Selection of Post-Acute Rehabilitation Facilities in the Northeast: A Survey of Discharge Planners

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1 Selection of Post-Acute Rehabilitation Facilities in the Northeast: A Survey of Discharge Planners Alyse Sicklick, MD, Joel Stein, MD, Robin Hedeman, OTR, MHA, Janet Prvu Bettger, ScD, Zainab Magdon-Ismail, Ed.M., MPH, Lila Martin, BS., 1 Northeast Cerebrovascular Consortium, 2 Department of Rehabilitation and Regenerative Medicine, Columbia University, 3 Division of Rehabilitation, Weill Cornell Medical College, 4 NewYork-Presbyterian Hospital, 5 Duke University School of Nursing, 6 Gaylord Specialty Hospital, 7 Kessler Institute for Rehabilitation, 8 American Heart Association International Stroke Conference 2014 On behalf of the Northeast Cerebrovascular Consortium (NECC) Rehabilitation & Recovery Workgroup Alyse Sicklick, MD Gaylord Specialty Healthcare, CT asicklick@gaylord.org

2 Faculty Disclosure Alyse Sicklick, MD Selection of Post-Acute Rehabilitation Facilities in the Northeast: A Survey of Discharge Planners Financial Disclosure: None Unlabeled/unapproved Uses Disclosure: None

3 NECC Background Established in Dedicated to Improving Stroke Care Across the Northeast (Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island and Vermont). The Consortium has focused on 7 key components of the Stroke System of Care from Primary Prevention through Rehabilitation.

4 NECC Rehabilitation Recommendations 1. All hospitalized stroke patients should be assessed for and referred to the appropriate level of post-stroke care. 2. Every stroke patient's functional status should be assessed during inpatient hospitalization with a standardized screening and assessment tool. 3. States within NECC should develop a uniform set of stroke rehabilitation quality measures. 4. Advocacy organizations should focus on ensuring that adequate rehabilitation resources exist within the NECC region.

5 NECC Discharge Planner Survey Process of determining the level and type of post-acute care for stroke patients has not been adequately studied. We surveyed stroke discharge planners regarding this process, and examined the factors perceived to influence the selection of post-acute care. Requests were sent to 471 acute care hospitals within the eight states in the Northeast Cerebrovascular Consortium. Experienced nurses and social workers responded (81.7% and 16.9% respectively, with 73% reporting >20 years healthcare experience) from 71 hospitals.

6 Demographics Respondents: were female (97.2%) were nurses (81.7%) Hospitals: had a designated unit for stroke patients (69%) identified as a voluntary-non profit (80.3%) identified as a teaching hospital (57.7%)

7 Professional Background of Respondents 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 81.7% 16.9% 0.0% 5.6% Nurse Social Worker PT/OT/ Speech Therapist Other

8 Years of Healthcare Experience 3% 73% 16% 8% greater than 20

9 Hospital Location 19.7% 32.4% Urban Suburban Rural 47.9%

10 Hospital Size 7.0% 5.6% 4.2% <50 beds 16.9% beds 11.3% 18.3% beds beds beds beds 36.6% >=800 beds

11 Who influences discharge destination? Greatest Influence: Discharge Planners Physical Therapists Patients/Families Less influence: Physicians (p<0.001).

12 Typical Level of Influence at Hospital 1=Lowest 10=Highest Case Manager/Social Worker/Discharge Planner Patient/family Physical Therapist Occupational Therapist Speech/Language Therapist Hospitalist/Internist Neurologist Nurse Physiatrist (Rehab Physician) Other Physician Neurosurgeon

13 Which factors influence care? Multiple factors were perceived to influence decision planning for post-acute facility type. Quality of post-acute facility received the highest ranking, closely followed by insurance. For patients and families, location seemed to be the largest driver in selection of a post acute provider.

14 Importance of Factors that Influence the Selection of a Post Acute Care Facility 1=Lowest 10=Highest Quality of post-acute facility Insurance Prognosis for functional improvement Stroke severity Likelihood of ultimate return to the community Location of post-acute facility Patient motivation Cognitive/Communication impairments Pre-stroke functional status Medical comorbidities/complexity Mobility (e.g. ability to walk, transfer) Ability to to perform ADLs ADL s Patient age Affiliation of post-acute facility with my hospital/health system Immigration Status (i.e. illegal immigrant)

15 For patients and their families, what is the number one driver in discharging patients to a post acute care provider? 6.0% 4.5% 14.9% Available bed Location (proximity to patient and or family) Physician recommendation 25.4% 1.5% 7.5% 40.3% Case Manager recommendation Patient/family preference Reputation Other-Please specify what other represents

16 The Need for Speed Is there pressure to discharge patients quickly?

17 How frequently does the speed with which you are able to discharge a stroke patient impact his or her final destination? 7.2% 4.3% 13.0% Always Very Frequently Frequently 39.1% Rarely Never 36.2%

18 Barriers to referring patients to appropriate level of care/facility Insurance was identified by 48% as the single greatest barrier in referring stroke patients to the most appropriate level of post acute care. The most significant barriers to referring patients to the most appropriate specific facility for post-acute care, were insurance (27%), bed availability (18%), and facility location (8%).

19 Conclusions Discharge planners in this sample perceive insurance as a major barrier, and physicians to have a less influential role in determining post-acute care. The pressure to discharge patients rapidly often influences the selection of post-acute care. Findings suggest non-clinical factors may disproportionately affect post-acute care decision making for stroke survivors. Follow-up study.

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