Post Acute Care of the Elderly Patient Rehabilitation and

							   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



                 HHS
    SNF
                 USE
    USE
Home Health Services




                  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

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

Mod-Sev Cog Imp     0.36 (0.14-0.92)       21                  37
Delirium            0.59 (0.17-2.00)       6                   9
Age >85             1.07 (0.35-3.30)       24                  35
>3 active disease   0.56 (0.21-1.47)       103                 86
process

                                       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 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
   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
      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 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
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