A Pilot Study: Post-Acute Geriatric Rehabilitation Versus Usual Care in Skilled Nursing Facilities

An Innovation Center Model to Transform Health Systems to Improve Care of Older Adults

The US population is aging faster than at any other time in our history. This growth, coupled with a slow adaptive health policy framework, is creating an urgent need to reengineer and improve the quality, safety, and cost-effectiveness of health systems to meet the needs of older adults and embrace the success we have achieved with longevity. Without rapid adoption of evidence-based models that are known to improve safety and health outcomes, we significantly jeopardize the lives of thousands of older adults receiving care under our current health systems' processes and models. This article describes an innovation and operations infrastructure that was successfully tested in two independent and geographically distinct community health systems. This operations and implementation framework can be scaled and used to accelerate the changes needed to improve care for older adults in health systems throughout the United States. J Am Geriatr Soc 68:15-22, 2019.

Facility-Level Factors and Outcomes After Skilled Nursing Facility Admission for Trauma and Surgical Patients

OBJECTIVE

Patients discharged to skilled nursing facilities (SNFs) have worse outcomes than those discharged to home, but whether this is due to differences in facility-level factors in addition to patient characteristics is not known. We aimed to determine whether SNF-level factors including nurse staffing and patient density are associated with outcomes after acute hospitalization for trauma or surgery.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

Retrospective study of patients discharged to Medicare-certified SNFs after trauma or major surgery from 2007 to 2009. We measured the ratio of beds per nurse and the proportion of trauma and surgery patients at each facility (density). Outcomes were 1-year mortality, hospital readmission, and failure to discharge home at first discharge disposition.

RESULTS

For 389,133 patients (mean age 78 years, 63% female) admitted to 3707 SNFs, mortality was 26%, hospital readmission 26%, and failure to discharge home 44%. After adjusting for patient-level factors, SNFs with fewer beds per nurse had lower odds of mortality [odds ratio (OR): trauma 0.84; (95% confidence interval: 0.77-0.91), surgery 0.80 (0.75-0.86)], readmission [OR: trauma 0.81 (0.74-0.88), surgery 0.71 (0.65-0.76)], and failure to discharge home [OR: trauma 0.82 [0.74-0.91], surgery 0.66 [0.60-0.72]). SNFs with greater density of specialty patients (>4.3% surgery, >14.1% trauma) had lower odds of readmission [OR: trauma 0.59 (0.53-0.66), surgery 0.62 (0.58-0.67)] and failure to discharge home [OR: trauma 0.48 (0.43-0.55), surgery 0.45 (0.42-0.49)].

CONCLUSIONS

There are modifiable SNF-level factors that influence long-term outcomes and may be targets for intervention. Staffing standardization and SNF specialization may reduce variation of quality in post-acute care.

Hospital readmission of skilled nursing facility residents: a systematic review

Hospital readmission of patients discharged to skilled nursing facilities (SNFs) is common and costly with increasing public attention over the past decade, particularly in light of the new health care environment surrounding the advent of the Affordable Care Act. The purpose of the current systematic review is to critically examine prevalence, predictors, and costs of hospital readmission of SNF residents found in the medical literature. Individual resident, facility, and intervention factors predicting hospital readmission of SNF residents were studied. Despite the heterogeneity of the reviewed articles' data sources and study designs, the existing literature asserts that hospital readmission of SNF residents is associated with individual resident and facility characteristics. Implementation of promising intervention programs can promote quality of care and reduce hospital readmission of SNF residents.

Long-term functional outcomes in the elderly after burn injury

Although the elderly represent a substantial proportion of the population, limited information exists on postdischarge long-term outcomes of elderly burn survivors. The purpose of this study was to assess elderly burn patient outcomes 2 to 10 years after discharge. This study was a prospective cross-sectional survey assessment of quality of life and retrospective trauma registry for the American College of Surgeons review of patients ≥ 60 years of age discharged alive after acute burn from 1997 to 2007. In-hospital treatment and burn demographic information were obtained from database and chart review. Surviving patients or their families were contacted, and the Short-Form-12 and Functional Independence Measure (FIM) administered. Of the 344 patients discharged, 232 participated. Mean age was 72.3 (60-85.8) years, TBSA burn was 7.8% (1-79), and length of stay was 11.2 ± 0.9 days (1-51). Most patients were discharged home (71%) or to a skilled nursing facility (SNF; 20%). Mean interval between discharge and survey administration was 46.1 months. In all, 24% of patients sent home died after discharge and prior to interview compared with 58% of patients sent to an SNF. On multivariate analysis, mortality increased with age (confidence interval [CI] 1.04-1.09), and government insurance (CI 0.34-0.94), but decreased with discharge to home (CI 1.68-4.47). There were no differences in FIM or Short-Form-12 scores between groups. Long-term mortality after discharge in elderly burn survivors is substantial. Patients sent to an SNF or with government insurance had increased mortality postdischarge. These data suggest that issues that may influence disposition status of elderly burn patients should be optimized prior to discharge to mitigate adverse outcomes associated with SNF placement.

Predictors of rehabilitation outcome among frail elderly patients living in the community

BACKGROUND AND PURPOSE

Physical therapy is frequently offered to community-dwelling frail elderly as part of home care rehabilitation programs. A better knowledge of predictors of rehabilitative success could allow a better targeting of limited resources. The purpose of this study is to evaluate the association of medical indicators of health status on functional recovery during rehabilitation of frail elderly living in the community.

SUBJECTS

Subjects included 598 patients aged 70 years or more admitted consecutively to a home care rehabilitation program from January 2004 to December 2004.

METHODS

A comprehensive geriatric multidisciplinary evaluation was offered to all patients, based on the Minimum Data Set for Home Care (MDS-HC) assessment form. Predictors of functional recovery were identified by a multiple logistic regression model. Data analyses were based on the items contained in the MDS-HC form.

RESULTS

An improvement in ADL score was seen in 33% of patients, while the others remained unchanged or worsened. In multivariate analysis the negative predictors of functional improvement were as follows: cognitive impairment (OR 0.67; CI 0.60-0.74), depression (OR 0.89, CI 0.82-0.96), visual (OR 0.32, CI 0.21-0.50) and hearing impairment (OR 0.42, CI 0.27-0.67), and urinary (OR 0.21, CI 0.14-0.33) and bowel incontinence (OR 0.16, CI 0.10-0.26).

CONCLUSIONS

Cognitive impairment, depressed mood, sensory impairment, and incontinence are key factors that need to be assessed in order to individuate patients at risk of failure in rehabilitation. A targeted intervention in these areas could offer the opportunity of improving rehabilitation outcome.