Transcript Post-Acute Care of the Elderly Patient Rehabilitation and Functional
Post-Acute Care of the Older Patient
Rehabilitation and Transitions of Care Thomas Price, MD
Emory University School of Medicine Department of Internal Medicine Division of Geriatric Medicine 4/2006
Overview
The (lack of) Data Barriers to Recovery Assessing the Patient Know Your Therapists Sample Cases
The (lack of) Data
Hazards of Hospitalization in Older Persons Creditor, Ann Intern Med 1993;118:219-223
A Bad Situation
Older persons can show functional decline after only 24 hrs of bed-rest Skilled Nursing Facility (SNF) care after acute hospitalization 1989 = 600,000 admissions 1996 = 1.1 million admissions Johnson MF et al.
JAGS
48, 2000
Current Trends
SNF USE HHS USE
Home Health Services
Home Health Visits, Medicare 300000 250000 200000 150000 100000 50000 0 1997 1998 1999 2000 2001 Visits (1k)
Murtaugh CM et al.
Health Affairs
22(5) 2003
And Quicker Health Services Discharges…
From
National Center for Health Statistics database
A Worse Situation
Acute rehabilitation significantly limited in 2002 by Medicare Stricter admissions criteria under PPS Rapid rise of “subacute” SNF units ↓ LOS = ↑ rehab efficiency … but led to increased mortality Ottenhacber KJ et al.
JAMA 292(14):
2004
Barriers to Recovery
Functional Independence Measure (FIM)
ACRM/AAPMR 18 Items Motor skills (13), Cognitive (5) Scale of 1 (total assist) to 7 (no assist) Ranges 13-91 Motor, 5-35 Cognitive Higher scores = Better function
FIM and Rehab Potential
Likourezos et al. (Mount Sinai NY 2002) 164 pts, equivalent disease severity SNF Rehab, avg LOS 40 days Higher admission FIM Motor and Cognition score => better functional recovery Likourezos A, Si M, Kim WO et al.
Am J Phys Med Rehabil
2002;81:373-379
Delirium
Marcantonio et al. (Harvard 2003) 551 admissions to subacute rehab Delirium associated with worse ADL and IADL recovery Marcantonio ER et al.
J Am Geriatr Soc
51:4-9, 2003
Delirium
Marcantonio ER et al.
J Am Geriatr Soc
51:4-9, 2003
Delirium
Marcantonio ER et al.
J Am Geriatr Soc
51:4-9, 2003
Cognitive Impairment
Landi et al. (Rome, Italy 2002) ↑ Cognitive scoring => ↑ ADL recovery Mod-Sev Cog Imp Delirium Age >85 >3 active disease process Adj. Odds Ratio (95% CI)
0.36 (0.14-0.92)
0.59 (0.17-2.00) 1.07 (0.35-3.30) 0.56 (0.21-1.47) Improved (n=138) 21 6 24 103 Unch/Worse (n=106) 37 9 35 86 Landi F et al.
J Am Geriatr Soc
50:679-684, 2002
Cognitive dysfunction and prior functional impairment are strong predictors of rehab potential.
Assessing the Patient
Assessing the Patient
The “Delta” Change in function predicts rehabilitation prognosis Smaller decline time = faster recovery Longer time impaired = worse potential
Assessing the Patient
History Baseline functional level • IADL:
Do you do your finances?
• BADL:
Do you need help to bathe?
Living situation and social support Cognitive history
Assessing the Patient
Exam identifies deficits and barriers Musculoskeletal • • Get up and go (Gait/LE proximal muscle) Tone (spasticity) Neurologic and Psychiatric • Focal findings (incl. dysarthria) • Cognitive (3 word recall or MMSE) • Delirium (Confusion Assessment Method) • Depression (SIG E CAPS or GDS) Skin • Pressure ulcers
The Interdisciplinary Approach
The Interdisciplinary Team
Holistic approach Multi-angle (POV) assessment Too many variables for one person!
The Interdisciplinary Team
Social Services Assess living situation and social support Develop options for providing safe discharge pathway for patient Enable supportive resources if available (home health, etc)
The Interdisciplinary Team
Physical Therapy Evaluate and restore mobility and endurance Main benchmark is gait • Feet walked • Assist needed • Device used
The Interdisciplinary Team
Occupational Therapy Evaluate and restore ability to interact safely with the environment Benchmarks are ADLs and IADLs • Manual dexterity • Activity independence
The Interdisciplinary Team
Speech Therapy Evaluate and restore cognitive, speech, and swallowing function Treat aphasia, dysarthria, dysphagia Bedside swallowing challenge
The Interdisciplinary Team
Nursing Assess patient’s pattern of behavior Technical skills of IV therapy Nutrition Identify risk or presence of malnutrition Provide options for care and correction
The Interdisciplinary Team
Wound Care Evaluate and manage wounds • Pressure ulcers, surgical sites, ostomy Assess barriers to wound healing • Poor mobility • Nutritional status
Assessing the Patient
What are skilled needs of the patient?
• Nursing • IV therapy • • Wound care Enteral feeding (if new only) • Therapy • • • Physical therapy Occupational therapy Speech therapy
Interdisciplinary Jargon
Types of assistance Max assist (1 person-2 person) Mod assist (1 person) Min assist • • CGA: contact guard assist HHA: hand hold assist • • S: Supervision Mod I: Modified independent Independent Ambulatory assist device
Devices
Cases
“Next, an example of the very same procedure when done correctly”
Case 1
89 y.o. female Hypertension, past CVA with RHP (partial) Fall with hip fracture (FNF s/p THR) No significant delirium Ambulates with walker Husband is healthy, active and drives safely
Case 1
OT assessment Patient near baseline for IADLs PT assessment Patient ambulating 200 300’ with S/W SW assessment Home environment stable, social support adequate
Settings
Outpatient Therapy
Modalities: PT, OT, ST, MD Requirements • Medicare B, Medicaid • Patient not “home bound” Usual interval 2-8 wks, 2-3x weekly
Case 2
76 y.o. male Mild moderate Alzheimer’s Disease Admitted for CHF exacerbation Hospitalized x10 days Bed rest for 3-4 days Slow Get-Up and Go test MMSE 20/30 Patient’s wife cannot drive (Macular Degeneration)
Case 2
OT assessment Below baseline for IADLs, ADLs Unsafe to drive (endurance, cognition) PT assessment Ambulating 150 200’ with rolling walker SW assessment Safe home environment but no transport available to rehab center
Settings
Home Health therapy
Modalities: PT, OT, ST, RN, SW Requirements • • • • Medicare A benefit, Medicaid Safe environment ADL/IADL independent
or
compensated at baseline completely Patient must be “home-bound” Usual interval: 90 day certification periods with recertification possible
Case 3
82 y.o. male with invasive pneumococcal pneumonia History of COPD, HTN, CASHD, DM Needs 1 more week of IV antibiotics Was bedbound for 5 days Lives alone in a senior hi-rise Delirium present
Case 3
OT assessment Below baseline for IADL, ADL with fatigue Mod-max assist for bathing, transfers PT assessment Walks 5 10’ with rolling walker Needs CGA for ambulation Frequent stops for endurance SW assessment Pt previously independent, can return home if meeting functional needs
Settings
Subacute Rehabilitation
Modalities: PT, OT, ST, RN, SW, MD Requirements • Medicare A or carrier covered benefit • • • Medicare 20/80 day split payment
Not available for Medicaid patients
Tolerate at least 90 minutes of therapy 5x/wk Usual interval: 4-8 weeks
Case 4
68 y.o. post-CVA Dense RHP, aphasia, dysphagia Got thrombolytics RHP and aphasia recovered by 50% in 3-4 days Lives with wife
Case 4
OT assessment PT assessment Walking 100’ x2 with CGA Improving, but 1-person assist for bathing, transfers Balance and safety concerns Tolerates 2-3 sessions/day SW assessment Good social support, wife can help with short term ADL and IADL dependence
Settings
Acute Rehabilitation
Modalities: PT, OT, ST, RN, SW, MD Requirements • Medicare A • • •
Specific disease entities
High level of function potential Require at least three hours of therapy 5x week or more Usual interval 7-14 days
Case 5
87 y.o. post-pneumonia 7 day hospitalization length with IV ABT History of dementia x5 years Family says “unable to take her back home” Patient impoverished, Medicaid only Cognitive impairment severe Multiple pressure ulcers
Case 5
OT assessment Moderate to max assist for ADLs Limited ability to follow commands PT assessment Baseline mobility poor Unable to participate in PT sessions SW assessment Primary caregiver shows signs of fatigue, limited support from other family members
Settings
Nursing Facility (Chronic Care)
Modalities: PT, OT, ST, RN, SW, MD Requirements • Private pay, Medicaid (entry through skilled Medicare benefit possible) • Rehab provided a la “Part B” Medicare “Short-stayers” starting to increase “Respite stays” possible Placement
is going to be tough!
Because…
The Problem Revealed
Nursing Home Residents and Discharges, USA (1985-1999) 10 9 8 3 2 1 0 7 6 5 4 Residents Discharges 1985 1997 1999
Conclusions
Older patients are vulnerable to declines in functional status during acute illness Discharge planning requires input from multiple team members Transitions in care incorporate a number of settings and must be tailored to needs of every patient