Where Should Rehabilitation Take Place?!

Where Should Rehabilitation Take Place?!

Three Basic Questions! 1. Is rehabilitation effective in improving a patient s functional abilities?!yes" yes" 2. Is rehabilitation cost effective?!yes" where" yes" 3.Where should rehabilitation take place?"

! Inpatient Rehabilitation Hospital" vs.! Skilled Nursing Facility" (Nursing Home)! IRH" SNF"

Signs Changed! The mere changing of a sign from Nursing Home to Rehabilitation Center does not necessarily change what takes place inside.! signs"

! Research:" Animal Studies! Clinical Studies!

Neural Plasticity! Neural plasticity" The ability of the central nervous system (CNS) to adapt to injuries or environmental requirements.!

Rehabilitation Drives Recovery! Rehabilitation (learning) can drive recovery by rehabilitation" enhancing interconnections to reconfigure the! neural circuits and restore function.! restore function"

Rescue vs. Collapse! Intermediate loss of connections! Critical state! Either lose connectivity permanently or recover! Need REHAB!!

Dr. Nudo s Research! 3 groups of monkeys! Stroke with paralysis of the left arm! Dr. Nudo s research"

Dr. Nudo s Research! First group: No rehabilitation! Second group: Range of motion (ROM) exercises only! Third group: Rehabilitation incorporating functional tasks driven by activities of daily living (ADLs)! Dr. Nudo s research"

Third Group Conclusions! Neural bases for motor recovery after stroke" By permission of Academic Press, 1997!

Speed and Intensity Matters! During the initial four weeks after stroke, the brain is most receptive to regain or reroute lost functional area.! After initial recovery period, brain slowly recruits other areas of the brain to regain function.! American Scientist 2008! Azari and Seitz! Intensive weight supported treadmill training modifies brain mapping and promotes recovery of paralyzed legs! intensity" Journal of Rehabil Research & Dev 2008!!!!!Forrester, et al.! time"

AutoAmbulator!

Enriched Environment! Nature 1997 Kemperman, et al

Standard Environment! Nature 1997 Kemperman, et al

Comparing Clinical Environments! Characteristic! IRH! SNF! Attending MD Visit! Usually 5-7 times a week" Only required every 30 days! Multidisciplinary Team! Required" Not required! RN Oversight! 24 hours/day" At least 8 consecutive hours/day! Nursing hours per patient day! Between 6.0 and 7.5 hrs" Between 2.5 and 4.0 hrs! Specialty nursing/rehabilitation! Yes" Not required! PT/OT/Speech Therapy! 3 hrs/day 5 days per week minimum" No minimum!

! Evidence-Based Medicine" What does EBM tell us:! About stroke?! About other diagnoses?!!

Where Should Rehabilitation Take Place?! Evidence-Based Medicine Tells the Story!! Definition:! Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.!! definition" Centre for Evidence-based Medicine! Sackett, et al 1996!

Three Groups of Stroke Survivors! 10-20 % recover full independence in two weeks! 10-20 % have severe residual deficits! 60-80 % are in the middle group! stroke survivors"

Glass Ceiling Effect! If stroke survivors are denied access to inpatient rehabilitation hospitals, they may never be able to reach their full recovery potential.! rehabilitation"

Most Severely Affected Need Rehabilitation! Caregiver training!! Bladder and bowel! Seating and splinting! Feeding! need rehabilitation" Transfer techniques!

Are Managed Care Patients at a Disadvantage?! Outcome of Stroke Patients in Medicare Fee-for-Service and Managed Care! patient outcome" JAMA July 9,1997! Retchin, Brown, et al!

Study Results! less likely" HMO v. Fee-for-service patients:! HMO patients were less likely to be admitted to rehabilitation hospitals! HMO patients were more likely to be sent to nursing homes! nursing homes" Patients going to rehabilitation hospitals were three times more likely to go home than patients going to nursing homes! to go home"!!!!!!! 3x"more likely"!!!!!!!jama July 9, 1997!!!!!!!!Retchin, SM, Brown, RS, et al!

Compliance with Guidelines Matters! Agency for Healthcare Policy and Research (AHCPR) recommendations for post-acute stroke care! 288 patients! Evaluated compliance with guidelines! stroke" guidelines"

Dimensions of Care Duncan, et al! Multidisciplinary structure! Baseline assessment! Goal setting! Treatment plan! Monitoring of progress! Management of impairments! Prevention of complications! Family involvement! Patient and family education! Discharge planning! dimensions of" care"

Compliance with Guidelines Matters Duncan et al.! positive" Statistically significant positive association between compliance with guidelines and outcomes 6 months after stroke! Patients who receive rehabilitative care in a nursing home experience worse outcomes! worse" outcomes in" a nursing home"

Duncan s Conclusion: SNF Strategy Detrimental! This strategy (of sending patients to SNFs) is now shown to be potentially cost-ineffective over the longer term, being detrimental to patient recovery.! detrimental to patient"

Inpatient Rehab: Evidence-Based Choice for!! Severe Stroke! Stroke patients who are in formal rehabilitation have better outcomes than patients who are in nursing homes.! Over 63% were discharged home! over" 63" %"

Joint Replacements and Fractures! Advantages of IRH Care" Superior functional outcomes and shorter length of stay! More likely to attain 95% or more pre-fracture functional!status! Superior outcomes" 90 IRH SNF 60 80.2 75 30 0 10.3 LOS (days) 20.8 38.3 41.2 Walker at discharge (%) Need home care (%) Walsh et al 2006! Munin et al 2006!

JOINTS Study: IRH vs. SNF! IRF patients receive more intensive therapy, achieve functional gains more rapidly, and return home more quickly.! gains" IRFs exhibited higher length-of-stay efficiency.! higher efficiency" Gerben DeJong, Ph.D.! Principal Investigator, JOINTS Project!

Cardiopulmonary Patients! More patients achieved functional independence, had shorter length of stay, and had a higher rate of homebound discharge in the IRF than in SNF! Am J Phys Med Rehabil May 2008! Vincent and Vincent! superior outcomes"

! Interpreting the Evidence" What does EBM tell us?!

Kramer s Findings on SNFs! SNFs that met expert criteria had no better outcomes than traditional Skilled Nursing Facilities! no better outcomes" Top Stroke Rehabilitation 1997! Kramer, et al!

Comparing the Settings: SNF vs. IRH! SNF rehabilitation" The data clearly demonstrate that rehabilitation in a SNF is less effective.! less effective"

rehabilitation hospitals: Providing a Higher Level of Care! Physician availability and visits! Nursing hours/day! Nursing skill mix! Therapy hours! Case Management! higher" Level of" care"

rehabilitation hospitals: Demonstrating a Higher Level of Care! Outcomes Measurement (FIM)! Average length of stay! Patient satisfaction! Discharge to community! Quality of life issues! quality"

Demonstrating Results! FIM Measures 18 Items On a scale of 1 (most severe) to 7 (independent)!! Motor Items! Activities of Daily Living (ADLs, e.g. feeding, grooming, bathing, dressing)! Bowel and Bladder Control! Mobility (transfer to bed, toilet, tub/shower)! Locomotion (walking, stairs)! Cognitive Items! Communication! Social Cognition (problem solving, memory)! FIM"

Demonstrating Results! accurate" reliable" consistent" objective"

Function according to FIM Change! FIM Items When Admitted When Discharged Stairs Unable to even try stairs Able to walk up and down 4 stairs Walking Takes a few steps Walks 150 feet with someone steadying Showering Getting Dressed Going to the Bathroom Grooming Eating Problem Solving Comprehension Needs 1-2 people to help lift in and out of shower Requires assistance with more than 25-50% of dressing tasks Gets into tub or shower with someone steadying Patient requires some clothing to be gathered but patient dresses on own 1 person assists more than 50% Steadying while patient gets on or off toilet Requires assistance with more than 25% of grooming tasks Requires opening of containers and steadying during eating and drinking Requires assistance to solve very basic problems more than 25% of the time Requires cues to understand basic speech or reading 25% of the time Expression Requires cues to communicate 25% of the time Requires some grooming items to be gathered, then patient does own grooming Someone is with patient while eating to open containers or provide encouragement Solves basic problems such as knowing what to do to get meals, get dressed, stay warm, contact family, and move around the home. Requires occasional repeating less than 10% of the time Is asked to repeat words less than 10% of the time

Kramer s Conclusion on SNFs! Second to dying, nursing home placement" for an older person who was in the community! is the worst possible outcome.!

Summarizing the Evidence! Intensity of rehab drives success! Functional focus of rehab is crucial! Even modest functional improvement affects the future for people with severe impairments! Rehab hospitals are superior to nursing homes for achieving greater gains and getting patients home!

Be a Patient Advocate! There is only one failure in life possible, and that is not to be true to the best one knows.! George Eliot! aka Mary Ann Evans!