 Does postacute care site matter: a longitudinal study assessing functional recovery after a stroke.Â, Hoenig  et al. 0000018480 00000 n 0000070972 00000 n  DE, Alter  HS, Shim Results of instrumental variable analyses are summarized in Table 3 and show similar results, including by differential distance from acute care hospital to nearest IRF or SNF (mean [SE] difference: mobility score, 8.2 [0.34] points; self-care score, 9.8 [0.39] points), by differential distance from patientâs residence to nearest IRF or SNF (mean [SE] difference: mobility score, 5.6 [0.63] points; self-care score, 8.7 [0.72] points), by percentage of IRFs within the acute hospital HRR (mean [SE] difference: mobility score, 10.4 [0.21] points; self-care score, 11.9 [0.25] points), and by previous IRF or SNF assignment by stroke type within each hospital (mean [SE] difference: mobility score, 9.2 [0.30] points; self-care score, 10.7 [0.34] points). In unadjusted analyses, patients with stroke who were discharged from IRF had lower mortality than those discharged from SNF (17.5% vs 30.5%, OR, 0.48 [95% CI, 0.46-0.49]).  MA, Graham Administrative, technical, or material support: Mallinson. This study was approved by the institutional review board of the University of Texas Medical Branch and complies with the Centers for Medicare & Medicaid Services (CMS) Data Use Agreement requirements, which waived the need for informed consent for use of the study data because data were deidentified. JAMA Netw Open. 0000009636 00000 n 0000071574 00000 n We used the crosswalk developed by Mallinson et al14 to construct comparable admission and discharge functional scores for the postacute care settings.15 The scores at admission and discharge for mobility and self-care are reported on a scale of 0 to 100 points, with higher scores indicating greater functional status. For self-care, the change was 13.6 (95% CI, 13.5-13.7) points vs 3.2 (95% CI, 3.1-3.3) points. Y.-L. Lin reported grants from National Institutes of Health during the conduct of the study. However, starting on day 21 through day 100, the patient is responsible for a daily copayment equal to one-eighth of the initial hospital deductible (in 2020, that amount is $176). Additionally, patients in IRF compared with those in SNF had larger improvements for mobility score (11.6 [95% CI, 11.5-11.7] points vs 3.5 [95% CI, 3.4-3.6] points) and for self-care score (13.6 [95% CI, 13.5-13.7] points vs 3.2 [95% CI, 3.1-3.3] points). 0000042508 00000 n  KJ, Hsu Funding/Support: This study was supported with funding from the National Institutes of Health (R01-AG033134, P2C HD065702, R01-HD069443, K01-HD086290, P30-AG024832, K12 HD055929, and 1UL1TR001439) and the Agency for Healthcare Quality and Research (R01-HS024711, R24-HS022134). 0000006251 00000 n As the IMPACT Act3 and unified payment are implemented, it will be important to accurately identify subgroups and target patients who would do better in one setting vs another. Inpatient Rehabilitation Unit (IRU) vs Skilled Nursing Facility (SNF) Patients have various options to meet their rehabilitation needs, however it is essential that they be educated on the differences in those options. Get free access to newly published articles. 0000032977 00000 n  BR.  Postacute care setting, facility characteristics, and poststroke outcomes: a systematic review.Â, Centers for Medicare & Medicaid Services, HHS. Obtained funding: Reistetter, Ottenbacher.  et al.  Hospital variation in functional recovery after stroke.Â, Mees 0000001892 00000 n When it comes to inpatient rehabilitation, the Encompass Health difference is our people, our approach and our outcomes. Reports by the National Academy of Sciences1 and the Institute of Medicine2 have found that postacute care was the largest contributor to geographic variation in Medicare costs.  GM, Brock Care in an inpatient rehabilitation facility was associated with greater improvement in mobility and self-care compared with care in a skilled nursing facility, and a significant difference in functional improvement remained after accounting for patient, clinical, and facility characteristics at admission.  Using propensity scores to help design observational studies: application to the tobacco litigation.Â, Hausman An IRF requires no pre-qualifying hospital stay for Medicare coverage. Concept and design: Goodwin, Reistetter, Kuo, Karmarkar, Ottenbacher.  JP, Garber  ES, Wennberg Amount (and intensity) of therapy: In a skilled nursing facility you’ll receive one or more therapies for an average of one to two hours per day. Our findings also have implications regarding the IMPACT Act.3 Studies that compare functional outcomes for all patients discharged to postacute care may be missing treatment effects that appear only in some impairment groups requiring the intense or specialized rehabilitation available in IRFs.30 For many hospital discharges, the postacute care setting may not matter, but our results suggest that, for at least one-third of patients with a stroke, discharge to an IRF vs SNF was associated with a significant difference in self-care and mobility at discharge. 0000049131 00000 n Dr Ottenbacher reported receiving grants from the NIH during the conduct of the study and personal fees from the Kessler Foundation outside the submitted work. We used several analytic approaches to control for potential confounders across IRF and SNF settings, including multivariable analysis, inverse probability weighting with propensity scores and instrumental variable analyses. Changes in mobility and self-care measures during an IRF or SNF stay were compared using multivariate analyses, inverse probability weighting with propensity score, and instrumental variable analyses. © 2019 Hong I et al. © 2020 American Medical Association. Author Contributions: Dr Ottenbacher had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.  et al. Acute Rehab vs. SNF Patients have various options to meet their rehabilitation needs, however it is essential that they be educated on the differences in those options.  M, Klein  Association between cholecystectomy with vs without intraoperative cholangiography and risk of common duct injury.Â, Stukel JAMA Network Open. In this cohort study of a large national sample, inpatient rehabilitation in IRFs for patients with stroke was associated with substantially improved physical mobility and self-care function compared with rehabilitation in SNFs. Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.  I, Woo 0 Is change in physical function associated with receiving postacute care after a stroke in inpatient rehabilitation vs skilled nursing facilities? We believe the difference in conditions (ie, hip fracture and joint replacement vs stroke) is the most plausible explanation. In unadjusted analyses, patients with stroke admitted to IRF compared with those admitted to SNF had higher mean scores for mobility on admission (44.2 [95% CI, 44.1-44.3] points vs 40.8 [95% CI, 40.7-40.9] points) and at discharge (55.8 [95% CI, 55.7-55.9] points vs 44.4 [95% CI, 44.3-44.5] points), and for self-care on admission (45.0 [95% CI, 44.9-45.1] points vs 41.8 [95% CI, 41.7-41.9] points) and at discharge (58.6 [95% CI, 58.5-58.7] points vs 45.1 [95% CI, 45.0-45.2] points). Our findings are based on Medicare files for IRF and SNF settings only and are not applicable to stroke rehabilitation in other postacute venues (eg, home health care, long-term care hospitals, or outpatient care). Our findings and the research of Buntin et al36 indicate that it may be possible to improve our ability to identify appropriate candidates for the high-intensity, specialized services provided in IRFs. 0000003667 00000 n  L, Liang In order to assess the ability of the various analytic techniques to adjust for unmeasured confounders, we assessed mortality between 30 and 365 days as a control outcome (Table 4).  Z, Sicklick We were not able to examine cognitive function before and after the stroke, stroke severity, or location of the stroke. This cohort study included 99â¯185 patients who received postacute care in inpatient rehabilitation or skilled nursing facilities after a stroke. Our data included Medicare files from 2012 to 2014. The propensity score was generated with a logistic regression model using an average treatment effect estimation20 that incorporated all covariates listed in eTable 4 and eTable 5 in the Supplement. She was not compensated for her contribution. In this study, we used all-cause mortality between 30 and 365 days after hospital discharge as a control outcome. The changes in mobility and self-care scores were substantially greater among IRF patients. doi:10.1001/jamanetworkopen.2019.16646. In this study, we compared functional outcomes of patients with stroke who were discharged from a hospital to an IRF or SNF. Definitions of Skilled and IRF Care Definition of Definition of the Skilled Rehabilitation Care Nursing Care: The Inpatient Rehabilitation Facility (IRF) provides The SNF provides services to an inpatient intermittent and/or daily who needs a relatively skilled care services. The 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act3 requires the Secretary of the Department of Health and Human Services to establish a unified payment system for postacute care.  S, Li  KA, Lunt In a skilled nursing facility, Medicare pays for 100 days per stretch, with the first 20 days fully paid for under certain conditions. 0000039660 00000 n  DA, Gottlieb eFigure.  MJ. Health care reform legislation and Medicare plans for unified payment for postacute care highlight the need for research examining service delivery and outcomes. Hospital characteristics included location (urban or rural), hospital type (ie, for-profit, nonprofit, or other), presence of swing beds (yes or no), rehabilitation unit within hospital (yes or no), teaching hospital (yes or no), number of stroke discharges from the index hospital in the same year of the index stroke discharge, and number of beds in index stroke hospital. 0000002254 00000 n For the sixth measure, hospital readmissions, IRF patients had fewer hospital readmissions than SNF patients for five of the 13 conditions (amputation, brain injury, hip fracture, major medical complexity, and pain syndrome). Yang Multivariable, propensity score, and instrumental variable analyses showed a similar magnitude of better improvements in patients admitted to IRF vs those admitted to SNF.  CM, Lapane The outcomes were changes in mobility and self-care scores during the IRF or SNF stay.  N, Escarce  CM  GC, Kautter The race/ethnicity variable was defined by the CMS and was included because some outcomes differ among racial/ethnic groups.18 The 30 most frequent CMS Hierarchical Condition Categories for comorbidities were identified through diagnoses on the inpatient claims from the previous year and the secondary diagnoses during the index stroke hospitalization (eTable 4 and eTable 5 in the Supplement).19 In addition, we added 6 diagnoses related to cognitive function (eTable 6 in the Supplement).  P.  Predicting discharge destination after stroke: a systematic review.Â, Werner More than 40% of Medicare beneficiaries are discharged from acute care hospitals to postacute care each year. 0000006541 00000 n 0000039541 00000 n  J, Raji  L, Sandel 0000070360 00000 n Postacute care reform based on the IMPACT Act3 must avoid a payment system that shifts patients with stroke who could benefit from intensive inpatient rehabilitation to lower cost settings. A total of 99â¯185 patients with stroke from 3405 hospitals were included in the study, including 66â¯082 patients (66.6%) who received stroke rehabilitation in an IRF and 33â¯103 patients (33.4%) who received stroke rehabilitation in an SNF.  AM, All Rights Reserved, Challenges in Clinical Electrocardiography, Clinical Implications of Basic Neuroscience, Health Care Economics, Insurance, Payment, Scientific Discovery and the Future of Medicine, United States Preventive Services Task Force. 0000004344 00000 n 304 0 obj <> endobj  M, Reker  AW, Black 0000003831 00000 n This cohort study included 99â¯185 patients who received postacute care in inpatient rehabilitation or skilled nursing facilities after a stroke.  GN. Ickpyo Hong, PhD, OTR, and Kenneth J. Ottenbacher, PhD, OTR. 0000005883 00000 n A higher proportion of women were admitted to SNFs (21â¯466 [64.8%] women) than IRFs (36â¯462 [55.2%] women) (Pâ<â.001). Needing supervision simply involves another person being present to monitor the activity but not provide physical assistance unless required.  CA.  RP, Garber 0000049774 00000 n It is not possible to directly measure the size of the population of marginal patients. At an SNF, Medicare Part A will cover up to 100 days of skilled nursing care per spell of illness. The CMS 60% rule identifies 13 diagnostic conditions that classify a facility as an IRF for Medicare reimbursement.35 Stroke is the largest category of these conditions, with 20.5% of all patients in IRFs in 2017.6. Table 1 presents the baseline differences in the patient characteristics between those admitted to IRFs or SNFs. Hong I, Goodwin JS, Reistetter TA, et al. Differences between inpatient rehabilitation & skilled nursing care 1. These findings suggest that there is room for payment reform in postacute care and highlight the need to target decision-making regarding discharge to postacute facilities based on patient needs and potential for recovery. Adjustment for patient and hospital characteristics in a multivariate adjustment model increased the OR to 0.72 (95% CI, 0.69-0.74), which was similar to results of the inverse probability weighted propensity models (adjusted odds ratio, 0.75 [95% CI, 0.72-0.77]). We hypothesized that patients discharged to IRFs would have larger improvements in mobility and self-care function than those discharged to SNFs. Patients at the level of needing supervision are usually ready for discharge to home, while patients needing maximal assistance will require continued institutional care or in-home nursing support after discharge from postacute care.32,33. These files included Master Beneficiary Summary for patient demographics, Medicare Provider Analysis and Review for claims from hospital and postacute care stays with clinical variables, Inpatient Rehabilitation Facility-Patient Assessment Instrument from IRF,4,11 Minimum Data Set 3.0 from SNF,12 and the Provider of Services Current Files for hospital characteristics. 0000050089 00000 n  A, Hedeman Lastly, for each outcome, we calculated the E-value to assess the minimum strength of association that an unmeasured confounder would need to have with the outcome and postacute care setting to eliminiate the association between postacute care setting and each outcome (eTable 9 in the Supplement). Additional Diagnoses Related to Cognitive Function, eTable 7. Impact: The update increased reimbursement for skilled nursing facilities.  NB, Qi In contrast, the 4 instrumental variable models resulted in odds of mortality closer to 1.0, with ORs ranging from 0.92 (95% CI, 0.76-1.11) when adjusted for previous IRF or SNF assignment by stroke type within each hospital to 1.25 (95% CI, 0.88-1.76) when adjusted by differential distance from patientâs residence to the nearest IRF or SNF (Table 4). A higher proportion of women were admitted to SNFs (21â¯466 [64.8%] women) than IRFs (36â¯462 [55.2%] women) (Pâ<â.001).  A.  More accurate racial and ethnic codes for Medicare administrative data.Â, Pope  30- to 365-d Mortality From Hospital Discharge Between IRFs and SNFs. • IRF patients experienced an 8 percentage point lower mortality rate during the two-year study period than SNF patients (p<0.0001) • IRF patients experienced 5 percent fewer emergency room (ER) visits per year than SNF patients (p<0.0001) • For five of the 13 conditions, IRF patients …  RC. 0000006067 00000 n According to the U.S. Department of Health and Human Services, 35% of Americans will require care in a nursing facility at some point, with long-term acute care facility and inpatient rehabilitation facility (IRF) stays only adding to that figure. We estimated the parameters using 2-stage least square regression.22-24 For the control outcome of 30- to 365-day mortality, the parameters were estimated from 2-stage residual inclusion models because the outcome was dichotomous. If the statistical analyses show significant IRF vs SNF differences in 30- to 365-day mortality, that result would suggest that underlying selection biases remain.  Patient outcomes after hospital discharge to home with home health care vs to a skilled nursing facility.Â, Chan  AA, Cloft 2019;2(12):e1916646. Table 2 presents the unadjusted mobility and self-care scores at admission and discharge for patients in IRFs and SNFs, along with the change in scores between admission and discharge. Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. Our methods are described in more detail in the eAppendix in the Supplement. Data were analyzed from January 17, 2017, through April 25, 2019. IRF vs SNF coding are different, and yes, some invasive procedures should be captured on the IRF side as long as the patient’s head is back in the bed the same day before midnight.  J.  Selection of Postacute stroke rehabilitation facilities: a survey of discharge planners from the northeast cerebrovascular consortium (NECC) region.Â, Bettger 0000023767 00000 n The next chart provides an explanation of acute vs. sub-acute rehabilitation services. 0000049696 00000 n IRF: Higher level of care than a SNF. Stroke is a complex neurological condition affecting multiple body systems and requiring intensive rehabilitation from several disciplines with different areas of expertise. 0000056853 00000 n  W, Rabinstein  Jr, Goodwin For patients who are seeking rehabilitation services, there are typically two options to select: Inpatient Rehabilitation Hospital or Skilled Nursing Facility. This pattern is consistent with prior comparative effectiveness studies using observational data7-9 and reinforces the view that such techniques should be avoided in the face of strong selection bias.  YF, Duan The LOS in SNFs was more than 2-fold that in IRFs (mean [SD], 38.1 [24.1] days vs 15.2 [7.3] days).  Hospitalization costs for acute ischemic stroke patients treated with intravenous thrombolysis in the United States are substantially higher than Medicare payments.Â, Mallinson Drafting of the manuscript: Hong, Goodwin, Ottenbacher. Additional research is necessary to confirm our findings and to identify whether any of the other 13 conditions identified by CMS as priority diagnoses for receiving services in IRFs (the 60% rule) may also show differences in functional outcomes based on treatment in IRFs vs SNFs. A recent systematic review reported better functional outcomes and higher costs for patients in IRFs compared with those in SNFs and emphasized the need for additional research.4 Limited research has reported generally better functional outcomes associated with patients in IRFs vs SNFs after a stroke.4,29,31,32 The findings of our study support this trend. 0000049018 00000 n  SJ. We also found differences in functional outcomes between IRF and SNF using logistic regression and propensity scores. The current CMS rules for identifying priority patients for IRFs are a good start, but challenges remain, such as the large disparity in the availability of IRFs vs SNFs. These findings suggest that there is room for payment reform in postacute care and highlight the need to target decision-making regarding discharge to postacute facilities based on patient needs and potential for recovery. 0000010004 00000 n 0000005343 00000 n Data analyses were conducted from January 17, 2017, through April 25, 2019.  JS. 0000049580 00000 n All Rights Reserved. Centers for Medicare & Medicaid Services. The number of items to measure cognitive function in the IRF and SNF assessment protocols are small, and our preliminary analyses to develop a cocalibrated crosswalk revealed low precision.16,38 Instead, we included diagnoses associated with cognitive dysfunction in the comorbidities that were controlled for (eTable 6 in the Supplement).  JP, Thomas Open Access: This is an open access article distributed under the terms of the CC-BY License. Congress and CMS have set in motion an ambitious plan to significantly reform post-acute care, which includes long-term care hospitals (LTCH), inpatient rehabilitation facilities (IRF), skilled nursing facilities SNF) and home health (HH) agencies. We used instrumental variable analysis to adjust for unmeasured confounders across patients and facilities.21 The instrumental variables included difference in the distance from the acute care hospital to the nearest IRF vs the nearest SNF, difference in the distance from the beneficiaryâs residence to the nearest IRF vs nearest SNF, number of stroke patients discharged to an IRF in the hospital referral region (HRR) in 2013 through 2014, and the previous discharge location assignment (IRF or SNF) for patients with the same type of stroke from the same acute care hospital (eTable 7 and eTable 8 in the Supplement). These resources will help determine what is best for you or your loved one. Q: What do the DTC-PAC measures assess? <<27EF291824D86C4395D1B75C06CED14C>]/Prev 95442/XRefStm 2254>> %%EOF The.  L, 381 0 obj <>stream Regardless of covariate adjustment method, the patients with stroke who were discharged from IRF had higher mobility and self-care scores than those discharged from SNF. Published: December 4, 2019. doi:10.1001/jamanetworkopen.2019.16646. Results Critical revision of the manuscript for important intellectual content: All authors.  The central role of the propensity score in observational studies for causal effects.Â, Kuo 0000071342 00000 n For mobility, the change was 11.6 (95% CI, 11.5-11.7) points for patients in IRFs vs 3.5 (95% CI, 3.4-3.6) points for those in SNFs. Patients treated in a SNF as a result of the 60% Rule who could have otherwise been treated in an IRF might be adversely affected by an increased risk of death, increased use of facility-based care, and more ER visits and hospital readmissions.  A, Mancher Additionally, we used ordinary least squares models with inverse probability treatment weighting, with propensity scores also adjusted for unbalanced covariates, to compare functional status outcome (ie, mobility and self-care) at discharge from IRF or SNF.  RP, Rubin 0000020662 00000 n Instrumental Variables Across Inpatient Rehabilitation Facilities (IRFs) and Skilled Nursing Facilities (SNFs), eTable 8. The national average length of time spent at a skilled nursing facility rehab is 28 days. The differences between SNF and IRF in odds of 30- to 365-day mortality (unadjusted odds ratio, 0.48 [95% CI, 0.46-0.49]) were reduced but not eliminated in multivariable analysis (adjusted odds ratio, 0.72 [95% CI, 0.69-0.74]) and propensity score analysis (adjusted odds ratio, 0.75 [95% CI, 0.72-0.77]). 0000049209 00000 n  Factors influencing selection for rehabilitation after stroke: a questionnaire using case scenarios to investigate physician perspectives and level of agreement.Â, Xian Care in an inpatient rehabilitation facility was associated with greater improvement in mobility and self-care compared with care in a skilled nursing facility, and a significant difference in functional improvement remained after accounting for patient, clinical, and facility characteristics at admission.  Change in Score From Admission to Discharge in IRF and SNF, Table 4.  et al. Were in a SNF in the prior 6 mo. 2019;2(12):e1916646. Significantly more of the SNF-treated patients required a walker (80.2%) for ambulation at discharge compared with patients treated at the IRF (38.3%, P < 0.001). Stroke Comorbidities Across Inpatient Rehabilitation Facilities (IRFs) and Skilled Nursing Facilities (SNFs) Before and After Inverse Probability of Treatment Weighting, eTable 6. The study sample included Medicare beneficiaries 66 years or older discharged from January 1, 2013, to November 30, 2014, to an IRF or SNF after an index acute stay for stroke denoted by Medicare Severity Diagnosis Related Group codes 061 to 066 (eFigure in the Supplement).13 Additional inclusion criteria included Medicare Part A coverage without enrollment in a health maintenance organization in the year before and 1 month after the index stroke discharge, residing in the community prior to the index stroke hospitalization, and full mobility and self-care functional measures at the IRF admission and discharge or SNF admission and last follow-up (eTable 1 and eTable 2 in the Supplement). %PDF-1.4 %���� An IRF is designed to provide intensive rehabilitation to complex patients who need specialized care. Skilled Nursing Facility (SNF) IRFs SNFs Physician approval of preadmission screen and admission Yes No Patient requires resource-intensive inpatient care Yes No Close medical supervision by a physician with specialized training Yes No Inpatient Rehab Facility (IRF) vs. xref  A comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after lower-extremity joint replacement surgery.Â, Masters 0000021775 00000 n Demographics Across Inpatient Rehabilitation Facilities (IRFs) and Skilled Nursing Facilities (SNFs) Before and After Inverse Probability of Treatment Weighting, eTable 5.  Medicare spending and outcomes after postacute care for stroke and hip fracture.Â, Ottenbacher We used mobility and self-care items from the Inpatient Rehabilitation Facility-Patient Assessment Instrument and the Minimum Data Set 3.0 (eTable 3 in the Supplement). Is change in physical function associated with receiving postacute care after a stroke in inpatient rehabilitation vs skilled nursing facilities? The national average length of time spent at an acute inpatient rehab hospital is 16 days. Lastly, we calculated E-values for mobility scores, self-care scores, and mortality between patients admitted to IRF or SNF, to assess the potential magnitude of unmeasured confounding that might have produced the results.10 Data were analyzed using SAS statistical software version 9.4 (SAS Institute). Compared with patients admitted to IRFs, patients admitted to SNFs were older (mean [SD] age, 79.4 [7.6] years vs 83.3 [7.8] years; Pâ<â.001) and had longer hospital length of stay (mean [SD], 4.6 [3.0] days vs 5.9 [4.2] days; Pâ<â.001) than those admitted to IRFs. Inpatient Rehabilitation Facilities (IRF) In my previous blog titled The Top 5 Benefits of Inpatient Rehabilitation, I discuss the benefits of choosing inpatient rehabilitation if recommended by healthcare staff. 0000070242 00000 n The lower confidence limit of the E-value was 4.0 for the change in mobility and 4.2 for self-care scores.  JS. Next, we used hierarchical general linear mixed-effects models to account for patients nested within hospitals.  Equating activities of daily living outcome measures: the Functional Independence Measure and the Korean version of Modified Barthel Index.Â, Eicheldinger  Y, Kuo Terms of Use| In a study of Medicare spending and outcomes after postacute care for stroke and hip fracture, Buntin et al36 estimated the percentage or marginal patients as between 20% to 30% of patients with hip fracture or stroke. 0000053855 00000 n  M, Ulbricht 0000014526 00000 n In this cohort study of a large national sample, inpatient rehabilitation in IRFs for patients with stroke was associated with substantially improved physical mobility and self-care function compared with rehabilitation in SNFs. 0000008507 00000 n Skilled Nursing Facility Payment Update In accordance with the Bipartisan Budget Act of 2018, the aggregate impact of SNF payments are estimated to increase by 2.4% in the Fiscal Year 2019. Whether you are transferred to an IRF or a skilled nursing facility is an important distinction because Medicare covers a different number of days for an IRF than it does for skilled nursing, and you pay a different co-payment. 0000071429 00000 n Comparison of Functional Status Improvements Among Patients With Stroke Receiving Postacute Care in Inpatient Rehabilitation vs Skilled Nursing Facilities.  RD, Zolkewitz All Rights Reserved. Skilled Nurisng Facilities -- Services, Expenditures, and Payment Methods 0000007540 00000 n Our study adds to the accumulating scientific literature that better functional outcomes, such as mobility and self-care, are associated with discharge from IRFs vs SNFs among stroke survivors.4,29,31,32 This has not been true for other conditions, such as hip fracture or joint replacement.34 A study by Mallinson et al34 comparing mobility and self-care outcomes, which were measured in the same way as in our study, among patients with hip fracture receiving rehabilitation from IRFs, SNFs, or home health agencies found no statistically significant differences in fully adjusted models.  R, Horner For patients who are seeking rehabilitation services, there are typically two options to select: Inpatient Rehabilitation or Skilled Nursing Facility. 0000014349 00000 n endstream endobj 380 0 obj <>/Filter/FlateDecode/Index[26 278]/Length 31/Size 304/Type/XRef/W[1 1 1]>>stream Acute Rehab vs. SNF. 0000021591 00000 n |���_�m���6�A���4y���l6����2�p&�x���OU�!���� ���/87�:�1�`g�R@FjY�o����E�F����K��cf'�Ly��V���n�f��|��$c��f�m �F� What Constitutes an IRF vs. a Skilled Nursing Facility. 0000050260 00000 n Skilled Nursing Facility (SNF) Click the chart below to expand the details and differences between each service. Medicare claims were used to link to IRF and SNF assessments.  CV, Fiedler 304 78 Question Several studies7-9 have shown that traditional methods of controlling for patient characteristics, such as logistic regression and propensity analyses, tend not to be effective in the face of strong selection biases.  J, 0000010453 00000 n  D, Dalton  D.  Differences in rehabilitation services and outcomes among stroke patients cared for in veterans hospitals.Â, Deutsch Maximal assistance requires another person to physically assist the patient. There are challenges in comparing outcomes in observational studies, the most important of which is bias by indication, or selection bias.  J, Goodwin This method has demonstrated efficacy in several settings.16,17. The development of a standardized measure of cognitive function is an important area for future research and is included as part of the IMPACT Act.3 Previous investigations have consistently reported that the costs for rehabilitation services provided in SNFs are significantly lower than in IRFs, even when the longer LOSs associated with SNFs are considered.4,36 We did not conduct cost comparisons or cost benefit analyses associated with outcomes across the 2 postacute settings.  TR, Bateman  M, Konetzka This cohort study included patients with stroke who were discharged from acute care hospitals to IRF or SNF from January 1, 2013, to November 30, 2014. Our findings indicate the need to carefully manage discharge to postacute care based on the patientâs needs and potential for recovery.  Y, Granger  R, Bettger  Poststroke rehabilitation: outcomes and reimbursement of inpatient rehabilitation facilities and subacute rehabilitation programs.Â, Mallinson  Potentially preventable hospitalizations in Medicare patients with diabetes: a comparison of primary care provided by nurse practitioners versus physicians.Â.  P, Cras The critical issue in Medicare for IRF services is whether the patient required the care of a rehab physician, either due to comorbidities or some other concern which makes SNF care inappropriate.  L, Liang startxref 0000057261 00000 n Health care reform legislation and Medicare plans for unified payment for postacute care highlight the need for research examining service delivery and outcomes. Find Medicare-certified inpatient rehabilitation facilities and compare them based on the quality of care they provide to patients. Currently, the decision-making process in selecting postacute care services is heavily influenced by nonclinical factors.25-30 This is shown by the substantial geographic variation in the proportions of patients with stroke discharged to IRFs or SNFs.28 The choice is associated with measures of availability, such as distance to the nearest facility.29 The association of IRF vs SNF use with these nonclinical factors allows investigators to use them as instruments in an instrumental variable analysis, which should better control for unmeasured confounders that might be influencing the choice of IRF vs SNF. 0000057755 00000 n The assumption is that the underlying health of patients with stroke would vary somewhat among HRRs, but not markedly, and that the variation reflects local availability of the 2 types of facilities along with other medical cultural issues.  H, Sloane A 10-point difference in self-care in an IRF is the difference between a patient rating of needing maximal assistance vs needing supervision. We addressed the various bias and confounding issues listed in Dr. Burnettaâs Comment using the most current analytical approaches. Meaning 0000070457 00000 n A third approach is to use analytic approaches shown to minimize selection biases, such as instrumental variable analysis.7-9 We used these 3 approaches to compare outcomes of patients with stroke who were discharged from acute care to IRFs vs SNFs. Functional Measures: Mobility and Self-Care. The difference in findings between the Mallinson et al study34 and our study could be related to many factors. 0000023944 00000 n Another concern is the current cost differential between postacute care settings. As a step in this process, the Medicare Payment Advisory Commission recommended that inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) explore similar episode-based reimbursement for a given condition. 0000049525 00000 n There are several approaches to mitigating this problem. To effectively and safely implement unified payment in postacute care,3 it will be necessary to recognize differences in the rehabilitation needs of patients with stroke and other complex conditions. More are female.  HY, On July 31, the Centers for Medicare & Medicaid Services (CMS) released final rules to update the Medicare fee-for-service prospective payment systems for inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) for fiscal year (FY) 2018.. Had a longer hospital LOS h�bba`b``Ń3� ���� � ���  Risk adjustment of Medicare capitation payments using the CMS-HCC model.Â, Rosenbaum  P.  Sensitivity analysis in observational research: introducing the E-Value.Â, Centers for Medicare & Medicaid Services.  A, Bateman Results of instrumental variable analyses are summarized in Table 3 and show similar results, including by differential distance from acute care hospital to nearest IRF or SNF (mean [SE] difference: mobility score, 8.2 [0.34] points; self-care score, 9.8 [0.39] points), by differential distance from patient’s residence to nearest IRF or SNF (mean [SE] difference: mobility score, 5.6 [0.63] points; self-care score, …  J, Yperzeele 0000046431 00000 n 0000002595 00000 n 0000007026 00000 n Stays in skilled nursing facilities (SNFs) are also common. Appropriate Patient Placement 2. Mortality between 30 and 365 days after discharge was included as a control outcome as an indicator for unmeasured confounders. 0000050144 00000 n Identify all potential conflicts of interest that might be relevant to your comment. 0000025802 00000 n P values were 2-tailed, and statistical significance was set at less than .05.  The reliability of the functional independence measure: a quantitative review.Â. h�b``d`��������� �� @1v�'/S�1�G�$L$>aT��Д�tjZ�R)�4���^W�U����Wt A������l!F ��>`i>� ���}�́��L%��� �  JP.  Y-F, Chen This is an important topic for future research. Changes in mobility and self-care measures during an IRF or SNF stay were compared using multivariate analyses, inverse probability weighting with propensity score, and instrumental variable analyses. A significant difference in functional improvement remained after accounting for patient, clinical, and facility characteristics at admission. Main Outcomes and Measures Accepted for Publication: October 9, 2019. For patients who are seeking rehabilitation services, there are typically two options to select: Acute Rehab or Skilled Nursing Facility. No other disclosures were reported. Acute vs. Sub-Acute Rehabilitation. endstream endobj 305 0 obj <>/Metadata 24 0 R/Pages 23 0 R/StructTreeRoot 26 0 R/Type/Catalog/ViewerPreferences<>>> endobj 306 0 obj <. Patients receiving SNF vs IRF care were older (83 vs 79 years), had more comorbid illness, and higher unadjusted 7, 90, and 365 day mortality and rehospitalizations (Table).  L,  N-W, Baillargeon  J, Tseng Next, we used inverse probability treatment weighting with propensity scores with and without multilevel adjustment. Comparison of Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) With Minimum Data Set 3.0 (MDS) Items in the Mobility and Self-care Construct, eTable 4. I found this article very interesting. Have more severe strokes. The Minimum Data Set 3.0 consists of 6 mobility items with a 4-point rating scale and 5 self-care items with a 5-point rating scale. We reported the study findings according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. The instrumental variable analyses in this study describe the outcomes of the marginal patient, that is, those patients who reasonably could have been discharged either to an IRF or SNF. By contrast, Medicare patients in some subacute rehab SNF may not see a doctor more than once a week or in some instances even longer. 0000046580 00000 n Data analyses were conducted from January 17, 2017, through April 25, 2019. The proposal is based, in part, on the substantial overlap in patient populations served by IRFs and SNFs.4,5, The purpose of our study was to examine changes in functional status in a national sample of Medicare beneficiaries with stroke who received inpatient rehabilitation at an IRF or SNF following acute hospital discharge.  RT. Discharge to home, a skilled nursing facility (SNF), or an inpatient rehabilitation facility (IRF) was the primary outcome. 0000071050 00000 n  JA. These differences were no longer statistically significant in the instrumental variable analyses. 0000034254 00000 n Dr Mallinson reported receiving grants from National Institute on Disability and Rehabilitation Research outside the submitted work. 0000006429 00000 n Our website uses cookies to enhance your experience. 0000070681 00000 n  et al. Patient Characteristics Between Skilled Nursing Facility (SNF) Stays Included in the Cohort and Those Excluded Owing to Incomplete Data for Function Scores, eTable 2. 0000006655 00000 n The information will be posted with your response. Study Flow Diagram for the Sample, eTable 1. Compared with patients admitted to IRFs, patients admitted to SNFs were older (mean [SD] age, 79.4 [7.6] years vs 83.3 [7.8] years; Pâ<â.001), had longer hospital LOS (mean [SD], 4.6 [3.0] days vs 5.9 [4.2] days; Pâ<â.001), and had more comorbidities (mean [SD], 2.8 [2.0] comorbidities vs 3.3 [2.1] comorbidities; Pâ<â.001) (Table 1; eTable 4 in the Supplement).  Y, Thomas One way to estimate the size of the marginal patient population is to examine the distribution in variation in percentage of patients with stroke discharged to an IRF or SNF among HRRs. E-values for Mobility and Self-care Scores and 30- to 365-Day Mortality From Hospital Discharge. Objective  Specification tests in econometrics.Â, Kennedy Please allow up to 2 business days for review, approval, and posting.  MA, Goodwin Corresponding Author: Kenneth J. Ottenbacher, PhD, OTR, University of Texas Medical Branch, School of Health Professions, Division of Rehabilitation Sciences, 301 University Blvd, Galveston, TX 77555-1137 (kottenba@utmb.edu). Of the patients who were discharged home, 75% of the SNF-treated patients required homecare services compared with 41.2% of the IRF-treated patients (P < 0.001).  Geographic variation in health care spending in the United States: insights from an Institute of Medicine report.Â, Alcusky 0000016541 00000 n After IPW adjustment mortality and rehospitalization/mortality rates remained significantly better for …  AW, If you have no conflicts of interest, check "No potential conflicts of interest" in the box below.  TA, Fisher However, the inability of more analytical techniques to eliminate the differences in the control outcome of all-cause mortality between 30 and 365 days suggests that those approaches did not eliminate selection biases. CMS developed the DTC-PAC measures to meet the IMPACT Act mandate and finalized them through rulemaking in Fiscal Year 2017 (IRF, LTCH, SNF) and Calendar Year 2017 (HH).  SH, Kuo Privacy Policy| In the multilevel multivariate propensity score inverse probability of treatment weighting model, the mean (SE) difference in scores between patients from IRF vs SNF was 8.0 (0.04) points for mobility and 9.9 (0.05) points for self-care. This cohort study included patients with stroke who were discharged from acute care hospitals to IRF or SNF from January 1, 2013, to November 30, 2014. A federal government website managed by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244 0000070603 00000 n We selected stroke because it is a major cause of disability in the United States and an important public health issue, patients with stroke have complex neurological disorders that require a range of treatments and expertise, and stroke represents the largest impairment group treated in IRFs.6. Acquisition, analysis, or interpretation of data: All authors. Dr Karmarkar reported receiving grants from the National Institutes of Health (NIH) and being an employee of RTI International outside the submitted work. Patients Discharged to an IRF vs. SNF are Different Compared with IRF patients, SNF patients: Are older. Our findings are similar to what Buntin et al36 estimated as the percentage of patients with marginal stroke and hip fracture. People generally receive inpatient therapy in a skilled nursing facility (SNF) or inpatient rehab facility (IRF) following hospitalization for a health event and need to be in an environment where they can receive skilled care and oversight before transitioning to the home.  et al. 0000002436 00000 n Medicare coverage for SNF stays is more limited than at an IRF.  MB, Colla This cohort study found that Medicare beneficiaries who received services at an IRF after a stroke demonstrated greater improvement in mobility and self-care compared with patients who received inpatient rehabilitation at a SNF.  AM, Newhouse The Inpatient Rehabilitation Facility-Patient Assessment Instrument includes 5 mobility items and 6 self-care items, with a 7-point rating scale. 0000007974 00000 n Medicare Requirements for Inpatient Rehabilitation Facility (IRF) vs. 0000023591 00000 n Conflict of Interest Disclosures: Dr Reistetter reported receiving grants from the Agency for Healthcare Research and Quality (AHRQ) during the conduct of the study. The Medicare Payment Advisory Commission reports6,37 consistently demonstrate that IRF costs are higher than those of SNF and home health. Newhouse Brinjikji  Z, Hortobagyi This study has limitations.  Comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after hip fracture repair.Â, Buntin  Limits of observational data in determining outcomes from cancer therapy.Â, Sheffield Conclusions and Relevance  YC, Joseph © 2020 American Medical Association.  KL, Wang  RM, Coe 0000003694 00000 n  TS, Han  Translating measures across the continuum of care: using Rasch analysis to create a crosswalk between the Functional Independence Measure and the Minimum Data Set.Â, Hong 0000021088 00000 n 0000018293 00000 n  PR, Rubin  AM. Please see our commenting policy for details. The investigation included 99,185 stroke patients who received post-acute care services at a SNF or IRF between Jan. 2013 and Nov. 2014. IRF versus SNF.  KL.  YF, Townsend 0000042411 00000 n Inpatient rehabilitation received in IRFs vs SNFs.
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