Association of Length of Stay, Recovery Rate, and Therapy Time per Day With Functional Outcomes After Hip Fracture Surgery.

Importance: Medicare is shifting from payment for postacute care services based on the volume provided to payment based on value as determined by patient characteristics and functional outcomes. Matching therapy time and length of stay (LOS) to patient needs will be critical to optimize functional outcomes and manage costs. Objective: To investigate the association among therapy time, LOS, and functional outcomes for patients following hip fracture surgery. Design, Setting, and Participants: This retrospective cohort study analyzed data on patients from 4 inpatient rehabilitation facilities and 7 skilled nursing facilities in the eastern and midwestern United States. Participants were patients aged 65 years or older who received inpatient rehabilitation services for hip fracture and had Medicare fee-for-service as their primary payer. Data were collected from 2005 to 2010. Analysis was conducted from November 2018 to June 2019. Exposure: Therapy minutes per LOS day. Main Outcomes and Measures: Functional Independence Measure mobility and self-care measures at discharge. Patients were categorized into 9 recovery groups based on low, medium, or high therapy minutes per LOS day and low, medium, or high rate of functional gain per day. Results: A total of 150 patients (101 [67.3%] female; 148 [98.6%] white; mean [SD] age, 82.0 [7.3] years) met inclusion criteria. Participants in all gain and therapy minutes per LOS day trajectories were similar in function at rehabilitation admission (mean [SD] mobility, 16.2 [3.2]; F8,141 = 1.26; P = .27) but differed significantly at discharge (mean [SD] mobility, 23.9 [5.2]; F8,141 = 14.34; P < .001). High-gain patients achieved mobility independence by discharge; low-gain patients needed assistance on nearly all mobility tasks. Medium-gain patients with a mean LOS of 27 days were independent in mobility at discharge; those with a mean LOS less than 21 days needed supervision with toilet transfers and were dependent with stairs. Length of stay and functional gain rate explained much of the variance in mobility and self-care scores at discharge. Although medium- and high-therapy minutes per LOS day groups were statistically significant in the regression model (ß = 6.99; P = .001; and ß = 11.46; P = .007, respectively), they explained only 1% of the variance in discharge outcome. Marginal means suggest that medium-gain patients with shorter LOS would have achieved mobility independence if LOS had been extended. Conclusions and Relevance: In this study, rate of recovery and LOS in skilled nursing and inpatient rehabilitation facilities were associated with mobility and self-care outcomes at discharge following hip fracture surgery, particularly for medium-gain patients. Therapy time per day explained only 1% of the variance in discharge outcome. Discharging medium-gain patients before 21 days LOS may transfer burden of care to family and caregivers, home health, and outpatient services.

Changes in Payment Regulation and Acute Care Use for Total Hip Replacement: Trends in Length of Stay, Costs, and Discharge, 1997-2012.

PURPOSE: To describe trends in the length of stay (LOS), costs, mortality, and discharge destination among a national sample of total hip replacement (THR) patients between 1997 and 2012. DESIGN: Longitudinal retrospective design METHODS: Descriptive analysis of the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample data. FINDINGS: A total of 3,516,636 procedures were performed over the study period. Most THR patients were women, and the proportion aged 44-65 years increased. LOS decreased from 5 to 3 days. Charges more than doubled, from $22,184 to $53,901. Deaths decreased from 43 to 12 deaths per 10,000 patients. THR patients discharged to an institutional setting declined, while those discharged to the community increased. CONCLUSION: We found an increase in THR patients, who were younger, women, had private insurance, and among those discharged to community-based settings. CLINICAL RELEVANCE: Findings have implications for patient profiles, workplace environments, quality improvement, and educational preparation of nurses in acute and postacute settings.

Long-term Effect of Home Nursing Intervention on Cost and Healthcare Utilization for Patients with Chronic Obstructive Pulmonary Disease: A Retrospective Observational Study.

PURPOSE: The present study aimed to examine the long-term effects of a home nursing intervention on healthcare utilization and costs among patients with chronic obstructive pulmonary disease (COPD). DESIGN: A 3-year retrospective study. METHODS: Eleven COPD patients who had received home nursing intervention after hospital discharge were enrolled. We retrospectively investigated their healthcare utilization and costs for 1 year before the intervention and during 2 years of the intervention. FINDINGS: The number and length of hospitalizations decreased gradually from the pre-intervention period through the second year. The number of hospital and home nursing visits increased from the pre-intervention period through the first and second years. The hospitalization costs were decreased by approximately half from the pre-intervention period through the first year and from the first year through the second year. The total medical cost did not change significantly. CONCLUSIONS AND CLINICAL RELEVANCE: Our home nursing intervention decreased the number and length of hospitalizations and the hospitalization costs; however, it did not affect the total medical cost. It is possible that the continuation of home nursing interventions may decrease the number of hospitalizations, number of home nursing visits, and the total medical cost by maintaining the health condition of patients.

A cost-utility analysis of a rehabilitation service for people living with and beyond cancer.

BACKGROUND: We conducted a wait-list control randomised trial of an outpatient rehabilitation service for people living with and beyond cancer, delivered in a hospice day care unit. We report the results of an economic evaluation undertaken using the trial data. METHODS: Forty-one participants were recruited into the study. A within-trial stochastic cost-utility analysis was undertaken using Monte-Carlo simulation. The outcome measure for the economic evaluation was quality adjusted life years (QALYs). Costs were measured from the perspective of the NHS and personal social services. Uncertainty in the observed data was captured through probabilistic sensitivity analysis. Scenario analysis was conducted to explore the effects of changing the way QALYs were estimated and adjusting for baseline difference in the population. We also explore assumptions about the length of treatment benefit being maintained. RESULTS: The incremental cost-effectiveness ratio (ICER) for the base-case analysis was £14,231 per QALY. When QALYs were assumed to change linearly over time, this increased to £20,514 per QALY at three months. Adjusting the estimate of QALYs to account for differences in the population at baseline increased the ICER to £94,748 per QALY at three months. Increasing the assumed length of treatment benefit led to reduced ICERs in all scenarios. CONCLUSIONS: Although the intervention is likely to be cost-effective in some circumstances, there is considerable uncertainty surrounding the decision to implement the service. Further research, informed by a formal value of information analysis, would reduce this uncertainty.

Assessing the effectiveness of health care cost containment measures: evidence from the market for rehabilitation care.

This study empirically evaluates the effectiveness of different health care cost containment measures. The measures investigated were introduced in Germany in 1997 to reduce moral hazard and public health expenditures in the market for rehabilitation care. Of the analyzed measures, doubling the daily copayments was clearly the most effective cost containment measure, resulting in a reduction in utilization of about [Formula: see text] . Indirect measures such as allowing employers to cut federally mandated sick pay or paid vacation during inpatient post-acute care stays did not significantly reduce utilization. There is evidence neither for adverse health effects nor for substitution effects in terms of more doctor visits.

Examining the cost per caregiver of an intervention designed to improve the quality of life of spousal caregivers of stroke survivors.

BACKGROUND AND PURPOSE: There is a growing consensus among healthcare researchers that, within the field of family caregiving, cost-effectiveness research is needed to determine which programs have the greatest benefit for family members. This study examines the cost per caregiver of an intervention designed to improve the quality of life of spousal caregivers of stroke survivors. METHOD: Cost data from the CAReS study were analyzed to determine the cost of the intervention per caregiver. RESULTS: The cost of the intervention per caregiver was $2,500 at the 2009 median wage estimate. It was $1,700 at the 2009 10 percentile wage estimate and $3,500 at the 2009 90 percentile wage estimate. CONCLUSIONS: This study provides a prototype cost analysis from which researchers can build. In future analyses, costs should be tracked at a participant level so uncertainty can be calculated using the bias-corrected percentile bootstrapping method and plotted to calculate cost-effectiveness acceptability curves, enabling cost-effectiveness comparisons between interventions.

Medicare postacute care payment reforms have potential to improve efficiency of care, but may need changes to cut costs.

The Affordable Care Act mandates changes in payment policies for Medicare postacute care services intended to contain spending in the long run and help ensure the program's financial sustainability. In addition to reducing annual payment increases to providers under the existing prospective payment systems, the act calls for demonstration projects of bundled payment, accountable care organizations, and other strategies to promote care coordination and reduce spending. Experience with the adoption of Medicare prospective payment systems in postacute care settings approximately a decade ago suggests that current reforms could, but need not necessarily, produce such undesirable effects as decreased access for less profitable patients, poorer patient outcomes, and only short-lived curbs on spending. Policy makers will need to be vigilant in monitoring the impact of the Affordable Care Act reforms and be prepared to amend policies as necessary to ensure that the reforms exert persistent controls on spending without compromising the delivery of patient-appropriate postacute services.

Reforming Medicare payments to skilled nursing facilities to cut incentives for unneeded care and avoiding high-cost patients.

Despite many changes made in 2010 and 2011 to Medicare's payment system for short-term stays in skilled nursing facilities, a flawed payment structure continues to underpay facilities for certain types of patients and overpay for others. The flaws in the payment structure create incentives to selectively admit or refuse patients based on the type and complexity of their conditions, while payments that vary with level of use encourage providers to furnish therapy services, such as rehabilitation care, that some patients might not need. We propose an alternative payment design and demonstrate that it would dampen such incentives by making payments that are more closely matched to costs and based on characteristics of the patients treated. We propose replacing the existing therapy component of payment with one that varies payments according to the expected care needs of the patient and adding a separate payment component that covers drugs and other nontherapy ancillary services, such as support for patients on ventilators. We also propose adding an outlier policy to provide additional reimbursement for patients requiring exceptionally high-cost care.

Medicare's bundled payment pilot for acute and postacute care: analysis and recommendations on where to begin.

In the National Pilot Program on Payment Bundling, a subset of Medicare providers will receive a single payment for an episode of acute care in a hospital, followed by postacute care in a skilled nursing or rehabilitation facility, the patient's home, or other appropriate setting. This article examines the promises and pitfalls of bundled payments and addresses two important design decisions for the pilot: which conditions to include, and how long an episode should be. Our analysis of Medicare data found that hip fracture and joint replacement are good conditions to include in the pilot because they exhibit strong potential for cost savings. In addition, these conditions pose less financial risk for providers than other common ones do, so including them would make participation in the program more appealing to providers. We also found that longer episode lengths captured a higher percentage of costs and hospital readmissions while adding little financial risk. We recommend that the Medicare pilot program test alternative design features to help foster payment innovation throughout the health system.

Spinal cord injury/disorder teleconsultation outcome study.

The purpose of this study was to compare the costs of providing specialty wound care to spinal cord injury/disorder (SCI/D) veterans by teleconsultation and traditional care. A retrospective design was used to conduct this descriptive, correlational study. A convenience sample of 76 SCI/D veterans (2 women, 74 men) met inclusion criteria from a possible 123 subjects. Variables were compared between groups using nonparametric methods (Wilcoxon rank sums and chi-square). There was no significant difference in inpatient admissions or inpatient bed days of care between the two groups. The teleconsultation group had more outpatient encounters (medians 12 vs. 4, p = .007; Wilcoxon statistic = 412.5) and longer inpatient stays (medians 81 vs. 19 days/admission, p = .05; Wilcoxon statistic = 227.0) compared to the traditional care group. There was no significant difference in inpatient cost between the two groups; however, the teleconsultation group had a significantly higher median cost per outpatient encounter ($440 vs. $141, p <.0001; Wilcoxon statistic = 469.0). Although this study only looked at costs directly associated with wound management, continued research exploring the use of teleconsultation in other areas of SCI/D specialty is needed to enhance its application.

[REDIA--impacts of DRG introduction in the acute sector on medical rehabilitation]. / REDIA - Auswirkungen der DRG-Einführung auf die Rehabilitation.

The REDIA study is the only long-term (2003-2009), prospective, multicentre study analyzing the impact of the DRG system on quality and costs in rehabilitation facilities. In 2004, Diagnosis Related Groups (DRG) were implemented on a mandatory basis in the German healthcare system as a reimbursement scheme for hospitals based on administered prices for procedures. Experiences from other countries revealed that introduction of DRG does not only have a significant impact on hospitals but also on rehabilitation facilities. The study approach ensures a comprehensive analysis as it considers major clinical, therapeutic, psychological and economic aspects. The REDIA study is the only nationwide empirical study that includes all stages of the implementation process: before DRG implementation, during the convergence phase and following implementation. An indication-specific comparison of the phases showed significantly shorter stays in the acute sector as well as shorter transition times between the sectors, resulting in admission of patients into rehabilitative care at an earlier stage of their recovery process. Significant diversions of treatment efforts from the acute sector to the rehabilitative sector have been proven in terms of increased nursing efforts and potential changes in the therapeutic and medical treatments to be provided.

Medicare prospective payment and the volume and intensity of skilled nursing facility services.

In 1998, Medicare adopted a per diem Prospective Payment System (PPS) for skilled nursing facility care, which was intended to deter the use of high-cost rehabilitative services. The average per diem decreased under the PPS, but because per diems increased for greater therapy minutes, the ability of the PPS to deter the use of high-intensity services was questionable. In this study, we assess how the PPS affected the volume and intensity of Medicare services. By volume we mean the product of the number of Medicare residents in a facility and the average length-of-stay, by intensity we mean the time per week devoted to rehabilitation therapy. Our results indicate that the number of Medicare residents decreased under PPS, but rehabilitative services and therapy minutes increased while length-of-stay remained relatively constant. Not surprisingly, when subsequent Medicare policy changes increased payment rates, Medicare volume far surpassed the levels seen in the pre-PPS period.

[Elzach concept and intervention catalogue of nursing therapy in postacute neurological rehabilitation within the German DRG System]. / Elzacher Konzept und Leistungskatalog der therapeutischen Pflege in der neurologischen Frührehabilitation (Phase B).

The German DRG system defines specialized treatments through a set of minimal requirements, the documentation of which and its assessment by external specialists of the medical service of the statutory health insurance causing frictions between rehabilitation hospitals and the medical service. It is especially problematic to make a clear distinction between nursing care and treatment. To reduce frictions and interface problems, a catalogue of acts of therapy performed by nurses was agreed for neurological early rehabilitation in Baden-Württemberg. This Elzach concept and catalogue describe therapeutic nursing in neurological rehabilitation and increase transparency and accountability both for providers and cost carriers.

Patient rehabilitation in hospitals a prioritized discipline after hospital reform: a Norwegian perspective.

AIM: The purpose of the present study was to highlight the effects of hospital reform introduced in Norway 2002 on patient rehabilitation. BACKGROUND: The Norwegian hospital reform is an activity-controlled financing system with diagnosis-related groups (DRG). METHOD: A multi-case study with embedded design methods was used. Document analysis and interviews are sources of evidence. RESULTS: The rehabilitation service offered a treatment service that was inadequately funded. The focus of the rehabilitation team was negatively affected by the lack of organization. The different patient groups did not receive optimal and individualized rehabilitation as required by individual treatment plans. There were two different levels of rehabilitation at the hospitals. CONCLUSIONS: The financing system did not provide for a differentiated treatment service tailored to each patient's individual plan, as stipulated by health policy. An increase in the number of patients receiving rehabilitation in the health authorities was not accompanied by an increase in allocated resources, leading to an insufficient overall rehabilitation service. The organizations included in the case study were not those who finance specialized rehabilitation at specialized rehabilitation centres. IMPLICATIONS FOR NURSING MANAGEMENT: Specially trained nurses are strategically placed to shape and influence funding of rehabilitation programmes through leadership.

Wound management in vulnerable populations.

While wound management is a significant challenge for many rehabilitation patients, vulnerable populations are at particular risk. In addition, considerable focus is being placed on vulnerable populations within health care. Rehabilitation nurses should understand issues related to working with vulnerable patients with wounds, including poverty and payment for care, culture, and literacy. Nursing research to advance the care of individuals from vulnerable populations requires a special approach designed to establish the integrity of the research and gain the trust of potential participants.

Reducing employee slips, trips, and falls during employee-assisted patient activities.

Following a remodeling of patient care rooms at Mary Free Bed Rehabilitation Hospital, the nursing staff reported frequent slipping in patient care areas. Data were analyzed and revealed that most slips were occurring during transfer of patients from shower chairs. An extensive literature review was done, and solutions to slipping were sought from areas outside of the healthcare industry. Specifically, ideas were borrowed from the commercial fishing industry and the restaurant industry. Both industries rely heavily on footwear to reduce slipping in the workplace. A trial was initiated with nursing staff members wearing positive-grip shoe covers that can be worn over regular footwear. No slips occurred during the trial. The purpose of this article is to motivate nurses who are involved in transferring patients from shower chairs (often used in rehabilitation settings) to consider the role their footwear has in reducing slips and potential injury.