Involvement of Acute Care Physical Therapists in Care Transitions for Older Adults Following Acute Hospitalization: A Cross-sectional National Survey

What mobility factors are critical to include in a comprehensive mobility discharge assessment framework for older adults transitioning from hospital-to-home in the community? An international e-Delphi study

PURPOSE

To prioritize and achieve consensus on mobility determinant factors [cognitive, financial, environmental, personal, physical, psychological, social] considered critical to include in the COmprehensive Mobility Discharge Assessment Framework (COMDAF) for older adults transitioning from hospital-to-home.

MATERIALS AND METHODS

We conducted a three-round modified e-Delphi process with 60 international experts (seven older adults, nine family caregivers, 24 clinicians, and 20 researchers) from nine countries with universal or near-universal health coverage. Expert members rated 91 factors identified from scoping reviews using a 9-point scale: not important (1-3), important (4-6), and critical (7-9).

RESULT

A total of 41 of 91 factors (45.1%) met the a-priori consensus criterion after three rounds: five cognitive, five environmental, two personal, 19 physical, six psychological, and six social factors. No financial factors reached a consensus. The older adult steering committee member recommended the addition of two environmental factors, resulting in 43 mobility factors included in the COMDAF.

CONCLUSIONS

We advanced a comprehensive mobility framework by developing, through consensus, 43 mobility factors to be assessed as part of a COMDAF. However, its use in hospital-to-home may not be feasible. Therefore, future research will determine the core mobility factors for COMDAF and which measurement instruments best measure these factors.

RELEVANCE

An interdisciplinary discharge rehabilitation team can utilize the COMDAF during hospital-to-home transition.Implications for rehabilitationMobility assessment following a hospital discharge is a complex process requiring an interdisciplinary discharge rehabilitation team.This study provided a comprehensive list of 91 factors across all seven mobility determinants (cognitive, environmental, financial, personal, physical, psychological, and social) for clinicians in other care settings to use as a starting point to determine which mobility factor should be assessed during older adults' hospital-to-home transition.This international e-Delphi study identified 43 factors within mobility determinants (cognitive, environmental, personal, physical, psychological, and social) to be included in a Comprehensive Mobility Discharge Assessment Framework to assess older adults' mobility during the hospital to home transition.Using these 43 factors, clinicians can identify which assessment tool is best suited to assess the factors while reflecting on the logistics and feasibility; this is the next phase of this project.

Ready for Discharge, but Are They Ready to Go Home? Examining Neighborhood-Level Disadvantage as a Marker of the Social Exposome and the Swallowing Care Process in a Retrospective Cohort of Inpatients With Dementia

PURPOSE

Socioeconomically disadvantaged areas are more resource poor, impacting adherence to swallowing care recommendations. Neighborhood-level disadvantage metrics, such as the Area Deprivation Index (ADI), allow for examination of social determinants of health (SDOH) in a precise region. We examined ADI in a cohort of persons living with dementia (PLWD) to determine representation of those residing in areas of socioeconomic disadvantage (high ADI), distribution of swallowing care provided, and frequency of SDOH-related counseling or resource linking prior to discharge.

METHOD

A retrospective chart abstraction was performed for all inpatients with a diagnosis of dementia (N = 204) seen by the Swallow Service at a large academic hospital in 2014. State ADI Deciles 1 (least) to 10 (most socioeconomic disadvantage) and decile groups (1-3, 4-7, and 8-10) were compared with the surrounding county. Frequency of videofluoroscopic swallowing evaluations (VFSEs) based on ADI deciles was recorded. To determine whether SDOH-related counseling or resource linking occurred for those in high ADI (8-10) neighborhoods, speech-language pathology notes, and discharge summaries were reviewed. Descriptive statistics, independent samples t tests, and one-way analysis of variance were calculated.

RESULTS

ADI was significantly higher in this cohort (M = 3.84, SD = 2.58) than in the surrounding county (M = 2.79, SD = 1.88, p = .000). There was no significant difference in utilization of swallowing services across decile groups (p = .88). Although the majority (85%) in high ADI areas was recommended diet modifications or alternative nutrition likely requiring extra resources, there was no documentation indicating that additional SDOH resource linking or counseling was provided.

CONCLUSIONS

These findings raise important questions about the role and responsibility of speech-language pathologists in tailoring swallowing services to challenges posed by the lived environment, particularly in socioeconomically disadvantaged areas. This underscores the need for further research to understand and address gaps in postdischarge support for PLWD in high-ADI regions and advocate for more equitable provision of swallowing care.

Prioritizing mobility factors for assessment during the transition of older adults from hospital to home: a cross-sectional survey of physiotherapists in Southeastern Nigeria

BACKGROUND

Assessing all factors influencing older adults' mobility during the hospital-to-home transition is not feasible given the complex and time-sensitive nature of hospital discharge processes.

OBJECTIVE

To describe the mobility factors that Nigerian physiotherapists prioritize to be assessed during hospital-to-home transition of older adults and explore the differences in the prioritization of mobility factors across the physiotherapists' demographics and practice variables.

METHODS

This cross-sectional study included 121 physiotherapists who completed an online questionnaire, ranking 74 mobility factors using a nine-point Likert scale. A factor was prioritized if ≥ 70% of physiotherapists rated the factor as "Critical" (scores ≥7) and ≤ 15% of physiotherapists rated a factor as "Not Important" (scores ≤3). We assessed the differences in the prioritization of mobility factors across the physiotherapists' demographics/practice variables using Mann Whitney U and Kruskal-Wallis tests.

FINDINGS

Forty-three of 74 factors were prioritized: four cognitive, two environmental, one financial, four personal, eighteen physical, seven psychological, and seven social factors. Males and those with self-reported expertise in each mobility determinants more frequently rated factors as critical.

CONCLUSION

Prioritizing many mobility factors underscores the complex nature of mobility, suggesting that an interdisciplinary approach to addressing these factors may enhance post-hospital discharge mobility outcomes.

Association between physical therapy frequency and postacute care for a national cohort of patients hospitalized with pneumonia

BACKGROUND

Annually more than 300,000 patients hospitalized for pneumonia need postacute care. Patients and systems prefer home discharge, but physical limitations often necessitate postacute care. It is unknown whether frequency of physical therapy in the hospital affects postacute care discharges.

OBJECTIVE

Examine the relationship between physical therapy visit frequency and disposition among a national sample of patients hospitalized with pneumonia.

DESIGNS

Observational cohort study.

SETTING

Acute care hospital.

PARTICIPANTS

Adult patients with primary diagnosis of pneumonia in the Premier Data Set who received physical therapy in the hospital during a 5-day window, with therapy on at least days 1 and 5.

INTERVENTION

Physical therapy visit frequency.

MAIN OUTCOME AND MEASURES

Discharge disposition (home or postacute care).

RESULTS

We included 18,886 patients from 595 hospitals. Just over half were discharged home (n = 9638; 51.0%) and 558 (2.95%) died. Patients getting more frequent therapy were older, non-Hispanic white, treated in small non-teaching rural hospitals in the West, Midwest, or South, and had fewer severe illness indicators. In adjusted models, patients who received physical therapy on 100% of days were 7% [(95% confidence interval, 4.3-9.7), p < .0001] more likely to go home than patients who received physical therapy on 40% of days. As a falsification test, we found that there was no relationship between physical therapy frequency and all-cause mortality. Physical therapy visit frequency was positively associated with discharge to home. Increasing visit frequency of physical therapy in hospitals might reduce the need for postacute care, but randomized controlled trials are needed to confirm the effect.

A comprehensive mobility discharge assessment framework for older adults transitioning from hospital-to-home in the community—What mobility factors are critical to include? Protocol for an international e-Delphi study

Background

Mobility deficits have been identified as an independent risk factor for hospital readmission for adults ≥65 years. Despite evidence indicating how determinants additively influence and predict mobility, no hospital-to-home care transition models comprehensively assess all seven mobility determinants, cognitive, financial, environmental, personal, physical, psychological, and social. There is currently a lack of clarity regarding what factors clinicians and researchers should evaluate for each mobility determinant. The purpose of this e-Delphi study is to prioritize and reach consensus on the factors for each mobility determinant that are critical to assess as part of the Comprehensive Mobility Discharge Assessment Framework (CMDAF) when older adults are discharged from hospital-to-home.

Methods

This protocol paper is an international modified e-Delphi study following the Recommendations for the Conducting and Reporting of Delphi Studies. International researchers, clinicians, older adults and family caregivers residing in a country with universal or near-universal health coverage will be invited to participate as ‘experts’ in three e-Delphi rounds administered through DelphiManager©. The e-Delphi Round 1 questionnaire will be developed based on scoping review findings and will be pilot tested. For each round, experts will be asked to rate factors for each determinant that are critical to assess as part of the CMDAF using a 9-point scale: Not Important (1–3), Important but Not Critical (4–6), and Critical (7–9). The scale will include a selection option of "unable to score" and experts will also be asked to provide a rationale for their scoring and suggest missing factors. Experts will receive feedback summaries in Rounds 2 and 3 to guide them in reflecting on their initial responses and re-rating of factors that have not reached consensus. The criteria for reaching consensus will be if ≥70% of experts rate a factor as "critical" (scores ≥7) and ≤ 15% of experts rate a factor as "not important" (scores≤ 3). Quantitative data will be analyzed using median values, frequencies, percentages, interquartile range, and bar graphs; Wilcoxon matched-pairs signed-rank test will be used to assess the stability of participants’ responses. Rationale (qualitative data) provided in the open-ended comments section will be analyzed using content analysis.

Conclusion

This study is a first step in developing the CMDAF and will be used to guide a subsequent e-Delphi survey to decide on the tools that should be used to measure the examples of each factor included in our framework.

Disparities in the allocation of inpatient physical and occupational therapy services for patients with COVID-19

BACKGROUND

Survivors of the novel coronavirus (COVID-19) experience significant morbidity with reduced physical function and impairments in activities of daily living. The use of in-hospital rehabilitation therapy may reduce long-term impairments.

OBJECTIVE

To determine the frequency of therapy referral and treatment amongst hospitalized COVID-19 patients, assess for disparities in referral and receipt of therapy, and identify potentially modifiable factors contributing to disparities in therapy allocation.

DESIGN, SETTING AND PARTICIPANTS

Retrospective cohort study using data collected from the University of Colorado Health Data Compass data warehouse assessing therapy referral rates and estimated delivery based on available administrative billing.

MEASUREMENTS

Multivariable logistic regression was used to determine the association between sex and/or underrepresented minority race with therapy referral or delivery.

RESULTS

Amongst 6239 COVID-19-related hospitalization, a therapy referral was present in 3952 patients (51.9%). Hispanic ethnicity was independently associated with lower odds of receipt of therapy referral (adjusted OR [aOR]: 0.78, 95% confidence interval [CI]: 0.67-0.93, p = .001). Advanced age (aOR: 1.53, 95% CI: 1.46-1.62, p < .001), greater COVID illness severity (aOR for intensive care unit admission: 1.63, 95% CI: 1.37-1.94, p < .01) and hospital stay (aOR: 1.14, 95% CI: 1.12-1.15, p < .01) were positively associated with referral.

CONCLUSIONS AND RELEVANCE

In a cohort of patients hospitalized for COVID-19 across a multicenter healthcare system, we found that referral rates and delivery of physical therapy and/or occupational therapy sessions were significantly reduced for patients of Hispanic identity compared with patients of non-Hispanic, Caucasian identity after adjustment for potential confounding by available demographic and illness severity variables.

The Use of Physical Therapy ICU Assessments to Predict Discharge Home

OBJECTIVES

To establish cutoff values for making recommendations for discharge to the home setting using standardized physical therapy assessments.

DESIGN

Retrospective study.

SETTING

Five ICUs at a large academic medical center.

PATIENTS

1,203 ICU patients.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

The Functional Status Score for the ICU and the ICU Mobility Scale were collected during the initial physical therapy assessment, at ICU discharge, and prior to hospital discharge. The Activity Measure for Post-Acute Care-Inpatient Mobility Short Form "6 clicks" was only collected during the initial physical therapy assessment. Receiver Operating Characteristic curves were used to determine a potential cutoff value for discharge home. The Receiver Operating Characteristic was adjusted for ICU and hospital length of stay along with mobility status prior to hospital admission. Cutoff values were then determined by using Youden's Index. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated based on these cut off values. The Functional Status Score for the ICU at ICU discharge was the best predictor of a discharge to the home setting in patients who had an ICU admission. The area under the curve for the Functional Status Score for the ICU at ICU discharge was 0.80. A Functional Status Score for the ICU score at ICU discharge of 19 or higher predicted discharge to home with a sensitivity of 82.9% and specificity of 73.6% CONCLUSIONS:: The Functional Status Score for the ICU at ICU discharge provided the best accuracy for making a timely recommendation for discharge home in patients who had an ICU admission.

Innovative Care Delivery of Acute Rehabilitation for Patients With COVID-19: A Case Report

OBJECTIVE

The novel coronavirus 2019 (COVID-19) has impacted acute rehabilitation delivery by challenging the reliance on in-person care and the standard practice of delivering separate physical and occupational therapy services. Health care systems are rapidly developing innovative models of care that provide essential acute rehabilitation services while mitigating viral spread. We present 2 case reports to illustrate how we used technology and COVID-19-specific decision-making frameworks to deliver acute rehabilitation.

METHODS

We iteratively developed 2 decision-making models regarding care delivery and discharge planning in the context of the challenges to delivering care in a pandemic. We leveraged use of video communication systems installed in all COVID-19 rooms to reduce the number of in-room providers and frequency of contact. Two patients were admitted to the hospital with symptomatic COVID-19 (males, ages 65 and 40 years).

RESULTS

With the use of a video communication system and the decision-making frameworks for care delivery and discharge planning, we avoided 7 in-person sessions. Both patients demonstrated functional gains and were dischargedhome.

CONCLUSION

The 2 case reports highlight the innovative use of a technology and COVID-19-specific decision-making processes to provide patient-centered care given the challenges to care delivery during the COVID-19 pandemic.

IMPACT

The use of technology and decision-making models allows for delivery of safe acute rehabilitation care that minimizes contact, conserves personal protective equipment, and prepares for COVID-19 surges. The discussion points raised have applicability to patients without COVID-19 and other health care systems. Future research is needed to determine the effectiveness, costs, and downstream effects of our novel approach to acute rehabilitation for patients with COVID-19.

Using Systematic Functional Measurements in the Acute Hospital Setting to Combat the Immobility Harm

Hospitalized patients often experience unnecessary immobility and inactivity leading to direct harms and poor outcomes. Despite growing evidence that early and regular mobility and activity are safe and helpful for patients in the hospital, there remains substantial room for improvement in clinical practice. Key to improvement is establishing an interdisciplinary approach to measurement and communication using a common language of function. Here we provide a framework for systematic functional measurement in the hospital. We also provide 3 specific examples of how this framework has been used to improve care: (1) targeting specialized rehabilitation providers to the patients most likely to need their services, (2) generating a daily mobility goal for all patients, and (3) identifying patients early who are likely to require postacute care.

Physiotherapists’ role during hospital-to-home transition for older adults with hip fracture and mobility limitation: A research protocol

Introduction

Functional deficits such as gait speed, muscle strength or reduced activities in daily living after discharge are predictors for hospital readmission for older adults with hip fractures. However, physiotherapists (PTs) who are inherently mobility experts, do not actively participate during the hospital-to-home transition of older adults with hip fractures in the developing countries, including Nigeria. This qualitative study aims to describe and explore how PTs working within inpatient rehabilitation units prepare older adults (≥60 years) with a hip fracture for transfer to their home in the community.

Methods

We will adopt Sally Thorne’s Interpretive Description approach to purposively select 25 PTs with 5-years experience of participating in discharging older adults with hip fractures from inpatient rehabilitation-to-home. Data collection will include (a) semi-structured, one-on-one interviews with PTs, (b) discharge summaries of two older adults, and (c) final focus group discussion with PTs. We will ask the physiotherapists to provide discharge summaries of two older adults - one that they described as a “difficult” case and one that they described as an “easy” case during inpatient rehabilitation-to-home transition. Data will be analyzed employing Sally Thorne’s “borrowing techniques”- content and thematic analysis for the patients’ discharge summaries and PT interviews, respectively.