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
Visits (1k)
150000
100000
50000
0
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

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
(95% CI)
Improved
(n=138)
Unch/Worse
(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
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

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


PT assessment


Patient near baseline for IADLs
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 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



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
Rate per 1000
Nursing Home Residents and Discharges,
USA (1985-1999)
10
9
8
7
6
5
4
3
2
1
0
1985
1997
1999
Re s ide nts
Dis char ge 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