Predicting Improvement in Self-Care Among Medicare Beneficiaries With an Orthopedic Hip Condition Discharged to Home From Skilled-Nursing Facilities

PURPOSE: Older adults who are discharged from an acute care setting due to an orthopedic hip condition, such as hip fracture, often receive rehabilitation services in a post-acute care setting to improve performance in activities of daily living so they can return home more independently and safely. How to plan and justify the amount of rehabilitation services needed in terms of therapy intensity and duration in a post-acute care setting is critical for occupational therapists because the Medicare payment system has shifted from volume-based care to value-based care. However, studies that examined the relationship between the amount of rehabilitation services and self-care outcomes are scarce. The purpose of this study was to examine how therapy intensity and the length of stay predict the improvement in self-care skills among Medicare beneficiaries with an orthopedic hip condition in skilled nursing facilities.

DESIGN: This was a retrospective study using one-year Medicare quality measure data reported from 83 skilled nursing facilities in three Midwestern states. Electronic medical records between October 2016 to September 2017 were extracted and de-identified for analysis. Patients were included in the analysis if they were 65 years of age or older, utilized Medicare Part A insurance, admitted to one of the study skilled nursing facilities because of an orthopedic hip condition after an acute care stay, and were later being discharged to home. Patients were excluded if they did not have a completed record in study variables.

METHOD: Data of age, gender, Section GG self-care scores at admission and discharge, length of stay in days, total physical therapy time in minutes, and total occupational therapy time in minutes were extracted. Therapy intensity was defined as the average therapy minutes received per day, which is obtained by dividing the total therapy time over the length of stay. Hierarchical multiple regression analysis was conducted using the self-care change score of Section GG as the dependent variable. Age, gender, Section GG self-care scores at admission, the length of stay, occupational therapy intensity, and physical therapy intensity were entered into the regression model sequentially.

RESULTS: In total, 170 Medicare beneficiaries (mean age = 83 years) were included in the regression model. The average length of stay was 34 days. The average intensity was 54 minutes per day for occupational therapy and 64 minutes per day for physical therapy. The final saturated model explained 18% of the variance, and the model was significant, F (6, 163) = 6.03, p < .01. After controlling for the variance of age, gender, and Section GG self-care scores at admission, the length of stay significantly predicted the improvement of Section GG self-care scores (Beta = .22, p < .01), while the occupational therapy intensity and physical therapy intensity did not (Beta = .09, p = .52; Beta = .17, p = .18).

CONCLUSION: To help older adults recover from a hip orthopedic condition, the amount of therapy over time seems to be a more important determining factor to predict the improvement in independence in self-care skills than the amount of therapy per day. This study provides occupational therapists support to justify the need to increase the length of stay in order to meet the goal of functional independence for their clients with a hip orthopedic condition in a skilled nursing facility.

References

Jette, D. U., Warren, R. L., & Wirtalla, C. (2005). The relation between therapy intensity and outcomes of rehabilitation in skilled nursing facilities. Archives of Physical Medicine and Rehabilitation, 86, 373–379. doi: 10.1016/j.apmr.2004.10.018

Mallinson, T., Deutsch, A., Bateman, J., Tseng, H.-Y., Manheim, L., Almagor, O., & Heinemann, A. W. (2014). Comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after hip fracture repair. Archives of Physical Medicine and Rehabilitation, 95, 209–217. doi: 10.1016/j.apmr. 2013.05.031

Kroll, C., & Fisher, T. (2018). Health Policy Perspectives—Justifying rehabilitation intensity through functional performance measures in postacute care. American Journal of Occupational Therapy, 72, 7201090010p1-7201090010p6. doi:10.5014/ajot.2018.721002