Inpatient Rehabilitation in Canada

Transcription

1 Inpatient Rehabilitation in Canada N a t i o n a l R e h a b i l i t a t i o n R e p o r t i n g S y s t e m

2 All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying and recording, or by any information storage and retrieval system now known or to be invented, without the prior permission in writing from the owner of the copyright, except by a reviewer who wishes to quote brief passages in connection with a review written for inclusion in a magazine, newspaper or broadcast. Requests for permission should be addressed to: Canadian Institute for Health Information 495 Richmond Road Suite 600 Ottawa, Ontario K2A 4H6 Phone: Fax: ISBN (PDF) 2008 Canadian Institute for Health Information How to cite this document: Canadian Institute for Health information, Inpatient Rehabilitation in Canada, (Ottawa: CIHI, 2008). Cette publication est aussi disponible en français sous le titre Réadaptation pour patients hospitalisés au Canada, ISBN (PDF) The 18-item FIM instrument and the Rehabilitation Client Groups referenced herein are the property of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. Rehabilitation Client Groups: Copyright 1997, Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc., all rights reserved.

3 Inpatient Rehabilitation in Canada, Table of Contents Acknowledgements... v Executive Summary...vii Introduction and Background... 1 Objectives of the Report... 1 About the Canadian Institute for Health Information (CIHI)... 2 About the National Rehabilitation Reporting System... 3 The National Rehabilitation Reporting System Data Set... 3 The FIM Instrument... 4 Scope of Participation in the National Rehabilitation Reporting System... 4 Data Quality and the National Rehabilitation Reporting System... 5 Chapter 1. Characteristics of Inpatient Rehabilitation Clients... 7 Chapter Key Findings... 7 Facility Type... 7 Admission Class... 8 Source of Referral to Rehabilitation... 9 Days Waiting for Admission How have wait times changed over time? Demographic Characteristics Length of Stay Reasons for Discharge Services Referred to at Discharge Where do people go after their inpatient rehabilitation stay? Chapter 2. Rehabilitation Client Groups Chapter Key Findings Overall Distribution of Rehabilitation Client Groups Rehabilitation Client Group by Type of Facility Days Waiting for Admission Demographic Characteristics Total Function Scores Change in Total Function Scores From Admission to Discharge Do all clients improve in function during their inpatient rehabilitation stay? Length of Stay How has length of stay (LOS) changed over time? Length of Stay Efficiency Pre-Admission and Post-Discharge Living Setting... 32

4 Conclusions and Future Directions Appendix A: NRS Glossary of Terms Appendix B: Rehabilitation Client Groups (RCGs) Definition of Rehabilitation Client Group (RCG) Appendix C: FIM Instrument Subscales and Domains Appendix D: Methodological Notes Scope of Participation in the National Rehabilitation Reporting System Records Included in This Report Tables and Statistics for This Report Data Suppression Computations Appendix E: List of Quick Stats Tables List of Tables Table 1-1 Facility Types in the NRS, Table 1-2 Table 1-3 Table 2-1 Demographic Characteristics of Inpatient Rehabilitation Clients With Data in the NRS, Canadian Population for 2006 and Inpatient Rehabilitation Clients With Data in the NRS by Age Group and Sex, Demographic Characteristics of Inpatient Rehabilitation Clients With Data in the NRS by RCG, Table D-1 NRS Clients With Multiple Episodes of Care,

5 List of Figures Figure 1-1 Figure 1-2 Figure 1-3 Figure 1-4 Type of Admission to Inpatient Rehabilitation by Facility Type, Source of Referral to Inpatient Rehabilitation by Facility Type, Distribution of Days Waiting for Admission to Inpatient Rehabilitation, Cumulative Length of Stay in Inpatient Rehabilitation by Facility Type, Figure 1-5 Reasons for Discharge From Inpatient Rehabilitation, Figure 1-6 Figure 2-1 Figure 2-2 Figure 2-3 Figure 2-4 Figure 2-5 Figure 2-6 Figure 2-7 Services Referred to After Discharge From Inpatient Rehabilitation, Distribution of Inpatient Rehabilitation Clients by Rehabilitation Client Group, Distribution of Rehabilitation Client Groups by Facility Type, Median Days Waiting for Admission to Rehabilitation by Rehabilitation Client Group, Distribution of Admission and Discharge Total Function Scores of Inpatient Rehabilitation Clients, Distribution of Change in Total Function Score From Admission to Discharge, Admission and Discharge Total Function Scores by Rehabilitation Client Group, Median Length of Stay of Inpatient Rehabilitation Clients by Rehabilitation Client Group, Figure 2-8 Cumulative Length of Stay for Selected RCGs, Figure 2-9 Receipt of Paid Health Services in the Home After Discharge for Clients Who Were Living at Home Prior to Admission by Rehabilitation Client Group,

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7 Acknowledgements Acknowledgements The Canadian Institute for Health Information (CIHI) wishes to acknowledge and thank the National Rehabilitation Reporting System (NRS) team for its contribution to Inpatient Rehabilitation in Canada, This report was produced by the Rehabilitation program area at CIHI. This report could not have been completed without the generous support and assistance of staff at participating NRS facilities. CIHI 2008 v

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9 Executive Summary Executive Summary Through analysis of client and facility characteristics, Inpatient Rehabilitation in Canada, presents a snapshot of the clients who received rehabilitation in inpatient rehabilitation facilities that participate in the National Rehabilitation Reporting System (NRS) and the outcomes of their care. The goal of the report is to enhance knowledge about inpatient rehabilitation services in participating facilities across the country. This report reveals a number of key findings pertaining to clients admitted to inpatient rehabilitation facilities that participate in the NRS: The vast majority of clients were successful in their rehabilitation programs; 89% of them returned to their pre-admission living setting following discharge from inpatient rehabilitation, with 84% returning to a private house or apartment. In addition, 91% of clients were determined to have sufficiently met their service goals upon discharge. Almost half (47%) of all clients received rehabilitation relating to orthopedic conditions, with an additional 16% receiving rehabilitation following a stroke. Greater gain, on average, in Total Function Score is seen for clients in major multiple trauma (29.6) and burn (22.6) Rehabilitation Client Groups (RCGs); lesser gain, on average, in Total Function Score is seen for clients in pulmonary (11.3) and arthritis (11.6) RCGs. In addition, the report reveals some distinct differences in the client groups, demographics and lengths of stay of clients admitted to specialty and general rehabilitation facilities. Clients in the brain dysfunction, spinal cord injury and burn RCGs, among others, were much more likely to be admitted to a specialty facility than to a general facility, whereas clients in the orthopedic, debility and arthritis RCGs, among others, were much more likely to be admitted to a general facility. Differences seen in the demographics and lengths of stay between the two facility types may very well be related to the differences in client groups admitted. Information in this report will be of interest to clinicians and managers in the facilities that participate in the NRS, as well as to system planners, policy-makers, researchers and the public. While inpatient rehabilitation is only one part of the continuum of rehabilitation, the report s findings suggest that it provides an important role in ensuring that Canadians maintain functional independence and autonomy after an injury or illness or following surgery. CIHI 2008 vii

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11 Introduction and Background Introduction and Background Objectives of the Report Inpatient Rehabilitation in Canada, is the fifth public report based on data from the National Rehabilitation Reporting System (NRS). The Canadian Institute for Health Information (CIHI) developed the NRS to support inpatient rehabilitation service planning and policy development. Data are available for inpatient rehabilitation episodes from fiscal year onwards. This year s report provides information on inpatient physical rehabilitation services that occurred between April 1, 2006, and March 31, 2007, in participating rehabilitation facilities. This report was developed to provide information for people involved with or interested in the provision of inpatient rehabilitation services, including clinicians, hospital managers, system managers and policy-makers. The overall goal of the report is to enhance knowledge about inpatient rehabilitation services in participating facilities across the country. In doing so, CIHI hopes to facilitate discussion on the current state of hospital-based rehabilitation and on future challenges and opportunities facing the sector. Specific objectives for this report are: to provide background information on the NRS; to present aggregate data from the NRS; and to stimulate discussion on the information needs for the inpatient rehabilitation sector and further enhancement of the NRS. Inpatient Rehabilitation in Canada, contains two chapters. While there may be few changes in patterns of rehabilitation services in a single year, data received since the NRS s inception make trending analyses possible. A few of these trends are highlighted in text boxes throughout the report. Chapter 1 provides an overview of the socio-demographic characteristics of the clients who were discharged from participating facilities following rehabilitation during Chapter 2 presents information on clients, as grouped in the Rehabilitation Client Groups (RCGs) i reported in the NRS. Indicators are presented for the various groups, including days waiting for admission to rehabilitation and reasons for discharge. This chapter also introduces analyses on clinical outcomes assessed during inpatient rehabilitation. i. Rehabilitation Client Groups (RCGs) adapted with permission from the UDSMR impairment codes. Copyright 1997 Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc., all rights reserved. CIHI

12 Inpatient Rehabilitation in Canada, While many readers may be familiar with the concepts used within this report, others may be encountering NRS data for the first time. A glossary of terms (Appendix A) is included at the end of the report. Appendix B contains a brief description of each Rehabilitation Client Group. More details on the items assessed by the FIM instrument, ii a standardized assessment tool developed by Uniform Data System for Medical Rehabilitation (UDSMR), are available in Appendix C. More detailed notes on specific methodologies used in the report are referenced in Appendix D. These appendices will assist readers in understanding the terms and definitions commonly used in the NRS. Q Wherever the icon above appears beside the text, it indicates that the aggregate data used to produce the figures in this report are available on the CIHI website at by selecting Quick Stats from the menu bar and selecting From Source NRS. A complete list of tables in Quick Stats is also available in Appendix E. NRS Quick Stats are presented in one of two ways: 1. Pre-formatted tables that provide a snapshot of the data. Frequently, these have been published in analytic products such as annual reports or Analyses in Brief. 2. Interactive data that provide a dynamic presentation of health statistics, in which data can be manipulated, printed and exported. About the Canadian Institute for Health Information (CIHI) CIHI collects and analyzes information on health and health care in Canada and makes it publicly available. Canada s federal, provincial and territorial governments created CIHI as a not-for-profit, independent organization dedicated to forging a common approach to Canadian health information. CIHI s goal: to provide timely, accurate and comparable information. CIHI s data and reports inform health policies, support the effective delivery of health services and raise awareness among Canadians of the factors that contribute to good health. For more information, visit the CIHI website at ii. The FIM instrument and impairment codes referenced herein are the property of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. 2 CIHI 2008

13 Introduction and Background About the National Rehabilitation Reporting System Hospital-based inpatient rehabilitation is an important component of the continuum of health services in Canada. By facilitating the collection of standardized information on rehabilitation clients, the NRS provides an opportunity to enhance the knowledge surrounding inpatient rehabilitation services across the country. These rehabilitation services are provided in specialized rehabilitation facilities or in general hospitals with rehabilitation units, programs or designated beds. Inpatient rehabilitation clients receive services provided by health professionals such as nurses, physiotherapists, occupational therapists and physicians specializing in physical medicine and rehabilitation. These professionals assist clients in maximizing their physical and cognitive function through training and education, and prepare them to return to the community following illness or injury. Clients reported in the NRS include only those with a primary health condition that is physical in nature. As such, the term rehabilitation in the context of NRS reporting does not include rehabilitation services provided for a mental health condition or for drug or alcohol addiction. A cornerstone of the NRS is the concept of human function and the focus of rehabilitation in assisting individuals to achieve maximum independence in daily living, be it at home or in an assisted-living facility. The NRS indicators and reports provide a source of information for defining and describing functional outcomes for individuals who have received rehabilitation services. For greater comparability, this information is grouped according to the nature of the illness or injury. These groups form the basis for NRS reporting and are known as Rehabilitation Client Groups (RCGs). There are 17 major RCGs, including conditions such as stroke, limb amputation and brain injury. (See Appendix B for a complete list.) The National Rehabilitation Reporting System Data Set The NRS data set consists of 75 data elements grouped into the following major categories: Client Identifiers: These are data elements used to identify individual records. Client names are never collected for the NRS database. Socio-Demographics: Information such as birth date, sex, living arrangements and vocational status are collected to describe the types of clients admitted to rehabilitation programs. Administrative: Data are collected on wait times for admission and discharge, service interruptions, and provider types in order to better understand accessibility to rehabilitation, factors influencing length of stay and resource utilization. Health Characteristics: Diagnoses and related co-morbidities at admission provide information on conditions most often seen in a rehabilitation setting and conditions that may affect a client s ability to progress in the rehabilitation program. Activities and Participation: This is the largest section of the NRS data set and contains clinical assessments of motor and cognitive functional abilities of rehabilitation clients. The data are collected primarily using the 18-item FIM instrument and six additional elements developed at CIHI that provide further information on cognitive abilities. CIHI

14 Inpatient Rehabilitation in Canada, Facilities collect the data when clients are admitted to and when they are discharged from an inpatient rehabilitation program. Facilities can also choose to complete an optional follow-up assessment on their clients between three and six months following discharge from the program. Collection of this follow-up information provides an opportunity to assess sustainability of functional outcomes that were gained during rehabilitation, as well as the level of client re-integration into the community. The FIM Instrument The FIM instrument is a standardized assessment tool developed by Uniform Data System for Medical Rehabilitation (UDSMR) and is used in the NRS to measure functional independence. The FIM instrument is a measure of disability and looks at the caregiver burden associated with the level of disability. (See Chapter 2 and Appendix C for more details.) Scope of Participation in the National Rehabilitation Reporting System At the end of the fiscal year, 94 inpatient rehabilitation facilities in seven provinces were submitting data to the NRS. Facilities in Prince Edward Island and Manitoba began submission in Participation in the NRS is primarily voluntary in most provinces and efforts continue to promote the value of NRS participation across the country. 4 CIHI 2008

15 Introduction and Background Data Quality and the National Rehabilitation Reporting System Data quality is paramount to CIHI s work, and analysis of the quality of the data in all reporting systems, including the NRS, is an integral part of maintaining these information systems. CIHI has incorporated five dimensions of data quality into its corporate Data Quality Framework, first implemented during When used as a conceptual framework, these dimensions facilitate the assessment of data quality in many types of system-level data holdings. The framework implementation is part of the larger data quality cycle at CIHI in which issues are identified, addressed, documented and reviewed on a regular basis. It also standardizes information on data quality for users and helps to identify priority issues, which in turn is intended to trigger continuous improvements. The five dimensions of data quality assessed at CIHI are: 1. Accuracy: a measure of how well information within a database reflects what was supposed to be collected 2. Comparability: a measure of the extent to which a database can be properly integrated within broader health information systems 3. Timeliness: a measure of whether the data are available for user needs within a reasonable time period 4. Usability: a measure of how easily the storage and documentation of data allow users to utilize the data intelligently 5. Relevance: a measure of incorporation of all of the above dimensions to some degree, but focusing specifically on value and adaptability CIHI conducts regular data quality assessments on the NRS with respect to coding guidelines, data collection software specifications and other validation procedures in order to identify areas of strength and weakness. The five dimensions stated above are used to guide the ongoing evaluation. Areas needing improvement are flagged for further action. CIHI uses this information both internally for data quality improvement and externally to respond to stakeholder inquiries. CIHI

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17 Chapter 1. Characteristics of Inpatient Rehabilitation Clients Chapter 1. Characteristics of Inpatient Rehabilitation Clients This chapter provides information on all inpatient rehabilitation activity reported to the National Rehabilitation Reporting System (NRS) in the April 1, 2006, to March 31, 2007, reporting period. All of the information is drawn from data in the NRS database at CIHI. As of the fiscal year submission deadline (May 2007), 94 facilities from Newfoundland and Labrador, Nova Scotia, New Brunswick, Ontario, Saskatchewan, Alberta and British Columbia had submitted data to CIHI. At the present time, approximately 86% of the NRS data are submitted by participating NRS facilities in Ontario. Participating facilities submit data that are collected when rehabilitation clients are admitted to the facility and again just prior to discharge. The analyses in this report are based primarily on information from the 33,879 clients who were discharged from participating facilities during and for whom complete admission and discharge assessments were submitted to and accepted by CIHI. Chapter Key Findings Almost two-thirds (64%) of all clients were admitted to general facilities, and one-third (36%) were admitted to specialty facilities. The median length of stay (LOS) for clients in general facilities was 14 days; median LOS for clients in specialty facilities was 30 days. Ninety-one percent of all clients were determined to have sufficiently met their service goals upon discharge. Clients discharged from general facilities were more likely to be referred to home care agencies than those discharged from specialty facilities (43% versus 22%). Most clients (89%) returned to their pre-admission living setting following discharge from inpatient rehabilitation, the majority going back to a private house or apartment (84%). Facility Type Facilities participating in the NRS are classified as either general or specialty. This classification is specific to the NRS and is intended to facilitate comparative reporting; it is not necessarily consistent with facility classification methods used in various provinces or regions. The NRS defines a general rehabilitation facility as a rehabilitation unit or collection of beds designated for rehabilitation purposes. The general rehabilitation facility is part of a general hospital offering multiple levels or types of care. A specialty rehabilitation facility is one that provides more extensive and specialized inpatient rehabilitation services and is commonly a freestanding facility or a specialized unit within a hospital. The rehabilitation team at the facility decides which profile most closely represents its rehabilitation program(s) and categorizes itself as general or specialty when beginning submissions to the NRS. CIHI

18 Inpatient Rehabilitation in Canada, As shown in Table 1-1, in , 71% of facilities submitting data to the NRS classified themselves as general facilities and 29% classified themselves as specialty facilities. Of all clients admitted to NRS participating facilities, 64% were admitted to general rehabilitation facilities and 36% to specialty rehabilitation facilities. Table 1-1 Facility Types in the NRS, General Facilities Specialty Facilities All Facilities Facilities submitting to NRS in Number Percent Number Percent Number Percent Discharges 21, , , Note Refers to clients discharged in with complete admission and discharge assessments. Source National Rehabilitation Reporting System, Canadian Institute for Health Information, Admission Class Admission class refers to the type of inpatient rehabilitation admission. Initial rehabilitation refers to clients who are admitted for the first time to an inpatient rehabilitation facility for a given health condition (RCG). Short stay refers to clients who are primarily admitted to inpatient rehabilitation for a period lasting between 4 and 10 days. Re-admission refers to all clients who have received rehabilitation services relating to a condition for which they had previously received inpatient rehabilitation. Continuing rehabilitation refers to clients who were transferred directly to a rehabilitation facility from another inpatient rehabilitation unit or program for ongoing treatment of the existing illness or injury. The remaining admission class in the NRS is referred to as (un)planned discharge. Due to the short admission time frame (three days or fewer), the data collected on these clients are minimal, and a separate discharge assessment is not completed. In , (un)planned discharges accounted for 2,237 records in the NRS. The majority of analyses in this report include only those 33,879 clients for whom complete admission and discharge assessments were submitted, and therefore do not include the very small number of clients in the (un)planned discharge admission class. For more information, please see Appendix D. Q As seen in Figure 1-1, the majority of clients admitted to inpatient rehabilitation in were classified as initial rehabilitation. When accounting for facility type, general facilities had a lower proportion of initial rehabilitation clients (82%) compared to specialty facilities (95%). In contrast, 99% of clients categorized as short stay were admitted to general facilities, accounting for more than 15% of all admissions to general facilities reported in the NRS. Sixty-five percent of inpatient rehabilitation clients with data in the NRS classified as re-admission or continuing rehabilitation were admitted to specialty facilities, and together these two admission classes accounted for just more than 5% of all admissions to specialty facilities. (Quick Stats Table 1-1) 8 CIHI 2008

19 Chapter 1. Characteristics of Inpatient Rehabilitation Clients Figure 1-1 Type of Admission to Inpatient Rehabilitation by Facility Type, Percent of Clients Initial Rehabilitation Short Stay Re-Admission Continuing Rehabilitation Type of Admission (N = 33,879) General Facilities Specialty Facilities Source National Rehabilitation Reporting System, Canadian Institute for Health Information, Q Source of Referral to Rehabilitation The source of referral in the NRS is the facility, agency or individual that initiated the referral of the client for admission to rehabilitation. Differences exist among the referral sources of clients based on facility type. As shown in Figure 1-2, 69% of NRS clients admitted to general facilities were referred from an inpatient acute care unit of the same facility, and 26% were referred from an inpatient acute care unit of a different facility. In contrast, only 8% of clients admitted to specialty facilities were referred from an inpatient acute care unit within the same facility, while 78% were referred from inpatient acute care at a different facility. This is consistent with the commonly used definition of a specialty facility as being a freestanding building with a focus on rehabilitation services rather than on acute care services, and therefore receiving the majority of their clients from other facilities. (Quick Stats Table 1-2) CIHI

20 Inpatient Rehabilitation in Canada, Figure 1-2 Source of Referral to Inpatient Rehabilitation by Facility Type, Percent of Clients Inpatient Acute Unit, Same Facility Inpatient Acute Unit, Different Facility General Facilities Source of Referral (N = 33,879) Private Practice Specialty Facilities Other or Unknown Sources Source National Rehabilitation Reporting System, Canadian Institute for Health Information, Days Waiting for Admission The days waiting for admission indicator in the NRS refers to the number of days from the date a client is deemed ready for inpatient rehabilitation to the date he or she was actually admitted. The date ready for admission refers to the date that the client was clinically ready to start a rehabilitation program and met the criteria for admission to the rehabilitation facility. The date ready for admission is determined by the rehabilitation program accepting the client or by the referring facility, depending on the admission process at a particular facility. It does not refer to the date the client was put on a waiting list if this was done prior to when the client was clinically ready for rehabilitation. The NRS makes an allowance for the fact that the date ready for admission to rehabilitation is not always easily ascertained. Where this is the case, facilities may indicate on the admission assessment that the date ready for admission was not known. During , the date ready for admission was not known for almost one-sixth (16%) of clients during the fiscal year. Records where the date ready for admission was not known are excluded from the analyses for this section. Therefore, the information and data provided in the following paragraphs are based on the 28,539 records where the date ready for admission was known. As part of its ongoing data quality monitoring activities, CIHI has identified this as a potential issue and has initiated further investigation and action to address coding unknown for this data element. 10 CIHI 2008

21 Chapter 1. Characteristics of Inpatient Rehabilitation Clients Q Figure 1-3 shows that, as with some other indicators, when compared by facility type, differences exist between general and specialty facilities. Among clients who were admitted to a specialty facility, 30% were admitted the day they were deemed ready for admission, and a further 26% waited only one day. Fourteen percent of clients waited more than a week, and 3% waited more than one month. Among clients who were admitted to a general facility, 67% were admitted the day they were deemed ready for admission, and a further 14% waited only one day. Four percent of clients waited more than a week, and less than one-half of one percent waited more than one month. (Quick Stats Table 1-3) This is consistent with the finding that the majority of clients admitted to general facilities were referred by the inpatient acute care unit of that same facility, whereas specialty facilities often receive their clients from another facility. The inter-facility processes required for admission to specialty facilities for rehabilitation may contribute to the variation suggested by the NRS data. It is also possible that the variation may reflect differences in the RCGs seen by the two facility types. For example, a greater number of clients with neurological conditions are seen in specialty facilities and have longer wait times than clients with orthopedic conditions. Chapter 2 contains some analyses to explore this issue further. Figure 1-3 Distribution of Days Waiting for Admission to Inpatient Rehabilitation, Percent of Clients General Facilities Number of Days (N = 28,539) Specialty Facilities Source National Rehabilitation Reporting System, Canadian Institute for Health Information, CIHI