Date Presented 4/19/2018
Occupational therapy enables a full life by enhancing function. The unique value of occupational therapy as demonstrated by relationships between self-care and outcomes in a comprehensive joint replacement payment model is discussed. Data presented support this value and provide discussion to optimize occupational therapy intervention practices.
Primary Author and Speaker: Angela Edney
Additional Authors and Speakers: Susan Almon-Matangos, Donna Diedrich, Lynn Freeman
PURPOSE: Effective April 1, 2016, the Centers for Medicare & Medicaid Services (CMS; 2015) initiated the first Medicare-mandated care redesign model, Comprehensive Care for Joint Replacement (CJR). Anchor hospitals in 67 geographic areas are financially accountable for episode cost for lower extremity joint replacement (LEJR) performed at each hospital. The episode includes all care for services from hospital admission until 90 days after discharge, regardless of setting or services used.
Because of concern that occupational therapy postacute care (PAC) would be decreased or eliminated, this study was conducted to show the relevance and impact of occupational therapy services, specifically self-care, on CJR patients. We hypothesized that outcomes would be significantly higher in CJR sites. Supporting this hypothesis was the training provided to the staff in CJR sites on the value of care redesign and the use of functional pathways. The study examined whether participants with total knee replacement (TKR) and total hip replacement (THR) in CJR versus control sites had significantly different rehabilitation lengths of stay; mobility, self-care, and functional gains; and rehospitalization rates.
METHOD: This study was a quantitative retrospective analysis of 495 electronic medical records pertaining to patients who received LEJR. On the basis of referral from anchor hospitals, 343 patients were designated the CJR group and 152 patients the control group. Services were received between April and August 2016. Patients’ physical and occupational therapy records from PAC settings were reviewed. Settings included skilled nursing facilities (SNFs), home health, and outpatient clinics. Outcome measures used were the Rehabilitation Outcomes Measure (AccuMed Technology Solutions, 1994) and the Mobility and Self-Care sections of the CARE Tool (Gage et al., 2012). Data analysis included mobility, self-care, and overall functional gains with comparison to rehab length of stay and group comparison of rehospitalization. This retrospective data review was approved by the Aegis Therapies institutional review board.
RESULTS: Statistical analysis demonstrated like characteristics and no significant difference between groups. Mobility when looked at independently showed improvement that was not statistically significant. Significant differences were noted in rehab length of stay (15 days for CJR, 19 days for control), overall functional gain (62% improvement for CJR, 55% for control), and self-care gain (63% improvement for CJR, 52% for control). Rehospitalization occurred for 9.6% of CJR patients and 3.3% of control group patients.
CONCLUSION: Compared with control patients, patients receiving PAC in the CJR model made greater gains in self-care skills and overall function in significantly less time. Self-care was the primary driver in overall functional gain for the CJR group. Rehospitalization was significantly higher among CJR patients. However, this would be expected because of lower function and higher comorbidities of CJR patients admitted to SNFs versus those who went directly home or to outpatient clinics. There was no significant difference in rehospitalization between surgical procedure types (THR vs. TKR). Whether LEJR occurs because of a chronic condition such as arthritis or a traumatic event, occupational therapists benefit from educational materials to develop treatment plans that prompt patients’ movement through PAC settings while ensuring quality care and avoiding possible financial repercussions.
IMPACT STATEMENT: These findings highlight the key role occupational therapy plays in LEJR rehabilitation. Although the CJR model includes incentives to both contain costs and ensure quality, occupational therapy drives improved function in a shorter time frame and provides unique value for patient success.
References
AccuMed Technology Solutions. (1994). Rehabilitation Outcomes Measure. Milford, OH: AccuMed Services.
Centers for Medicare & Medicaid Services. (2015, November 19). Webinars: Comprehensive Care for Joint Replacement Model—Final rule introduction. Retrieved from https://innovation.cms.gov/resources/cjr-finalruleintro.html
Gage, B., Constantine, R., Aggarwal, J., Morley, M., Kurlantzick, V., Bernard, S., . . . Barch, D. (2012). The development and testing of the Continuity Assessment Record and Evaluation (CARE) item set: Final report on the development of the CARE item set (Vol. 1; CMS Contract No. HHSM-500-2005-00291). Research Triangle Park, NC: RTI International.
