Nursing home rehabilitation after acute rehabilitation: predictors and outcomes

Self-Reported Health and Safety Awareness Improves Prediction of Level of Care Needs in Veterans Discharged From a Postacute Unit

OBJECTIVES

To evaluate the differential value of a self-reported health and safety awareness measure relative to other medical, psychosocial, and cognitive factors in predicting level of care (LOC) needs after hospital discharge.

DESIGN

Retrospective medical record review.

SETTING

Community living center postacute care (CLC-PAC) unit at a Veterans Affairs hospital.

PARTICIPANTS

A total of 175 veterans admitted to the Veterans Affairs hospital or directly to the CLC-PAC from home.

METHODS

Cognitive status was assessed with the Mini-Mental State Examination, Digit Span Backward subtest, Trail Making Test (Part B), and Hopkins Verbal Learning Test-Revised. Self-report of health and safety awareness was measured with the Independent Living Scales Health and Safety (ILS-HS) subscale. Additional demographic and admission-related variables were coded, along with medical comorbidity, with the Charlson Comorbidity Index and depression using the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision Depression Checklist.

MAIN OUTCOME MEASUREMENTS

Increased level of care was collected from social work and occupational therapy notes and defined as increased assistance with activities of daily living or nursing home placement comparing prehospitalization with CLC-PAC discharge.

RESULTS

A total of 19% (n = 34) of residents required increased LOC on CLC-PAC discharge. The ILS-HS was a significant predictor of increased LOC above and beyond age and Mini Mental Status Examination score; for each standard deviation decrease in ILS-HS, there was an increased likelihood of greater LOC (odds ratio 0. 54, 95% confidence interval 0.35-0.83). Other neuropsychological tests (memory, executive functioning) did not significantly improve the model.

CONCLUSIONS

The inclusion of the ILS-HS to a standard cognitive screen (Mini Mental Status Examination) can improve prediction of increased LOC. Although select aspects of memory and executive functioning independently contribute to increased LOC prediction, the ILS-HS likely measures a unique aspect of cognitive functioning that may be specific to discharge planning needs in CLC-PAC residents.

LEVEL OF EVIDENCE

II.

Predictors of institution admission in the year following acute hospitalisation of elderly people

OBJECTIVES

The aim of the study was to identify factors related to institutionalisation within one-year follow up of subjects aged 75 or over, hospitalised via the emergency department (ED).

DESIGN

Prospective multicentre cohort.

SETTING

Nine French university teaching hospitals.

PARTICIPANTS

One thousand and forty seven (1 047) non institutionalised subjects aged 75 or over, hospitalised via ED. A sub-group analysis was performed on the 894 subjects with a caregiver.

MEASUREMENTS

Patients were assessed using Comprehensive Geriatric Assessment (CGA) tools. Cox survival analysis was performed to identify predictors of institutionalisation at one year.

RESULTS

Within one year after hospital admission, 210 (20.1%) subjects were institutionalised. For the overall study population, age >85 years (HR 1.6; 95%CI 1.1-2.1; p=0.005), inability to use the toilet (HR 1.6; 95%CI 1.1-2.4; p=0.007), balance disorders (HR 1.6; 95%CI 1.1-2.1; p=0.005) and presence of dementia syndrome (HR 1.9; 95%CI 1.4-2.6; p<0.001) proved to be independent predictors of institutionalisation; while a greater number of children was inversely linked to institutionalisation (HR 0.8; 95%CI 0.7-0.9; p<0.001). Bathing was of borderline significance (p=.09). For subjects with a caregiver, initial caregiver burden was significantly linked to institutionalisation within one year, in addition to the predictors observed in the overall study population.

CONCLUSIONS

CGA performed at the beginning of hospitalisation in acute medical wards is useful to predict institutionalisation. Most of the predictors identified can lead to targeted therapeutic options with a view to preventing or delaying institution admission.

A Nordic multi-center study on physical and daily activities for residents in nursing home settings: design of a randomized, controlled trial

BACKGROUND AND AIMS

Nursing home residents constitute a frail, multi-diseased and heterogeneous group. As physical activity is essential for the preservation of function, personalized training and activities are of great importance. The main objective of this study was to describe the influence of an individually tailored intervention program, in a nursing home setting, on physical capacity, degree of dependence in Activities of Daily Living (ADL), long-term participation in physical and/or daily activities, and self-rated wellbeing. The aim of the present work is to describe the overall design of the study.

METHODS

Nursing homes in Sweden, Norway and Denmark were involved, and 322 residents were randomized to either Intervention or Control groups. The intervention lasted for three months and consisted of physical and daily activities, led by physiotherapists and occupational therapists, and was built on their evaluations and on the goals expressed by each resident. Tests of muscle strength, mobility, balance function and confidence, ADL, level of physical activity, wellbeing and cognitive function were performed at baseline, directly after the intervention period and three months later.

RESULTS

They will be presented in articles to follow.

CONCLUSIONS

Although it is a great challenge to carry out an intervention study directed toward such a frail population, it is of great interest to find out whether individually tailored and enhanced activities can lead to decreased dependence in ADL and increased wellbeing.

Factors associated with physiotherapy provision in a population of elderly nursing home residents; a cross sectional study

Background

Although physiotherapy (PT) plays an important role in improving activities of daily living (ADL functioning) and discharge rates, it is unclear how many nursing home residents receive treatment. Furthermore, there is a lack of insight into the determinants that influence the decision for treatment. In this study, we investigated how many nursing home residents receive PT. In addition, we analysed the factors that contribute to the variation in the provision of PT both between nursing homes and between residents.

Methods

A random sample of 600 elderly residents was taken from a random sample of 15 nursing homes. Residents had to be admitted for rehabilitation or for long-term care. Data were collected through interviews with the nursing home physician and the physiotherapist. Multilevel analysis was used to define the variation in the provision of PT and the factors that are associated with the question whether a resident receives PT or not. Furthermore the amount of PT provided was analysed and the factors that are associated with this.

Results

On average 69% of the residents received PT. The percentage of patients receiving treatment differed significantly across nursing homes, and especially the number of physiotherapists available, explained this difference between nursing homes. Residents admitted to a somatic ward for rehabilitation, and male residents in general, were most likely to receive PT. Residents who were treated by a physiotherapist received on average 55 minutes (sd 41) treatment a week. Residents admitted for rehabilitation received more PT a week, as were residents with a status after a total hip replacement.

Conclusion

PT is most likely to be provided to residents on a somatic ward, recently admitted for rehabilitation to a nursing home, which has a relatively large number of physiotherapists. This suggests a potential under-use of PT for long-term residents with cognitive problems. It is recommended that physiotherapists reconsider which residents may benefit from treatment. This may require a shift in the focus of physiotherapists from 'recovery and discharge' to 'quality of life and well-being'.

Rehabilitation outcomes in cognitively impaired patients admitted to skilled nursing facilities from the community

OBJECTIVE

To examine the outcomes of patients with varying levels of cognitive impairment who received rehabilitation in skilled nursing facilities (SNFs).

DESIGN

A retrospective analysis of the records of people admitted to SNFs for rehabilitation.

SETTING

Seven SNFs in Colorado.

PARTICIPANTS

Community-dwelling persons (N=7159), 65 years of age and older, admitted for rehabilitation after a hospitalization or decline in function between May 1998 and May 2002. Interventions Not applicable.

MAIN OUTCOME MEASURES

Cognitive impairment was assessed using a 4-level categorization of the FIM instrument cognitive score at admission. Functional gain was measured using the FIM. Community discharge was measured as the proportion of patients discharged to home, board and care, or assisted living facility. Rehabilitation progress was measured as the number of FIM points gained per day.

RESULTS

Significant functional gains were made during rehabilitation in motor and cognitive FIM scores, regardless of cognitive impairment. The most cognitively impaired patients required more rehabilitation intervention, achieved less FIM gain, and were less likely to be discharged to the community. The strongest predictors of FIM gain were the amount of therapy hours and admission cognitive FIM score. The strongest predictors of discharge to the community were the discharge total FIM score and age. The strongest predictors of adequate rehabilitation progress were medical complexity and admission cognitive FIM score.

CONCLUSIONS

Patients with cognitive impairment were able to recover function with rehabilitation intervention. Patients with a more serious cognitive impairment received more rehabilitation intervention than patients with less impairment. Outcomes were predicted by admission and rehabilitation measures that were qualitatively different from other discharge outcomes. Health care professionals need to consider these factors as they create a rehabilitation plan of care for patients with cognitive impairment.

Payer incentives and physical rehabilitation therapy for nonelderly institutional long-term care residents: evidence from Michigan and Ontario

OBJECTIVE

To examine the effect of payment incentives on the provision of rehabilitation therapy to non elderly nursing home residents.

DESIGN

Retrospective cross-sectional study.

SETTING

Nursing homes in Michigan or complex continuing care facilities in Ontario, Canada, in 1998 or 1999.

PARTICIPANTS

Non elderly nursing home residents (N=5189) admitted to nursing homes.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The effect of payment on access to physical therapy (PT) and occupational therapy (OT) and total weekly time for each therapy type.

RESULTS

A Medicare policy change from cost-based to a patient-specific case-mix payment method was associated with greater likelihood of receiving OT but reduced weekly minutes of PT and OT provided to residents. Medicare cost-based and private insurance were associated with greater likelihood of receiving OT and PT and more therapy time for both types of therapy compared with private-pay residents. Global budget payment was associated with greater access to PT but fewer weekly minutes of OT and PT.

CONCLUSIONS

Little information exists to describe the characteristics and treatment of non elderly nursing home residents. This study found that many of these residents received rehabilitation and that residents whose care was paid for by more generous payers, such as Medicare, received more therapy than those paid for by less generous payers.

Predictors of a nursing home placement from a non-acute geriatric hospital

BACKGROUND

Identifying patients who need Nursing Home (NH) care following a hospital admission is important.

OBJECTIVE

To identify the factors that predispose to an NH discharge.

DESIGN

Prospective observational study with blinded end-point evaluation.

SETTING

A non-acute geriatric hospital.

SUBJECTS

Two hundred consecutive elderly patients who were admitted for rehabilitation following treatment for an acute illness.

MAIN OUTCOME MEASURES

Discharge to an NH or home.

RESULTS

Thirty-five out of the 150 live discharges (23.3%) were to an NH. NH discharges had a longer length of stay (38.5 versus 19.8 days; p < 0001). They were more likely to have visual impairment (p = 0.0009), confusion (p < 0.0001), wandering behaviour (p = 0.003), incontinence (p < 0.0001 or unsafe gait (p = 0.0005), to be on tranquillizers (p = 0.003), to be at risk of falls (p = 0.02) and to have sustained a fall while in hospital (p = 0.001). Multiple logistic regression identified confusion (p = 0.001), incontinence (p = 0.02), falls in hospital (p = 0.01), gait abnormalities (p < 0.001), tranquillizers (p < 0.001), impaired distant vision (p = 0.01) and living alone (p < 0.001) as independently associated with the risk of an NH discharge. This risk proportionately increased with the number of risk factors present: 4.28% for 0-2 factors, 25.8% for 3-4 factors and 81.8% for 5-6 factors (p < 0.0001).

CONCLUSION

These factors should be the target of specific rehabilitation in an attempt to reduce the risk of discharge to a nursing home and improve patient outcome.

Predictors of nursing home placement and home nursing services utilization by elderly patients after hospital discharge in Taiwan

BACKGROUND

Providing appropriate follow-up health/long-term care services after hospital discharge for elderly persons is important to enhance health and quality of life. Therefore, identifying factors that affect follow-up service utilization has become an important concern. Most studies of predictors of follow-up service utilization for elderly persons after discharge were conducted in the United States of America (USA). Taiwan differs substantially from the USA in health care system, clinical practice, case-mix, culture, and social organization; thus the findings from the USA need to be validated in Taiwan to ensure appropriate discharge referrals.

AIM

To investigate pre-discharge predictors of follow-up care including home nursing services and nursing home placement for elderly patients, discharged from hospitals in Taiwan.

METHODS

A prospective study with a case-control design was used.

FINDINGS

The strongest predictors of institutionalization in a nursing home at 1, 3 and 6 months after discharge were the elderly person's pre-admission institutionalization (0.33 to 0.48) and the caregiver's preference for institutional displacement (0.23 to 0.85). The strongest predictors of use of home nursing services were the elder's self-care ability (0.69 to 0.76), conscious level (0.51 to 0.73), and tubes remaining before discharge (0.58 to 0.79). These predictors were stable at 1, 3 and 6 months after discharge and could correctly classify 60-89% of sample.

CONCLUSIONS

When taking nursing home and home nursing utilization into considerations at the same time, the elderly person's pre-admission institutionalization and the caregiver's preference for institutional displacement strongly predicted nursing home utilization after hospital discharge. The elder's self-care ability, conscious level, and tubes remaining before discharge strongly predicted the use of home nursing services after discharge.

Measures of executive functioning as predictors of functional ability and social integration in a rehabilitation sample

OBJECTIVE

To examine the utility of executive function tests in predicting rehabilitation outcome.

DESIGN

A prospective, descriptive study of the value of neuropsychologic and motor functioning measures in the prediction of functional outcome 6 months after acute rehabilitation.

SETTING

A Midwestern, urban, university-affiliated rehabilitation hospital.

PATIENTS

Ninety consecutive admissions to traumatic brain injury, orthopedic, and spinal cord injury units. Age of the participants ranged from 17 to 73.

MAIN OUTCOME MEASURES

Community Integration Questionnaire (CIQ), Disability Rating Scale (DRS), SF-36 Health Survey.

RESULTS

Canonical correlation analyses indicated that measures of executive functioning and verbal memory were strongly related to measures of functional outcome 6 months after rehabilitation, as measured by the DRS and the CIQ. In contrast, perceived health status as measured by the SF-36 was highly related to estimated premorbid IQ and modestly related to visuospatial impairment.

CONCLUSIONS

Executive functioning, verbal memory, and estimated premorbid intelligence predict functional dependence after discharge from rehabilitation beyond information regarding basic sensory and motor skills. Moreover, there is a dissociation between measures of functional outcome, such that objective and behaviorally oriented measures of disability (CIQ and DRS) are strongly related to each other; however, they are not related to perceptions of general health status (SF-36).

Stroke rehabilitation. 4. Stroke outcome and psychosocial consequences

This self-directed learning module highlights recent research in assessment of stroke outcomes and management of the psychosocial consequences of stroke. It is a part of the chapter on stroke rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses predictive factors for mortality and functional recovery; proposed case mix adjustment and prospective payment systems for stroke rehabilitation; continuum of care and utilization of acute, nursing home, outpatient and home health rehabilitation programs; reintegration and socialization after stroke; vocational rehabilitation of stroke patients; and management of the psychosocial effects of stroke on patients and families.