The design elements of outpatient geriatric rehabilitation from patient, healthcare professional, and organizational perspective; a qualitative study

PURPOSE

To gain a rich understanding of the experiences and opinions of patients, healthcare professionals, and policymakers regarding the design of OGR with structure, process, environment, and outcome components.

METHODS

Qualitative research based on the constructive grounded theory approach is performed. Semi-structured interviews were conducted with patients who received OGR (n = 13), two focus groups with healthcare professionals (n = 13), and one focus group with policymakers (n = 4). The Post-acute Care Rehabilitation quality framework was used as a theoretical background in all research steps.

RESULTS

The data analysis of all perspectives resulted in seven themes: the outcome of OGR focuses on the patient's independence and regaining control over their functioning at home. Essential process elements are a patient-oriented network, a well-coordinated dedicated team at home, and blended eHealth applications. Additionally, closer cooperation in integrated care and refinement regarding financial, time-management, and technological challenges is needed with implementation into a permanent structure. All steps should be influenced by the stimulating aspect of the physical and social rehabilitation environment.

CONCLUSION

The three perspectives generally complement each other to regain patients' quality of life and autonomy. This study demonstrates an overview of the building blocks that can be used in developing and designing an OGR trajectory.

Geriatric home-based rehabilitation in Australia: Preliminary data from an inpatient bed-substitution model

Background

The REStORing health of acutely unwell adulTs (RESORT) is an observational longitudinal cohort, including geriatric rehabilitation inpatients aged ≥65 years admitted to a geriatrician‐led rehabilitation service at a tertiary hospital. The aim of this study is to describe a home‐based bed‐substitution rehabilitation model for geriatric inpatients, including patient phenotype, and health outcomes at preadmission, admission, discharge, and three‐month follow‐up.

Methods

A standardized Comprehensive Geriatric Assessment was performed on admission and discharge, including demographics (home situation, cognitive impairment, medical diagnoses, etc.), frailty (Clinical Frailty Scale (CFS)), mobility (patient‐reported and Functional Ambulation Classification), physical performance (Short Physical Performance Battery (SPPB), handgrip strength), and functional independence (Activities of Daily Living (ADL), Instrumental ADL (IADL)). Service provision data (health care staff visits, length of stay (LOS), and negative events (e.g., falls)) were extracted from medical records. Three‐month outcomes included mobility, ADL and IADL scores, institutionalization, and mortality.

Results

Ninety‐two patients were included with a mean age of 81.1 ± 7.8 years, 56.5% female. Twenty‐nine (31.5%) patients lived alone, 39 (42.4%) had cognitive impairment and the commonest geriatric rehabilitation admission reason was falls (n = 30, 32.6%). Patients received care from nurses, physicians, and a median of four (interquartile range (IQR) 3–6) allied health disciplines for a median LOS of 13.0 days (IQR 10.0–15.0). On a population level, patient mobility and functional independence worsened from preadmission to admission. CFS, SPPB, ADL, and IADL scores improved from admission to discharge, and seven (7.6%) patients fell. At three‐month follow‐up, patient‐reported mobility was comparable to preadmission baseline, but functional independence (ADL, IADL) scores worsened for 27/69 (39.1%) and 28/63 (44.4%), respectively.

Conclusions

Hospitalization‐associated decline in mobility and functional independence improved at discharge and three‐months, but was not fully reversed in the multidisciplinary home‐based geriatric rehabilitation bed‐substitution service. Future research should compare outcomes to equivalent hospital‐based geriatric rehabilitation and evaluate patient perspectives.

See related Editorial by William J. Hall in this issue.

Substituting inpatient rehabilitation beds for home-based multidisciplinary rehabilitation: A qualitative study of patient perceptions

OBJECTIVE

To understand the patients' perspectives of the pilot Better at Home program in order to inform the development of bed substitution rehabilitation services.

METHODS

Prospective qualitative study using semi-structured interviews undertaken 3-6 months following program participation was performed. Interviews were transcribed and themes developed by two independent researchers.

RESULTS

Nineteen participants (14 females) were interviewed. Major themes found included high satisfaction with the service and a high regard for the importance of communication both within the team and with the patients. Patients had inconsistent views on the provision of services with some feeling that the program was not specific to their needs, whilst others felt it was focused and flexible. Involvement in decision-making for referral to the service was also not always fully understood.

CONCLUSION

This study provides important information that can be utilised in the development of any bed substitution home-based model of care.

Length of Stay in Skilled Nursing Facilities Following Total Joint Arthroplasty

BACKGROUND

The most commonly used postacute care facility after total joint arthroplasty is a skilled nursing facility (SNF). However, little is known regarding the role of physical therapy achievements and insurance status on the decision to discharge from an SNF. In this study, we aim to compare functional outcomes and length of stay (LOS) at an SNF among patients with Medicare vs private health coverage.

METHODS

We retrospectively collected physical therapy data for 114 patients who attended an SNF following acute hospitalization for total joint arthroplasty. Medicare beneficiaries were compared with patients covered by Managed Care (MC) policies (health maintenance organization [HMO] and preferred provider organization [PPO]) using several SNF discharge outcomes, including LOS, distance ambulated, and functional independence in gait, transfers, and bed mobility.

RESULTS

LOS at the SNF was significantly longer for Medicare patients (Medicare: 24 ± 22 days, MC: 12 ± 7 days, P = .007). After adjusting for LOS and covariates, MC patients had significantly greater achievements in all functional outcomes measured. In a study subanalysis, Medicare patients were found to achieve similar functional outcomes by SNF day 14 as MC patients achieved by their day of discharge on approximately day 12. Yet, the Medicare group was not discharged until several days later.

CONCLUSION

Medicare status is associated with poor functional outcomes, long LOS, and slow progress in the SNF. Our results suggest that insurance reimbursement may be a primary factor in the decision to discharge, rather than the achievement of functional milestones.

Rehabilitation as "destination triage": a critical examination of discharge planning

PURPOSE

In this paper we examine how the intersection of various social and political influences shapes discharge planning and rehabilitation practices in ways that may not meet the espoused aims of rehabilitation programs or the preferences of older adults and their families.

METHODS

Taking a critical bioethics perspective, we used microethnographic case study methods to examine discharge-planning processes in a well-established older adult inpatient rehabilitation setting in Canada. The data included observations of discharge-planning family conferences and semi-structured interviews conducted with older adults facing discharge, their family members and rehabilitation professionals involved in discharge planning.

RESULTS

From the time of admission, a contextual push to focus on discharge superseded program aims of providing interventions to increase older adults' functional capabilities. Professionals' primary commitment to safety limited consideration of discharge options and resulted in costly and potentially unnecessary recommendations for 24-hour care. The resulting "rehabilitation" stay was more akin to an extended process of "destination triage" biased towards the promotion of physical safety than optimizing functioning.

CONCLUSIONS

The resulting reduction of rehabilitation into "destination triage" has significant social, financial and occupational implications for older adults and their families, and broader implications for healthcare services and overarching healthcare systems. Implications for Rehabilitation Current trends promoting consideration of discharge planning from the point of admission and prioritizing physical safety are shifting the focus of rehabilitation away from interventions to maximize recovery of function, which are the stated aims of rehabilitation. Such practices furthermore promote assessments to determine prognosis early in the rehabilitation stay when accurate prognosis is difficult, which can lead to overly conservative recommendations for discharge from rehabilitation services, thus further negating the impact of rehabilitation. Further work is required to examine the social, occupational and functional implications of superseding rehabilitation interventions to maximize capabilities with practices that prioritize safety over quality of life for older adults and their family members.

Prevalence and Costs of Rehabilitation and Physical Therapy After Primary TJA

This study evaluated the trends in discharge patterns and the prevalence and cost of post-discharge PT. The 5% Medicare database (1997-2010) was used to identify 50,886 primary THA and 107,675 TKA patients. More than 50% of patients were discharged from hospital to an inpatient facility. There were an increase in discharges to skilled nursing units and a reduced rate to rehabilitation facilities. In contrast to hospital, surgeon reimbursement, and implant costs, the average annual PT cost per patient rose through the study period. Approximately 25% of PT costs were used on less common modalities. PT costs more than $648 million a year. With the increased pressure to control costs for primary TJA, these patterns may change unless PT effectiveness can be demonstrated.