1 August 2011 Page 1 of 10 Grant Outcomes Report Using Adult Day Health Services as an Alternative to Existing Post-Acute Care to Prevent Hospital Readmission KEY INFORMATION: GRantEe Village Care of New York grant title A Short-Stay Adult Day Rehabilitation Pilot Dates January 2007 February grant amount I. Executive Summary $414,477 Nearly half of all patients who are discharged from hospitals following a stroke or congestive heart failure (CHF) are readmitted to the hospital within one year, 2 highlighting the need for better recovery options. To address this situation, Village Care of New York (VCNY) launched a pilot program to provide outpatient, short-term post-acute care in its Adult Day Health Center (ADHC) setting. The program was designed to demonstrate both the clinical benefits and cost-effectiveness of using this setting for post-acute patients who are not interested in, or qualified for, nursing home or certified home care, with the goal of reducing the number of patients who are readmitted annually to New York hospitals. Although pilot participants did experience few re-hospitalizations, the program had great difficulty recruiting participants, and staff observed that it mostly benefited less acute individuals. Thus, the grantee concluded that adult day rehabilitation is not a viable post-acute care option at this time. As such, a Medicare demonstration was not pursued, nor were plans to replicate the program to other New York State ADHCs. Nonetheless, the program resulted in important lessons for health policy and continued health system improvement. II. The Problem Each year, 125,000 patients who have been hospitalized for a stroke or congestive heart failure are discharged from New York hospitals. 3 They and their families often require ongoing help to ensure that they can maintain good health and continue to recuperate, but their options are limited. 1 The pilot was originally intended to run from January 1, 2007, through December 31, However, because of unforeseen start-up delays, it was not fully launched until August 2007, and NYSHealth granted a no-cost extension (which provided extra time, but no additional funding) to VCNY through June 30, Continuing unanticipated implementation issues necessitated a second extension, also granted without additional funding, and the pilot ended officially in February Paula Moyer, Nearly half of stroke survivors readmitted within one year after discharge, Neurology Today, 6, 8 (April 18, 2006): 4-5; H. M. Krumholz, E. M. Parent, N. Tu, V. Vaccarino, Y. Wang, M. J. Radford, and J. Hennan, Readmission after hospitalization for congestive heart failure among Medicare beneficiaries, Archives of Internal Medicine, 157, 1 (January 13, 1997): SPARCS [Statewide Planning and Research Cooperative System] data (2004). See
2 Page 2 of 10 Hospital discharge planners refer Medicare beneficiaries to a skilled nursing facility for inpatient rehabilitation services, or to a Certified Home Health Agency for homebased rehabilitation. Many, however, are not eligible for or do not wish to go to a nursing home. Home care is often insufficient for their needs, because it can be isolating and lacks the opportunity for peer support, which Village Care of New York (VCNY) believes is the crucial missing ingredient in helping these patients to recover. Home care also lacks interdisciplinary interventions, ongoing medication management, and lacks the appropriate equipment, and places a significant burden on the patient s family and caregivers. The remaining alternative outpatient rehabilitation visits is also often unable to provide the intensive and complex services, lacks the critical social supports that would benefit this population, and multiple outpatient therapy appointments are usually too logistically challenging for these patients and their caregivers. The upshot is that 45% of stroke discharges are re-hospitalized within one year, 4 and 44% of cardiac discharges are readmitted within six months. 5 In fact, the majority of all Medicare discharges are re-hospitalized within one year. 6 Given the limitations of current post-acute efforts in preventing re-hospitalizations, new approaches are needed to maintain health, and ensure longer-term positive health outcomes and cost-effectiveness. In particular, community-based, group-level post-acute options are needed. A template does exist for such an option in the form of Adult Day Health Centers (ADHCs). ADHCs have demonstrated therapeutic benefits for chronically ill and functionally impaired patients for many years now. As existing New York State-licensed, operating entities, ADHCs could fill the gap in services that exists for this population. While available research though limited suggests that adult day services can reduce health expenditures, 7 payers have been slow to reimburse for this service option, and most adult day service participants are limited to Medicaid beneficiaries. 4 Paula Moyer, Nearly half of stroke survivors readmitted within one year after discharge, Neurology Today, 6, 8 (April 18, 2006): H. M. Krumholz, E. M. Parent, N. Tu, V. Vaccarino, Y. Wang, M. J. Radford, and J. Hennan, Readmission after hospitalization for congestive heart failure among Medicare beneficiaries, Archives of Internal Medicine, 157, 1 (January 13, 1997): S. F. Jencks, M. V. Williams, and E. A. Coleman, Rehospitalizations among patients in the Medicare fee-for-service program, New England Journal of Medicine, 360 (April 2, 2009): Janet O Keeffe and Kristin Siebenaler, Adult Day Services: A Key Community Service for Older Persons (Washington, D.C.: U.S. Department of Health and Human Services, Office of Disability, Aging and Long-Term Care Policy, July 2006).
3 Page 3 of 10 The national average rate for adult day services is $64 per day, 8 which amounts to approximately $7 an hour for an average eight- to 10-hour day. By comparison, home health agencies charge an average of $18 to $20 an hour, while nursing homes average $310 per day in New York State, and $200 per day nationally. 9 Thus, the use of adult day health services as an alternative to these sub-acute care services should reduce costs not only because they are less expensive to provide, but also because they could help to prevent costly hospitalizations. III. Grant Strategy The Short-Stay Adult Day Rehabilitation Pilot was designed to fill the gap in post-acute care for stroke and cardiac patients by providing a community-based, group alternative to sub-acute stays and home care. The ADHC lends itself well to post-acute services, consolidating as it does the provision of therapies, nutritional interventions, medication management, patient education, and therapeutic recreation services that are delivered over the course of a five-hour day, several times a week, providing ample opportunity for peer interaction and support, as well as close clinical observation and modification. The primary strategy was for the ADHC s services to serve as the next step in the continuum of highquality rehabilitative care that is provided by New York University Medical Center and the Rusk Institute of Rehabilitation Medicine Network, 10 with which VCNY was affiliated. NYU staff were to recruit patients who they believed would benefit from this option explaining that it was an alternative to nursing home care or home care. The program designers expected that hearing this message from a trusted professional while still an inpatient would carry a great deal of weight and overcome any reluctance that these patients might have. NYU physiatrists and social workers were to recruit a minimum of 80 individuals to the program. Expected Outcomes 1. Demonstrate a superior episode of care approach by sustaining stroke and CHF survivors in their communities and offering more holistic services than would be attainable through home care. 2. Reduce post-discharge hospital readmissions among the target population by improving their physical functioning, improving medication compliance, and targeting depression through peer support opportunities. 3. Reduce caregiver burden by attending to all patient needs, and by providing caregivers with education and counseling. 4. Create a model that could be replicated throughout the 175 ADHCs in New York State. 8 The MetLife Market Survey of Adult Day Services & Home Care Costs (MetLife Mature Market Institute, in conjunction with LifePlans, Inc., September 2008). See 9 Ibid.; The MetLife Market Survey of Nursing Home & Assisted Living Costs (MetLife Mature Market Institute, in conjunction with LifePlans, Inc., October 2008). See 10 New York University Medical Center has since been renamed NYU Langone Medical Center.
4 Page 4 of 10 Program participants were to attend the Adult Day Rehabilitation Center three times a week for eight weeks, during which time they would receive individually tailored clinical services to improve their functionality, augmented by socialization opportunities and caregiver education and support. The comprehensive cost for pilot program participants who participate three times a week for eight weeks is $4,500. This represents significant potential cost savings across the post-acute population in New York when compared with a 45% chance of hospital readmission, an average cost of which is $15,000. IV. Grant Activities The grant activities were carried out in three phases: set-up, intervention, and evaluation/ dissemination of results. Set-up 1. New equipment was installed to better meet the needs of immediate post-acute patients, including telemetry equipment, specific cardiac and monitoring equipment, additional occupational therapy resources; and physical therapy equipment, including a treadmill, step machine, stationary and recumbent bicycles, and an upper body ergometer. 2. The rehabilitation staff was expanded, including an occupational therapist, additional physical therapy hours, and a part-time speech therapist. While traditional long-term adult day health care focuses on maintenance therapy, post-acute rehabilitation requires intensive treatment therapy and rapid progress. In addition, all therapy staff received targeted training on post-acute care complications, Rusk rehabilitation guidelines, and using the new equipment. 3. The grantee contracted with the Lewin Group to evaluate the pilot. 4. Procedures were established for referrals from NYU Medical Center. Although the original plan was that the NYU physiatrists and social workers would recruit the participants, during the set-up period, this was changed to only the social workers informing patients of the program. 5. Because of set-up delays and recruitment difficulties (see Challenges, below), the participation criteria were expanded in fall 2007 to any older adult with a recent hospitalization who warranted intensive rehabilitation. In particular, VCNY s geriatricians believed that certain chronic conditions, such as chronic obstructive pulmonary disease and Parkinson s disease, would benefit from shortterm holistic rehabilitation. As such, the grantee worked to identify patients leaving nursing home sub-acute care who could benefit from continued therapy and comprehensive care, as well as those under geriatric care in the community. One of the Adult Day Rehabilitation physical therapists was assigned as Lead Therapist and was responsible for finding pilot participants from non-hospital sources, including VCNY s Village Nursing Home.
5 Page 5 of To help staff adapt their long-term care practices to the short-stay model, the program designers met continually with existing staff, together with the nursing home s Short-Stay Director, to provide guidance for short-stay care planning and execution. Intervention 1. Each pilot participant started the program with a comprehensive assessment and care plan covering rehabilitation, clinical care, nutrition, social work, and recreation therapy needs and goals; for those with caregivers, a plan to educate and support caregivers was created. 2. Services were provided to 35 participants in total as follows: 17 individuals participated an average of 3 5 days a week (24 40 days over the 8 weeks); 9 participated 2 3 days a week (16 22 days over the 8 weeks); and 8 participated 1 2 days a week (8 15 days over the 8 weeks) The following services were provided: monitoring/patient education sessions with a registered nurse (RN), who coordinated with all treating physicians; physical and occupational therapy; speech therapy/swallowing treatments; individual dietician sessions and health education group sessions; therapeutic recreation activities, including lifestyle field trips to navigate typical errands; psychosocial support group sessions; transition visits to the patient s home with a therapist during the last week of the program; and off-hours telephone access to an RN for any major concerns a service that was eventually discontinued because of a lack of demand from participants. 4. Participants received transportation to and from the ADHC, and participated in all meals and recreation along with the traditional chronically ill patients. Recreation included activities such as Tai Chi, yoga, and art therapy. However, the program participants received all physical and occupational therapies as a distinct group. They also received individualized counseling sessions with the social worker and nutritionist. 5. The project team worked with VCNY s corporate marketing department, and the Lead Therapist spent approximately 50% of her time on marketing activities. Marketing materials were created and distributed to referral sources, including a video of the participants and brochures in Spanish 11 These data were unavailable for one participant.
6 Page 6 of 10 and English. In addition, patients could come into the ADHC for test drives, and the program was marketed internally to other VCNY programs. 6. A Case Manager worked with the pilot participants as their short-term program came to a close, to identify and initiate any ongoing supportive services in the community, such as Meals on Wheels or personal care services. The Lewin Group collected and analyzed outcomes for pilot participants during the evaluation and dissemination phase (which are described in the Key Findings section below). V. Challenges The grantee faced significant unanticipated challenges in implementing the program and recruiting participants. First, NYU s IRB (Institutional Review Board) approval took much longer than expected, and additional delays in arranging ADHC staff training from Rusk delayed the start of the program. More challenging, the task of establishing the recruitment processes from NYU inpatients proved to be a substantial and unforeseen barrier. VCNY was reluctant to insist upon the original responsibilities for NYU physiatrists because of concerns for the broader relationship between the organizations. At NYU s request, the hospital discharge planners became responsible for only referring patients to be recruited, and were trained by NYU rather than by VCNY staff. This casual approach proved insufficient to enable a shift in traditional referral patterns. Those patterns have focused on nursing homes and home care agencies with which hospital discharge planners have longstanding relationships. The discharge planners are under a lot of pressure, and they have many layers of care to deal with, so it was difficult for them to take on yet another layer. The hardest part was convincing them to think outside the box and buy in to this new program, said Lead Therapist Randi Schwartz. After six months, only four participants had been referred from NYU. Further, patients and their families were reluctant to enter the program for a number of reasons: depressed and/or physically impaired patients often preferred the less demanding home care option; the patient s level of ongoing needs was often unclear until a condition stabilized, making the safety of FUNDING INITIATIVE This grant was one of NYSHealth s inaugural grants, funded under its 2006 request for proposals (RFP). The RFP was an open call to organizations that would have a broad, enduring impact on the health of New Yorkers. The Foundation received more than 600 proposals under this RFP, and ultimately funded only 23 projects. This project addressed the Foundation s goals to improve community or public health and to increase access to health care services.
7 Page 7 of 10 a 24-hour skilled nursing home care seem necessary; and patients and their families were unfamiliar with adult day care facilities, although they have existed for more than 30 years. Most patients and their families know what nursing homes and home care are, and they receive visits from those facilities representatives during their hospital stay. Adult day rehab services, says Program Director Allison Nidetz, need similar exposure. Increasing awareness of short-stay adult day rehab services, which is even more specialized and brand new, will continue to be a challenge. Thus, the biggest challenge was marketing the program in order to increase both discharge planners and potential participants familiarity with and enthusiasm for it. Although some time was lost waiting for the NYU referral arrangement to result in success, VCNY soon refocused pilot participant recruitment efforts, and ultimately, recruited participants from patients being discharged from shortterm skilled nursing care. Finally, without a large enough treatment group, it remains a challenge to generate evidence of cost savings, which is needed to persuade Medicare and private payers to cover adult day rehabilitation, and to replicate the model at other facilities. VI. Key Findings A total of 53 individuals participated in the pilot, referred mostly by physicians and skilled nursing facility discharge planners. Of the 174 individuals who were referred for the intervention, 53 (30%) participated, and 35 of them (20%) completed participation. Those who dropped out were very frail or preferred home care, citing too long of a day or too burdensome of a commute. Staff interviews suggested that the program worked best for individuals with less acute conditions. To evaluate participant improvements, satisfaction, and post-discharge experiences, a post-discharge survey was administered to the 35 participants who completed the full program, by mail (with telephone completion calls made for those who did not respond), five months after their discharge. An additional telephone survey was conducted 12 months after program discharge to inquire about any further hospital admissions. The Lewin Group analyzed the survey results and found: 23% improved ADL functionality; 94% remained fully compliant with their medications; only 6% were re-hospitalized after 12 months (with one of those hospitalizations for a pre-existing condition ); and 14% improved their social interaction. Caregiver feedback was positive, citing a relief of burden and reduced stress. Although re-hospitalization information was not available for a comparison group, the 6% rehospitalization rate in the pilot group is substantially lower than the reported 45% among stroke and CHF patients, and also substantially lower than the 56.1% readmission rate reported for Medicare FFS beneficiaries in the New England Journal of Medicine article in S. F. Jencks, M. V. Williams, and E. A. Coleman, Rehospitalizations among patients in the Medicare fee-for-service program, New England Journal of Medicine, 360 (April 2, 2009):
8 Page 8 of 10 VCNY presented the activities and results of the program to long-term care audiences, including an online presentation for the National PACE Association in January 2008, which highlighted preliminary evaluation findings; a formal presentation at the National Council on Aging/American Society on Aging s annual national conference in March 2008; and an updated presentation at the New York Association of Homes and Services for the Aging Annual Spring Institute in June Although the results on the small sample are promising, the grantee ultimately concluded that shortstay adult day rehabilitation is not a viable post-acute option under current conditions. Recruiting participants was far too difficult, and the staff observed that the program mostly benefited less acute individuals. As such, a Medicare demonstration was not pursued, nor were plans to replicate the program in other New York ADHCs. VII. Lessons Learned Perhaps the biggest lesson learned from this pilot program was that without the evaluation and recommendation being completed by a physiatrist or other inpatient professional, participation would never be substantial. Moreover, such services will not be of interest to managed care companies, the Medicare program, and other payers without evidence of cost savings. Thus, any effort to adapt adult day health care for use as an alternative to traditional sub-acute care must begin with a prolonged marketing campaign to familiarize inpatient professionals and providers who are often unfamiliar with adult day health care about its benefits and the type of patient most likely to benefit. Until a sufficient number of patients participate in a post-acute adult day health care program, it will remain difficult to collect enough data to perform cost-benefit analyses. What is needed, as Nidetz has said, is a managed care company that is willing to take a risk and try it. Other lessons learned include the following: In the absence of opportunities to socialize, loneliness can be debilitating and depressing for both the patient and caregiver. Socialization which is intrinsic in ADHC settings should be considered in post-acute recovery, and efforts to capitalize on this feature should be promoted. The current regulations for ADHCs in New York State limit its application for health delivery improvement. For example, a minimum of a five-hour day not only limits the Center s appeal to consumers, but also adds significant cost. Studies continue to show the benefits of group physician visits and group physical therapy which ADHCs are well poised to provide but requirements for additional services, such as meals and recreation therapy, create barriers to use these existing resources for new purposes. Changes in ADHC regulations, which enable the program to simultaneously provide a group therapy option for Medicare payment, must be explored.
9 Page 9 of 10 Finally, hospital discharge planning is an area in great need of reform. Even in the face of continuous studies showing excessive re-hospitalization rates, 13 discharge planning practices and relationships remain entrenched. At the same time, New York State has a wealth of long-term care resources Skilled Nursing Facilities, ADHCs, Home Care, Assisted Living, and even informal caregivers that may be better applied to prevent re-hospitalizations. Without incentives for acute care hospitals to vary their discharge planning according to patient risk, however, the potential to best utilize these resources is lost. VIII. The Future The results of this pilot suggest that a potential market may exist to expand ADHCs role in post-acute recovery in New York, but more results are needed. While the VCNY pilot revealed that ADHCs, given current conditions and discharge planning traditions, do not represent a viable post-acute delivery option, it also detailed the equipment needs, staff training needs, outreach opportunities, participant preferences, and barriers to be addressed in their efforts to become comprehensive rehabilitation centers. For community-dwelling older adults who have been hospitalized, short-stay adult day rehabilitation holds promise as the means to maintain functional abilities, increase socialization, and prevent depression. This is consistent with past findings on ADHCs. 14 The overall results suggest that adult day rehabilitation services should not be limited to Medicaid clients and those who can afford to pay outof-pocket. Elderly individuals and those with diverse conditions and health/rehabilitation needs may benefit from the ADHC combination of therapy and group interventions. Hence, future projects might consider targeting a broader pool of participants. The VCNY pilot also underscored the importance of educating the public and other providers about ADHCs. A potential strategy for such marketing would be to partner with the New York Connects program, which provides New Yorkers with information about their long-term care options, similar to Aging and Disability Resource Centers in other states. Future adult day rehabilitation projects will need to invest considerable time and effort into participant recruitment and social marketing. With more familiarity of adult day health care and more active involvement of inpatient professionals in evaluation and recommendation, sufficient Day Rehabilitation participants can be recruited, and evidence for cost-savings will be collected. 13 S. F. Jencks, M. V. Williams, and E. A. Coleman, Rehospitalizations among patients in the Medicare fee-for-service program, New England Journal of Medicine, 360 (April 2, 2009): Janet O Keeffe and Kristin Siebenaler, Adult Day Services: A Key Community Service for Older Persons (Washington, D.C.: U.S. Department of Health and Human Services, Office of Disability, Aging and Long-Term Care Policy, July 2006).
10 Page 10 of 10 BACKGROUND INFORMATION: ABOUT THE GRANTEE Village Care of New York is a community-based, not-for-profit organization providing health and supportive services for the elderly, persons living with HIV/AIDS, and others with chronic and disabling conditions. Its mission is to accept people as they are, and engage them in an interactive process that moves them along on a path to better health and well-being. Village Care of New York comprises two skilled nursing facilities, four adult day health care centers, a certified home health care agency, a licensed home care services agency, a long-term home care program, a case management program serving both people living with HIV/AIDS and Adult Protective Services clients, ambulatory primary care, and a citywide food and nutrition program. The Village Adult Day Health Center, run by the Village Center for Care (a VCNY subsidiary), is a freestanding facility providing full-time nursing, rehabilitative, nutrition and case management services, combined with therapeutic recreation and meals. Every year the Center serves nearly 300 individuals with a variety of chronic and disabling conditions, almost all of them Medicaid recipients. GRANTEE CONTACT Allison Silvers Director, Strategic Planning 154 Christopher Street New York, NY Phone: (212) Fax: (212) Web address: NYSHealth contact George Suttles GRANT ID #