Responsiveness of Section GG Scores in Tracking Post-Stroke Functional Recovery From Inpatient Rehabilitation Admission to 90-Day Follow-Up.

OBJECTIVE: To evaluate the responsiveness and scale-to-sample targeting of Section GG of the Inpatient Rehabilitation Facility-Patient Assessment Instrument in measuring the trajectory of functional recovery in patients with stroke from inpatient rehabilitation admission to 90 days after discharge. DESIGN: Retrospective cohort study. SETTING: 150-bed inpatient rehabilitation facility. PARTICIPANTS: Patients with stroke (N=1087) discharged between December 2019 to April 2021. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Admission and discharge self-care and mobility scores from Section GG were analyzed for the Inpatient Only group (n= 817). Admission, discharge and 90-day post-discharge Section GG scores from telephone interviews with patients or caregivers were analyzed for the Follow-Up group (n=270). Standardized response means (SRM) determined responsiveness of the tool for each group and time interval. Score means, standard deviations, and floor/ceiling effects illustrated scale-to-sample targeting of the tool. RESULTS: Self-care and mobility scores improved significantly from admission to discharge (P<.001) for both groups and from discharge to 90 days (P<.001) for the Follow-Up group. Large SRM existed from admission to discharge for self-care and mobility scores in both groups. ​A small-to-moderate SRM was seen from discharge to 90 days for self-care (0.46) and a moderate SRM was observed for mobility (0.68). Overall floor effects were minor at admission for self-care (9.8%) and mobility (7.2.%). Overall ceiling effects were minor at discharge for self-care (11.2%) and mobility (4.6%)​ and significant at follow-up for both self-care (45.2%) and mobility (32.2%). CONCLUSIONS: Section GG is responsive to change and appropriately measures patients' functional ability during inpatient rehabilitation. More study is required for telephone follow-up after discharge from inpatient rehabilitation.

Prediction of Discharge Destination After Inpatient Rehabilitation for Stroke Using Mobility and Self-Care Assessment in Section GG of the Inpatient Rehabilitation Facility - Patient Assessment Instrument.

Objective: To determine the ability of Section GG of the Inpatient Rehabilitation Facility - Patient Assessment Inventory (Section GG)'s quantification of mobility and self-care to predict discharge destination for persons with stroke after inpatient rehabilitation. Design: Retrospective, observational cohort study. Setting: 150-bed inpatient rehabilitation facility within a metropolitan health system. Participants: Consecutive sample of adults and older adults with stroke admitted for inpatient rehabilitation from January 2020 to June 2021 (N=1051). Subjects were excluded for discharge to acute care or hospice or if they had COVID-19. Intervention: None. Main Outcome Measures: Section GG self-care and mobility scores used in reimbursement formulation by Centers for Medicare and Medicaid at admission to inpatient rehabilitation; age; sex; prior living situation; discharge setting. Logistic regression examined binary comparisons of discharge destinations. Receiver operating characteristic (ROC) curves determined cut-off admission Section GG scores for binary comparisons. Results: Logistic regression demonstrated that presence of a caregiver in the home was consistently the strongest predictor (P<.001) and admission Section GG scores were significant secondary factors in determining the discharge destination. An admission Section GG cut-off score of 33.5 determined home with homecare vs skilled nursing facility and a cut-off of 36.5 determined discharge to home with outpatient care vs skilled nursing facility. Conclusion: Clinicians responsible for discharge decisions for patients with stroke after inpatient rehabilitation might start by determining the presence of a caregiver in the home and then use Section GG cut-off scores to guide decisions about home (with or without homecare) vs SNF destinations. Such guidance is not advised for the home with outpatient services vs home with homecare decision; clinical judgment is needed to determine the best discharge plan because this ROC had a less robust area under the curve. Sex and race/ethnicity were not determining factors for binary choices of discharge destinations.

Activity Measure for Post-Acute Care "6-Clicks" Basic Mobility Scores Predict Discharge Destination After Acute Care Hospitalization in Select Patient Groups: A Retrospective, Observational Study.

Objectives: To establish cutoff scores for the Activity Measure for Post-Acute Care "6-Clicks" standardized Basic Mobility scores (sBMSs) for predicting discharge destination after acute care hospitalization for diagnostic subgroups within an acute care population and to evaluate the need for a second score to improve predictive ability. Design: Retrospective, observational design. Setting: Major medical center in metropolitan area. Participants: Electronic medical records of 1696 adult patients (>18 years) admitted to acute care from January to October 2018. Records were stratified by orthopedic, cardiac, pulmonary, stroke, and other neurological diagnoses (N=1696). Interventions: None. Main Outcome Measure: Physical therapists scored patients' sBMSs after referral for physical therapy and prior to discharge. Receiver operating characteristic curves delineated sBMS cutoff scores distinguishing various pairings of home, home with services, inpatient rehabilitation, or skilled nursing facility discharges. First and second sBMSs were compared with percentage change of the area under the curve and inferential statistics. Results: Home vs institution cutoff score was 42.88 for combined sample, pulmonary and neurological cases. The cutoff score for orthopedic diagnoses score was 41.46. Cardiac and stroke model quality invalidated cutoff scores. Home without services vs skilled nursing discharges and home with services vs skilled nursing discharges were predicted with varying cutoff scores per diagnosis. sBMS cutoff scores collected closer to discharge were either the same or higher than first cutoffs, with varying effects on predictive ability. Conclusions: sBMSs can help decide institution vs home discharge and finer distinctions among discharge settings for some diagnostic groups. A single sBMS may provide sufficient assistance with discharge destination decisions but timing of scoring and diagnostic group may influence cutoff score selection.

Redefining Pathways into Acute Rehabilitation during the COVID-19 Crisis.

The coronavirus disease 2019 (COVID-19) pandemic has necessitated drastic changes across the spectrum of health care, all of which have occurred with unprecedented rapidity. The need to accommodate change on such a large scale has required ingenuity and decisive thinking. The field of physical medicine and rehabilitation has been faced with many of these challenges. Healthcare practitioners in New York City, the epicenter of the pandemic in the United States, were among the first to encounter many of these challenges. One of the largest lessons included learning how to streamline admissions and transfer process into an acute rehabilitation hospital as part of a concerted effort to make acute care hospital beds available as quickly as possible.

Randomized controlled trial of the effectiveness of continuous passive motion after total knee replacement.

OBJECTIVE: To determine the effects of using a continuous passive motion (CPM) device for individuals with poor range of motion (ROM) after a total knee replacement (TKR) admitted for postacute rehabilitation. DESIGN: Randomized controlled trial. SETTING: Inpatient rehabilitation facility (IRF). PARTICIPANTS: Adults (N=141) after TKR with initial active knee flexion <75° on admission to the IRF. INTERVENTION: Two randomized groups: group 1 (n=71) received the conventional 3 hours of therapy per day, and group 2 (n=70) received the addition of daily CPM use for 2 hours throughout their length of stay. MAIN OUTCOME MEASURES: The primary outcome measure was active knee flexion ROM. Secondary outcome measures included active knee extension ROM length of stay, estimate of function using the FIM and Timed Up and Go test, girth measurement, and self-reported Western Ontario and McMaster Universities Osteoarthritis Index scores. RESULTS: All subjects significantly improved from admission to discharge in all outcome measures. However, there were no statistically significant differences in any of the discharge outcome measures of the CPM group compared with the non-CPM group. CONCLUSIONS: CPM does not provide an additional benefit over the conventional interventions used in an IRF for patient after TKR, specifically in patients with poor initial knee flexion ROM after surgery.

Effectiveness of continuous passive motion in an inpatient rehabilitation hospital after total knee replacement: a matched cohort study.

OBJECTIVE: To examine the use of continuous passive motion (CPM) as an adjunct to physical therapy after total knee replacement in patients who were transferred to an inpatient rehabilitation facility (IRF) and to compare the effectiveness of CPM on active range of motion (AROM), functional tasks, destination after discharge, the need for home care services, and the ambulation device at discharge. DESIGN: Matched cohort study. SETTING: IRF. PARTICIPANTS: Patients admitted to a rehabilitation setting after total knee replacement surgery with an initial AROM for knee flexion of less than 75° at admission to the IRF. From this initial population, a matched sample of 61 patient pairs was included in the analysis (61 who used the CPM and 61 who did not receive the adjunct therapy). INTERVENTION: Use of CPM for 2 hours per day as an adjunct to the 3 hours of physical and occupational therapy customary in an IRF. MAIN OUTCOMES: Primary outcomes were discharge active knee flexion ROM and flexion gain. Secondary outcomes were motor, cognitive, and total Functional Independence Measure scores; discharge ambulation device; destination after discharge; and the need for home care services after the inpatient stay. RESULTS: The outcome variables of 61 matched pairs of CPM users and non-CPM users were reported. No statistically significant differences were found in any of the outcome variables that were compared in this matched case design, including AROM knee, flexion gain, discharge to the community, need for home care services after discharge, and discharge with cane/no device. No significant difference was found in all functional scores as measured by the Functional Independence Measure scale. CONCLUSION: For this population, we determined at one facility that less than 30% are provided with a CPM as an adjunct to physical therapy. Using a matched cohort design, we compared CPM use with non-CPM use and determined that the application of CPM may not significantly influence ROM gain.

Rehabilitation following total knee replacement, total hip replacement, and hip fracture: a case-controlled comparison.

PURPOSE: To determine whether clinical outcomes and reimbursement for care differed between patients with hip fracture, total knee replacement (TKR), and total hip replacement (THR) undergoing an inpatient rehabilitation facility (IRF) versus skilled nursing facility (SNF). METHOD: A total of 541 patients (IRF = 409, SNF = 131) with unilateral hip fracture, TKR, and THR were recruited. The IRF and SNF patients were matched on age, sex, diagnosis, severity index, and ambulation Functional Independence Measure (FIM) score on admission. Comparisons of discharge motor FIM scores, length of stay, discharge ambulation devices, discharge disposition, use of home health services, transfer to acute care, and total reimbursement for the inpatient stay were carried out between matched pair groups. RESULTS: From a sample of 541 patients, 102 matched IRF-SNF pairs were created. The mean length of stay for those receiving care in IRF was 10.7 (4.2) days, compared to 25.5 (16.5) days for those receiving care in SNF (P < .001). Costs of care in the IRF setting were $11,984 ($5254) compared to that in the SNF setting, that is, $10,001 ($7141) (P = .008). As compared to patients receiving care in the SNF setting, those in the IRF were more likely to ambulate independently (87.5% vs 74.0%; P = .019), manage stairs independently (68.4% vs 34.7%; P < .001), require less home care (33.7% vs 76.4%; P < .001), and were less likely to use a walker at discharge (41.7% vs 67.7%; P < .001). There were no differences between settings in terms of transfers to acute care, ability to dress the lower body, toilet transfers, and discharge to home. CONCLUSION: When patients were matched for age, gender, operative diagnosis, severity index, and admission ambulation FIM score, those who received rehabilitation in the IRF had shorter length of stay and superior functional outcomes than those in the SNF setting. Cost of stay in an IRF was, however, significantly greater.

Outcome after rehabilitation for total joint replacement at IRF and SNF: a case-controlled comparison.

OBJECTIVE: The objective of this study was to determine whether outcomes differed between patients with single knee or hip joint replacement surgery undergoing rehabilitation in an inpatient rehabilitation facility (IRF) vs. skilled nursing facilities (SNFs). DESIGN: A retrospective chart review was performed on 87 pairs of patients treated in either an IRF or a SNF matched for age, gender, type of surgery, and Functional Independent Measure (FIM) motor score at admission. All patients discharged from the IRF for rehabilitation following single hip or knee replacement surgery in 2004 were eligible for comparison with index cases discharged from SNFs with the same diagnosis in 2004. At discharge, FIM motor scores, device used for ambulation, ambulation distance, disposition, and length of stay (LOS) were recorded. RESULTS: The mean LOS of IRF-treated patients was 10.3 +/- 3.3 days, compared with 20.0 +/- 10.8 days for SNF-treated patients (P < 0.005). A significantly higher percentage of IRF-treated patients were discharged directly home (IRF: 89.5%; SNF: 79.1%; P < 0.029). The mean discharge locomotion FIM score for IRF-treated patients was 5.71 +/- 0.91 compared with 4.90 +/- 1.92 for the SNF-treated patients (P < 0.004). At discharge, the mean ambulation distance of patients treated at the IRF was of 380 +/- 168 feet compared with 289 +/- 212 feet for patients treated at SNFs (P < 0.005). 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). 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). CONCLUSION: When patients were matched for age, gender, operative diagnosis, and admission ambulation FIM, those who received rehabilitation in the IRF had, on average, a shorter length of stay and superior functional outcomes than those treated in SNFs.