics workforce training might advance care efficiency of older adults with extremity fractures and guide to the insights of establishing the age-friendly state of Nevada in response to this utilization shift trends.

42 Utilizing FAB Scores to Determine Next Level of Care for Patients with Burn Injury

Abstract Introduction Determining next level of care for burn patients is a difficult task for the entire medical team. Secondary to the nature of the injury, patients often do not have the social or economic support required to return to their prior level of function. The Functional Assessment for Burns (FAB) score has been shown an objective measure to determine functional independence and a predictor of discharge outcomes in adults. However, it is undetermined whether this assessment can be utilized to guide next level of care and time which it takes to return to prior level of function. We hypothesized the number of therapy sessions to be positively associated with patients’ return to baseline FAB. Methods This single center, retrospective study of patients admitted to a single ABA-verified burn center was completed by collecting FAB assessment scores within 48 hours of admission and within 48 hours of discharge over the last year. Demographics, injury characteristics, surgical procedures, and number of treatment sessions were collected. Shapiro-wilk test was utilized to test for normality. Regression analysis was utilized to analyze variable associations with changes in FAB scores. A paired t test was used to compare paired FAB scores between admission and discharge. Results One-hundred patients were included with a median age of 53 (38.5, 64) years and 7 (3.5, 14) percent total body surface area burned (TBSA). The median FAB for preadmission (preadm.), admission (adm.), and discharge (DC) were 35 (35, 35), 17 (14, 24), and 24 (19, 32), respectively. The paired difference between adm. and DC scores (&amp;lt; 0.001) indicated significant improvement. TBSA and age, together, were significant predictors of change in preadm. to adm. FAB (r2=0.202, p&amp;lt; 0.001). Adm. FAB and TBSA were both associated with number of therapy sessions. Only 16% of patients returned to preadm. level of functional independence by discharge with only 20% qualifying for / entering a post-acute inpatient rehabilitation facility. Number of combined therapy sessions was not associated with return to preadm. FAB. Of note, only 28% returned within 90% of preadmission FAB by discharge. In fact, 13% actually saw their FAB regress from adm. to DC. None of the collected variables were associated with the negative change in FAB scores through admission. Conclusions In this sample, number of sessions was not predictive of return to preadmission FAB; however, this may be due to the low numbers that achieved the milestone at all. Despite this fact, there was an alarmingly small number admitted to a subsequent inpatient rehabilitation facility. There was a significant improvement in paired scores from admission to discharge. Taken together, there may be value in reassessing inpatient rehabilitation facility adm. criteria. Applicability of Research to Practice FAB scores may be a useful indicator of further rehabilitation needs.

Neurorecovery after Critical COVID-19 Illness

With the hundreds of millions of people worldwide who have been, and continue to be, affected by pandemic coronavirus disease (COVID-19) and its chronic sequelae, strategies to improve recovery and rehabilitation from COVID-19 are critical global public health priorities. Neurologic complications have been associated with acute COVID-19 infection, usually in the setting of critical COVID-19 illness. Neurologic complications are also a core feature of the symptom constellation of long COVID and portend poor outcomes. In this article, we review neurologic complications and their mechanisms in critical COVID-19 illness and long COVID. We focus on parallels with neurologic disease associated with non-COVID critical systemic illness. We conclude with a discussion of how recent findings can guide both neurologists working in post-acute neurologic rehabilitation facilities and policy makers who influence neurologic resource allocation.

Neuropsychological functioning predicts psychosocial adjustment after postacute rehabilitation for traumatic brain injury.

To examine neuropsychological functioning as a predictor of psychosocial adjustment difficulties at discharge from a postacute residential rehabilitation facility for traumatic brain injury (TBI) and depression as a potential mediator. A retrospective record review was conducted of 172 adults who received rehabilitation services for TBI. Individuals completed a full battery of neuropsychological tests, depression assessment, and functional assessments at admission. Functional assessments were also obtained at discharge. A two-phase structural equation model analysis was performed. The first phase specified a good fitting model of a cognitive functioning (CF) latent construct with four indicators of cognitive domains measuring verbal fluency, cognitive flexibility, verbal learning, and working memory. Worse CF was associated with greater psychosocial adjustment impairment at discharge, but not related to depression. Psychosocial adjustment impairment at admission was positively associated with depression when controlling for CF, however depression did not predict psychosocial adjustment at discharge. Thus, depression was not found to be a significant mediator of psychosocial adjustment impairment at discharge. Results provide support for neuropsychological functioning at the start of postacute rehabilitation for TBI as an important predictor of psychosocial functioning difficulties that remain upon discharge and highlights the need to examine mechanisms beyond depression.

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.

National survey of health services provided by pediatric post-acute care facilities in the US.

The need for pediatric post-acute facility care (PAC) is growing due to technological advances that extend the lives of many children, especially those with complex medical needs. The objectives were to describe [1] the types and settings of PAC; [2] the clinical characteristics of the pediatric patients requiring PAC; and [3] perceptions of PAC care delivery by clinical staff. An online survey was administered between 6/2018 to 12/2018 to administrative leaders in PAC facilities that have licensed beds for children and who were active members of the Pediatric Complex Care Association. Survey topics included types of health services provided; pediatric patient characteristics; clinical personnel characteristics; and perceptions of pediatric PAC health care delivery. Leaders from 26 (54%) PAC facilities in 16 U.S. states completed the survey. Fifty-four percent identified as skilled nursing facility/long-term care, 19% intermediate care facilities, 15% respite and medical group homes, and 12% post-acute rehabilitation facilities. Sixty-nine percent of facilities had a significant increase in the medical complexity of patients over the past 10 years. Most reported capability to care for children with tracheostomy/invasive ventilation (100%), gastrostomy tubes (96%), intrathecal baclofen pump (89%), non-invasive positive pressure ventilation (85%), and other medical technology. Most facilities (72%) turned away patients for admission due to bed unavailability occasionally or always. Most facilities (62%) reported that insurance reimbursement to cover the cost of providing PAC to children was not acceptable, and most reported that it was difficult to hire clinical staff (77%) and retain staff (58%). PAC in the U.S. is provided to an increasingly medically-complex population of children. There is a critical need to investigate financially-viable solutions for PAC facilities to meet the patient demands for their services and to sufficiently reimburse and retain staff for the challenging and important care that they provide.

Abstract TP31: Use Of Validated Tool To Guide Nutritional Support Pathways In Patients With Dysphagia After AIS

Background and Issues: Dysphagia is a common complication of AIS. Previously, there was no evidence-based predication tool to accurately predict the duration of post-stroke dysphagia. Without a prediction tool, post-acute rehabilitation facilities may not be able to accept patients with dysphagia without a gastrostomy tube. This may lead to some acute hospitals inadvertently placing gastrostomy tubes in patients who have a low likelihood of prolonged dysphagia. Dysphagia can also result in a prolonged acute hospital length of stay. Purpose: The goals of this quality improvement (QI) initiative were to reduce acute hospital length and improve selection of patients for gastrostomy in patients with dysphagia as a results of AIS. Methods: A multidisciplinary group from a Comprehensive Stroke Center (CSC) and a post-acute rehabilitation center identified an evidenced-based tool to help predict the duration of dysphagia after AIS. The CSC created a local practice guideline using the Predictive Swallowing Score (PRESS). PRESS was used to help predict a patient’s potential for recovery of swallowing, in order to help stratify patients into treatment pathways and guide decision making on nutritional support for post-stroke dysphagia. Stakeholders at both centers identified potential issues, including lack of a process for discharging patients to rehabilitation with a nasogastric tube (NGT). To address concerns, return-for-service pathways were developed; NGT replacement in the emergency department and outpatient gastrostomy tube placement. Results: This QI initiative and multidisciplinary collaboration across the care continuum, resulted in earlier identification of patients in need of gastrostomy placement for prolonged dysphagia, ultimately resulting in a reduced acute hospital length of stay. The pathways also helped reduce uncertainty for post-acute rehabilitation centers to accept patients with a NGT, allowing for more patients to be discharged with a NGT. Conclusions: In conclusion, it is feasible and beneficial to patient care to develop and implement pathways using an evidence-based tool to guide individualized nutritional support plans related to post-stroke dysphagia.

596. The ID Physician Is Out: Are Remote ID E-Consults an Effective Substitute?

BackgroundTelemedicine (TM) can provide specialty ID care for remote and underserved areas; however, the need for dedicated audio-visual equipment, secure and stable internet connectivity, and local staff to assist with the consultation has limited wider implementation of synchronous TM. ID e-consults (ID electronic consultations or asynchronous™) are an alternative but data are limited on their effectiveness, especially patient outcomes.MethodsIn the setting of the COVID-19 pandemic and ID physician outage, we were asked to perform ID e-consults at a 380-bed tertiary care hospital located in Blair County, PA. We performed retrospective chart reviews of 121 patients initially evaluated by ID e-consults between April 2020 and July 2020. Follow-up visits were also conducted via e-consults with or without direct phone calls with the patient. Key patient outcomes assessed were length of stay (LOS), disposition after hospitalization, 30-day mortality from initial ID e-consult and 30-day readmission post-discharge.ResultsThe majority of patients were white males and non-ICU (Table 1). The most common ID diagnosis was bacteremia (27.3%, 33/121), followed by skin and soft tissue infections (15.7%, 19/121) and bone/joint infections (14.9%, 18/121) (Figure 1). Table 2 shows patient outcomes. Average total LOS was 11 days and 7 days post-initial ID e-consult. 48.7% (59/121) of patients were discharged home and 37.2% (45/121) to a post-acute rehabilitation facility. 2.5% (3/121) of patients required transfer to a higher level of care facility; none of which were to obtain in-person ID care. The index mortality rate was 3.3% (4/121), which appears to be lower than published data for in-person ID care. The 30-day mortality rate was 4.1% (5/121), which is also comparable to previously reported for ID e-consults. 25.6% (31/121) of patients required readmission within 30 days but only 14.0% (17/121) were related to the initial infection.Table 1. Demographics *Immunosuppressive agents include: Apremilast, Dasatinib, Etanercept, Remicade, Rituximab, and Prednisone >10 mg/dayFigure 1. Variety of ID Diagnoses made by e-consults Table 2. Outcomes ConclusionWe believe that this is the first report of the implementation of ID e-consults at a tertiary care hospital. Mortality rates appear to be comparable to in-person ID care. In the absence of in-person ID physicians, ID e-consults can be a reasonable substitute. Further study is required to compare performance of ID e-consults to in-person ID consults.Disclosures John Mellors, MD, Abound Bio, Inc. (Shareholder)Accelevir (Consultant)Co-Crystal Pharma, Inc. (Other Financial or Material Support, Share Options)Gilead Sciences, Inc. (Advisor or Review Panel member, Research Grant or Support)Infectious DIseases Connect (Other Financial or Material Support, Share Options)Janssen (Consultant)Merck (Consultant) Rima Abdel-Massih, MD, Infectious Disease Connect (Employee, Director of Clinical Operations) Rima Abdel-Massih, MD, Infectious Disease Connect (Individual(s) Involved: Self): Chief Medical Officer, Other Financial or Material Support, Other Financial or Material Support, Shareholder

Rehabilitation Utilization by Cancer Patients with Pathology-Confirmed Leptomeningeal Disease Receiving Intrathecal Chemotherapy.

The incidence of leptomeningeal disease (LMD) is believed to be increasing in part because of more effective chemotherapy treatments allowing cancer progression behind the blood-brain barrier. However, little has been published about the rehabilitation of this growing patient population. In this study, impairments and rehabilitation utilization by cytology-proven LMD patients receiving intrathecal chemotherapy at a cancer center are described. A total of 109 consecutive patients with pathology-confirmed LMD who received an intrathecal chemotherapy infusion from January 1, 2017, through October 31, 2017, were retrospectively reviewed. Of the 109 patients, 103 (95%) had impairments described in their medical record that could impact physical function, including 74 of 109 (68%) who had deconditioning or fatigue. Kaplan-Meier median survival from initial LMD diagnosis was 13.1 mos. The median number of hospital admissions and intrathecal chemotherapy administrations was both 8. Of the 109 patients, 43 (39%) had magnetic resonance imaging radiology interpreted LMD. Most LMD patients used rehabilitation services (95/109, 87%) and most were able to forego post-acute inpatient rehabilitation facilities (96/109, 88%). Additional research and education for rehabilitation professionals about this increasingly common syndrome are needed.

Poetry: a healing voice for the frail and elderly

ABSTRACT The focus of this article is about a poetry healing group the author founded at a post-acute rehabilitation facility for senior citizens. The program was established a year and a half ago based on the need for mentally stimulating calendar activities. The group varies between high and low functioning frail and elderly participants with the notion of producing content to heal and stimulate, not for poetic craft. The program involves sharing poems with a specific a theme, so participants conjure lively discussions. The result is therapeutic healing through the art of storytelling. This article covers a description of the program along with the author’s observations. The therapeutic value of medical narrative to the elderly is also discussed.

Empathic Responses to Affective Film Clips Following Brain Injury and the Association With Emotion Recognition Accuracy

ObjectiveTo compare empathic responses to affective film clips in participants with traumatic brain injury (TBI) and controls, and examine associations with affect recognition. DesignCross sectional study using a quasi-experimental design. SettingMulti-site study conducted at a postacute rehabilitation facility in the United States and a university in Canada. ParticipantsAdults (N=120) with moderate to severe TBI (n=60) and those without TBI (n=60), frequency matched for age and sex. Average time postinjury was 14 years (range: .5-37). Main Outcome MeasuresParticipants were shown affective film clips and asked to report how the main character in the clip felt and how they personally felt in response to the clip. Empathic responses were operationalized as participants feeling the same emotion they identified the character to be feeling. ResultsParticipants with TBI had lower emotion recognition scores (P=.007) and fewer empathic responses than controls (67% vs 79%; P<.001). Participants with TBI accurately identified and empathically responded to characters’ emotions less frequently (65%) than controls (78%). Participants with TBI had poorer recognition scores and fewer empathic responses to sad and fearful clips compared to controls. Affect recognition was associated with empathic responses in both groups (P<.001). When participants with TBI accurately recognized characters’ emotions, they had an empathic response 71% of the time, which was more than double their empathic responses for incorrectly identified emotions. ConclusionsParticipants with TBI were less likely to recognize and respond empathically to others’ expressions of sadness and fear, which has implications for interpersonal interactions and relationships. This is the first study in the TBI population to demonstrate a direct association between an affect stimulus and an empathic response.

Knowledge assessment of the coding using CSARR nomenclature, two years after its establishment

French post-acute care and rehabilitation facilities describe and code their activity through the Program for Medicalization of Information Systems (PMSI). A new specific catalogue of rehabilitation procedures (CSARR) has been implemented to code rehabilitation acts since 2013. This study aimed to assess the coherence of the coding of the rehabilitation acts using the CSARR two years after its establishment through the analyze of 3 main items regarding patients and therapists. We analyzed the use of CSARR for coding rehabilitation acts from the PMSI national database for post-acute care and rehabilitation, in 2015. Analyses were made on specific items characterizing rehabilitation acts: "number of patients", "type of therapists" and "number of therapists". There were 72,014,731 rehabilitation acts coded in 2015 using CSARR nomenclature; 86% were individual rehabilitation acts. All acts of CSARR, except one, were used to describe rehabilitation activities. Physiotherapists coded the majority of rehabilitation acts (47%), then nurses (14%). Coding errors were identified as the "number of patients", coded with more than one patient for individual acts (13% of the acts) or with less than 2 patients for groups (6% of the acts), or the "number of therapists" coded with only one therapist for rehabilitation acts requiring several professionals. This first assessment indicated a good level of appropriation of the CSARR coding rules in the national PMSI database by post-acute care and rehabilitation facilities. However, a simplification of this catalogue and therapist training could increase the quality of the rehabilitation data.

Six-year review of traumatic brain injury in a regional trauma unit: demographics, contributing factors and service provision in Ireland

ABSTRACTBackground: Traumatic brain injury (TBI) represents a significant burden of care for acute surgical services, particularly in the absence of on-site neurosurgical cover or sufficient post-acute rehabilitation facilities. We examine factors contributing to TBI, prolonged lengths of stay (LoS) and implications for hospital resources. Long-term outcomes are assessed.Methods: This is a retrospective cohort study of patients admitted to a regional trauma unit with TBI from 2008 to 2013. Patients with LoS > 48 h were assessed. Demographic, clinical and longitudinal mortality data were collected using electronic clinical and radiological systems and chart review.Results: A total of 690 patients presented with TBI from 2008 to 2013; 213 patients with LoS > 48 h were assessed. One hundred and thirty (61%) were male. Mean age was 56 years (±SD 24). Mechanical fall was the most frequent injury mechanism (n = 120/213, 56%). Twenty-five per cent were associated with alcohol consumption; these were more likely to be male, involved in an Road Traffic Accident (RTA) or assault and necessitate transfer to a neurosurgical unit (p < 0.001, p = 0.029, p < 0.001, p = 0.05). A total of 112 patients(53%) had a prolonged LoS (>2 weeks). Mean LoS was 20 days (±SD 35), increasing to 39 days for patients requiring neurosurgical intervention. The 12-month all-cause mortality rate was 12%.Conclusions: TBIs result in significant utilisation of acute inpatient bed days. Improved rehabilitation services and strategies to reduce acute hospital LoS are warranted.

Assessment of venous thromboembolism risk and initiation of appropriate prophylaxis in psychiatric patients.

Introduction:Venous thromboembolism (VTE) prophylaxis is not included among the measures for the Inpatient Psychiatric Facilities Quality Reporting Program. Evidence suggests that antipsychotic agents may be an independent risk factor for the development of VTE; therefore, development of a VTE risk stratification tool would improve the quality and safety of care for the psychiatric inpatient population. This study aims to develop clinically relevant criteria to assess VTE risk upon admission to an inpatient psychiatric hospital.Methods:This retrospective, single-center cohort study enrolled patients in 2 cohorts from an inpatient psychiatric hospital. Patients in cohort I with new-onset VTE diagnosis during admission were identified through international classification of diseases 9 and 10 coding. Cohort II consisted of a random sample of 100 patients in a 3-month period. The percentage meeting criteria for prophylaxis in each cohort was assessed utilizing both the Padua Prediction Score and a modified score.Results:In cohorts I and II, 66.7% and 14% of patients, respectively, met criteria for VTE prophylaxis utilizing the modified Padua Prediction Score. One patient received VTE prophylaxis in each cohort, and the median time to VTE diagnosis in cohort I was 42 days. In cohort I, the rate of VTE was 0.08% based on estimated discharges in the 26-month period. This is less than the annual rate of 1% to 2.4% for nursing homes or postacute rehabilitation facilities.Discussion:We recommend the implementation of clinical decision support to prompt individualized reassessment of VTE risk when length of stay exceeds 30 days.

Trauma Care in Mongolia: INTACT Evaluation and Recommendations for Improvement.

Injury is the third leading cause of death in Mongolia, with a 29% increase in motor vehicle fatalities over the past decade. Half of the population lives outside the urbanized capital of Ulaanbaatar, where access to care is limited. This study evaluates and describes the Mongolian trauma system and makes recommendations for improvements. Hospital-level data were collected, and an International Assessment of Capacity for Trauma (INTACT) score (0-10) was calculated. INTACT is a validated measure for evaluating trauma capacity in developing countries based on resource availability; a score of 10 reflects ideal staffing and equipment. The survey was administered to key staff members at 10 rural and urban hospitals in spring 2016. INTACT scores were calculated for each hospital and compared to expected INTACT scores based on the World Health Organization Guidelines for Essential Trauma Care (GETC). Ulaanbaatar enjoys a centralized prehospital transportation service and two appropriately resourced tertiary hospitals. Rural Mongolians rely upon regionally located tertiary facilities with similar capabilities. INTACT scores for secondary-level hospitals (n=2) failed to meet expected GETC minimums, as did 2 of 4 primary facilities. There are no national standards guiding prehospital care, triage, or transfer. No outpatient rehabilitation facilities exist within Mongolia. The Mongolian trauma system utilizes regionalized care to provide emergency services. Among surveyed hospitals, 60% met GETC standards. Areas for improvement include increased resourcing of primary and secondary facilities, development of rural prehospital systems, adoption of universal standards for patient care, and creation of post-acute rehabilitation facilities.

Patient Involvement in Selecting Post-Acute Care Rehabilitation Facilities Following Stroke

To examine stroke survivor’s involvement in post-acute care (PAC) decisions.

Rehabilitation after traumatic brain injury: A survey in 70 European neurotrauma centres participating in the CENTER-TBI study.

To describe variation in structural and process characteristics of acute in-hospital rehabilitation and referral to post-acute care for patients with traumatic brain injury across Europe. Survey study, of neurotrauma centres. A 14-item survey about in-hospital rehabilitation and referral to post-acute care was sent to 71 neurotrauma centres participating in a European multicentre study (CENTER-TBI). The questionnaire was developed based on literature and expert opinion and was pilot-tested before sending out to the centres. Seventy (99%) centres in 20 countries completed the survey. The included centres were predominately academic level I trauma centres. Among the 70 centres, a multidisciplinary rehabilitation team can be consulted at 41% (n = 29) of the intensive care units and 49% (n = 34) of the wards. Only 13 (19%) centres used rehabilitation guidelines in patients with traumatic brain injury. Age was reported as a major determinant of referral decisions in 32 (46%) centres, with younger patients usually referred to specialized rehabilitation centres, and patients ≥ 65 years also referred to nursing homes or local hospitals. Substantial variation exists in structural and process characteristics of in-hospital acute rehabilitation and referral to post-acute rehabilitation facilities among neurotrauma centres across Europe.

Duration to Admission and Hospital Transfers Affect Facility Rankings from the Postacute 30-Day Rehospitalization Quality Measure.

To examine changes in facility-level risk-standardized rehospitalization rankings for postacute inpatient rehabilitation facilities after modifying two model parameters. We used national Medicare enrollment, claims, and assessment data to study 522,260 patients discharged from inpatient rehabilitation in fiscal years 2010-2011. We calculated risk-standardized 30-day unplanned rehospitalization rates for 1,135 inpatient rehabilitation facilities using four approaches. The first model replicated the current postacute risk-standardization methodology and included patients discharged from acute hospitals up to 30days prior to postacute admission and excluded patients transferred directly back to acute hospitals following rehabilitation. Our alternative models excluded patients with delayed admissions (>1day between acute discharge and postacute admission) and counted direct transfers back to acute as rehospitalizations. Excluding patients with delayed admissions and counting direct transfers back to acute care as rehospitalizations substantially impacted rankings of more than half the postacute providers: 29 percent had better and 27 percent had worse quintile rankings. Changing the timeframes for duration to admission and rehospitalization will have profound effects on postacute provider quality performance ratings. Reporting rehospitalization rates is an important issue with the explicit goal of improving the quality of postacute care. Research is needed to understand and minimize potential unintended consequences of this quality metric.

What is the Best Strategy to Minimize After-Care Costs for Total Joint Arthroplasty in a Bundled Payment Environment?

BackgroundThe post-acute care strategies after lower extremity total joint arthroplasty including the use of post-acute rehabilitation centers and home therapy services are associated with different costs. Providers in bundled payment programs are incentivized to use the most cost-effective strategies. MethodsWe used decision analysis to examine the impact of extending the inpatient hospital stay to avoid discharge of patients to a post-acute rehabilitation facility. ResultsThe results of this decision analysis show that extended acute hospital care for up to 5.2 extra days to allow for home discharge, rather than discharge to a post-acute inpatient facility can be financially preferable, provided quality is not negatively impacted. ConclusionThe data demonstrate that because the cost of additional acute care hospital days is relatively small and because the cost of an extended post-acute inpatient rehabilitation facility is high, keeping patients in the acute facility for a few extra days and then discharging them directly to home may result in an overall lower cost than discharge after a shorter hospital stay to an expensive post-acute facility. However, this approach will have challenges, and future studies are needed to evaluate this change in strategy.

Family needs at a post-acute rehabilitation setting and suggestions for supports

Objective: To explore the perceived needs, obstacles to services, psychological distress and social problem-solving abilities of family members of persons with ABI at a post-acute community-based brain injury rehabilitation facility and offer suggestions for methods of assessment and providing support.Participants: Twenty-nine family members who did not provide daily care, but were involved in the care process.Design: Participants completed self-report questionnaires including the FNQ:R, SOS, DASS-21, WHO-QOL BREF and SPSI:R-S.Results: Participants reported informational and professional needs as most met and involvement in care, instrumental support and emotional support as most unmet. Most were satisfied with the amount of professional help and services and had confidence in the quality of care. Nearly half of the family members felt there were few ABI-related resources in the community and one third were unaware of good ABI treatment resources in their community. Psychosocial functioning was generally average.Conclusion: Family members who do not provide daily care are still impacted by the neurobehavioural changes that progress throughout the long-term, post-acute community phase. This study offers suggestions regarding an effective methodology for assessing family needs and recommends accessible and practical supports.