Post-Acute Care of the Elderly Patient Rehabilitation and by olliegoblue33

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									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
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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
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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

Visits (1k)

1997 1998 1999 2000 2001

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
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FIM and Rehab Potential
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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
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Marcantonio et al. (Harvard 2003) 551 admissions to subacute rehab

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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
Adj. Odds Ratio (95% CI) Improved (n=138) Unch/Worse (n=106)

Mod-Sev Cog Imp Delirium Age >85

0.36 (0.14-0.92) 0.59 (0.17-2.00) 1.07 (0.35-3.30)

21 6 24

37 9 35

>3 active disease process

0.56 (0.21-1.47)

103

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
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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)
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The Interdisciplinary Team
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Physical Therapy
Evaluate and restore mobility and endurance  Main benchmark is gait • Feet walked • Assist needed • Device used
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The Interdisciplinary Team
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Occupational Therapy
Evaluate and restore ability to interact safely with the environment  Benchmarks are ADLs and IADLs • Manual dexterity • Activity independence
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The Interdisciplinary Team
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Speech Therapy
Evaluate and restore cognitive, speech, and swallowing function  Treat aphasia, dysarthria, dysphagia  Bedside swallowing challenge
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The Interdisciplinary Team
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Nursing
Assess patient’s pattern of behavior  Technical skills of IV therapy
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

Nutrition
Identify risk or presence of malnutrition  Provide options for care and correction
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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
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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
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Types of assistance
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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
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Case 1
  

OT assessment
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Patient near baseline for IADLs Patient ambulating 200-300’ with S/W Home environment stable, social support adequate

PT assessment
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SW assessment
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Settings
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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 completely compensated at baseline • 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




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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
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



OT assessment  Improving, but 1-person assist for bathing, transfers PT assessment  Walking 100’ x2 with CGA  Balance and safety concerns  Tolerates 2-3 sessions/day SW assessment  Good social support, wife can help with shortterm 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
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

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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
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Nursing Facility (Chronic Care)
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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 7 6 5 4 3 2 1 0

Rate per 1000

1985 1997 1999

Re side nts

Disc harge s

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


The End


								
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