Nursing homes may be underused in stroke recovery; new research urges better guidelines

 Guidelines don't guarantee recovery; you need EXACT PROTOCOLS FOR THAT!

This is the whole problem in stroke enumerated in one word; 'care'; NOT RECOVERY! 

Our non-existent stroke leadership should be demanding RECOVERY NOT 'CARE'!

My god, anyone in the business world would be fired immediately for managing or caring about something rather than delivering RESULTS. And this is why this is a complete fucking failure! This does nothing to guarantee recovery for survivors!

If your hospital is touting 'care' it means they are a failure because they are delivering 'care'; NOT RECOVERY! I would never go to a failed hospital! Anytime I see the word 'care' associated with a stroke hospital; I immediately think fucking failure!

YOU have to get involved and change this failure mindset of 'care' to 100% RECOVERY! Survivors want RECOVERY, NOT 'CARE'!

I see nothing here that states going for 100% recovery! You need to create EXACT PROTOCOLS FOR THAT!

ASK SURVIVORS WHAT THEY WANT, THEY'LL NEVER RESPOND 'CARE'! This tyranny of low expectations has to be completely rooted out of any stroke conversation! I wouldn't go there because of such incompetency as not having 100% recovery protocols!

RECOVERY IS THE ONLY GOAL IN STROKE!

GET THERE!

Nursing homes may be underused in stroke recovery; new research urges better guidelines

Hospitals are referring a larger share of stroke patients to inpatient rehabilitation facilities, which typically favor home health as the provider of any additional step-down care(NOT RECOVERY!), a recent study finds.

More than one-third (35%) of patients received no post-acute care(NOT RECOVERY!) after being hospitalized for stroke. But 28% were sent to an IRF within 10 days, followed by 24% admitted directly to a SNF after hospitalization, and another 13% referred directly to home care(NOT RECOVERY!).

The analysis of Medicare Part A claims from nearly three years ending in September 2019 additionally found that 14.6% of SNF and IRF patients also were referred for home care(NOT RECOVERY!) later in their recovery.

Researchers said the new data could inform new guidance regarding post-stroke care(NOT RECOVERY!) transitions, noting wide variability in post-acute care(NOT RECOVERY!) access by geography and patient demographics. 

“Our findings could help develop strategies to improve the continuity of care(NOT RECOVERY!) in patients with stroke with the goal to improve poststroke rehabilitation care(NOT RECOVERY!) and services,” they wrote in the November issue of JAMDA. “Current stroke care(NOT RECOVERY!) guidelines do not emphasize the comprehensive nature of the continuity and transition of care(NOT RECOVERY!). In the absence of clear guidelines on the transition of care(NOT RECOVERY!), there is a probability of patients who may underuse or overuse the services, and nonclinical factors might be associated with the decision of post-acute services use.”

The team, led by Amol Karmarkar of the Department of Physical Medicine and Rehabilitation at Virginia Commonwealth University, noted the important role of post-acute care(NOT RECOVERY!) across the phases of stroke recovery.

This map included in the study shows how stroke patients have typically progressed through post-acute care settings. (Screenshot)

Within 90 days of a stroke, patients experience a high risk of developing medical complications, which can adversely impact recovery, they wrote. But some 80% of patients in the study period received no secondary post-acute care(NOT RECOVERY!) after their first move, the study showed. 

“Patients may be deemed appropriate to continue requiring additional care(NOT RECOVERY!) services and rehabilitation following discharge from the first institutional post-acute care(NOT RECOVERY!), either in IRF or SNF,” said the authors, who identified and measured the prevalence of seven post-acute referral patterns and related trajectories.

Across the entire nation, only one small area in the Mountain West region saw IRF providers routinely send stroke survivors on to nursing homes for additional care(NOT RECOVERY!). On the East and West coasts, most patients went from home health care(NOT RECOVERY!) to no services or from SNF to no further services. Post-acute care(NOT RECOVERY!) across more than one setting was generally lower in rural regions.

“This finding may be related to differences in state policies and post-acute care(NOT RECOVERY!) market availability,” the researchers wrote. “Future studies are recommended to study the impact of these seven patterns on patient short-term and long-term outcomes to better address the appropriate level of care(NOT RECOVERY!) and the need for multiple post-acute care(NOT RECOVERY!) transitions.”

Emulating 3 clinical trials that compare stroke rehabilitation at inpatient rehabilitation facilities with skilled nursing facilities

FYI, for when you doctor is working on discharging you. The ONLY question for your doctor to answer is: 'Which facility will get me 100% recovered?' And keep asking that question until they finally acknowledge they don't know EXACTLY how to get you 100% recovered, then you ask for all payments for your care be refunded to you, pay for performance should be standard practice in stroke.

 Emulating 3 clinical trials that compare stroke rehabilitation at inpatient rehabilitation facilities with skilled nursing facilities

Archives of Physical Medicine and Rehabilitation , Volume 103(7) , Pgs. 1311-1319.

NARIC Accession Number: J89440.  What's this?
ISSN: 0003-9993.
Author(s): Simmonds, Kent P.; Burke, James; Kozlowski, Allan J.; Andary, Michael; Luo, Zhehui; Reeves, Mathew J..
Publication Year: 2022.
Number of Pages: 9.

Abstract: 

 Study emulated 3 trials where patient-level outcomes after stroke rehabilitation at inpatient rehabilitation facilities (IRFs) were compared with skilled nursing facilities (SNFs) to inform the design of a potential future randomized controlled trial (RCT). The 3 trials differed because facilities from rehabilitation networks with different case volumes were compared. Rehabilitation network case volumes were based on the number of patients with stroke that each hospital discharged to each specific IRF or SNF. Trial 1 included 60,529 patients from all networks, trial 2 included 34,444 patients from networks with medium and large case volumes (i.e., ≥5 patients), and trial 3 included 19,161 patients from networks with large case volumes (i.e., ≥10 patients). The E values were calculated to estimate the minimum strength that an unmeasured confounder would need to be to nullify the results. Outcome measures included one-year successful community discharge (home for >30 consecutive days) and all-cause mortality. Overall, 29,500; 15,156; and 7,450 patients were matched for trials 1, 2, and 3. For 1-year successful community discharge, absolute risk differences for IRF patients were 0.21, 0.17, and 0.12 in trials 1, 2, and 3, respectively. For 1-year all-cause mortality, corresponding risk differences were −0.11, −0.11, and −0.08. The E values indicated that a moderately sized unmeasured confounder, with a relative risk of 1.6 to 2.0 would nullify differences in successful community discharge. IRF patients had superior outcomes, but differences were attenuated when IRFs and SNFs from larger rehabilitation networks were compared. The vulnerability of the findings to unmeasured confounding supports the need for an RCT.
Descriptor Terms: HEALTH CARE, NURSING HOMES, OUTCOMES, REHABILITATION FACILITIES, REHABILITATION SERVICES, SERVICE DELIVERY, STROKE.


Can this document be ordered through NARIC's document delivery service*?: Y.

Citation: Simmonds, Kent P., Burke, James, Kozlowski, Allan J., Andary, Michael, Luo, Zhehui, Reeves, Mathew J.. (2022). Emulating 3 clinical trials that compare stroke rehabilitation at inpatient rehabilitation facilities with skilled nursing facilities.  Archives of Physical Medicine and Rehabilitation , 103(7), Pgs. 1311-1319. Retrieved 8/22/2022, from REHABDATA database.

Pressure injuries found in 11% of SNF stroke rehab patients: study

 More protocols for your doctor to have to make sure you are treated correctly. No protocols, you have an incompetent doctor and hospital. I take no prisoners in trying to hold stroke medical 'professionals' accountable.

Pressure injuries found in 11% of SNF stroke rehab patients: study

Fully 11% of older patients have pressure injuries when admitted to skilled nursing facilities for post-acute stroke rehabilitation(so it occurred while in the hospital!), a new study finds. Certain factors make such a diagnosis more likely, investigators say.

Providing care for pressure injuries early in stroke rehab may help improve these patients’ overall clinical outcomes and reduce associated costs, according to Shilpa Krishnan, PT, PhD, of Emory University School of Medicine in Atlanta, and colleagues.

The investigators examined data for more than 65,000 older adults aged 65 years and older who were admitted to SNFs following strokes. They aimed to determine the prevalence of pressure wounds upon admission and investigate factors that contributed to deep and superficial injury. 

The 11% of patients arriving for care with pressure wounds tracks closely with the numbers found across the long-term care facility spectrum, the researchers reported. Older adults, non-Hispanic Blacks and patients with multiple comorbidities were more likely to have these injuries. 

When compared to patients with superficial wounds, patients with deep pressure wounds were more likely to be younger than 75 years, non-Hispanic Black and have a lower socioeconomic status. Many had also experienced an intensive care unit stay, had higher functional impairments, skin integrity issues, system failure and infections.

Patients receive less PT, OT

For reasons that may be associated with higher comorbidities and pain, individuals with pressure wounds received less individual physical therapy and occupational therapy treatment than those with no pressure wounds. The researchers recommend that comorbid chronic disease be addressed during post-acute care. A reduction in stroke rehabilitation therapy secondary to a pressure wound may impede stroke recovery, they noted.

Study data came from the 2013 and 2014 Medicare’s Master Beneficiary Summary, Medicare Provider Analysis and Review, and Minimum Data Set 3.0. Pressure injury data came from SNF admission assessments.

Full findings, including more analysis of SNF skin care and restorative treatments for these patients, were published in JAMDA.

Inpatient rehab better for stroke patient’s recovery than SNFs, study suggests

So still a failure because you don't mention anyone getting to 100% recovery.  WHY THE FUCK should survivors accept your tyranny of low expectations? The only goal in stroke is 100% recovery, NOT 'greater improvements'. 

Inpatient rehab better for stroke patient’s recovery than SNFs, study suggests

Inpatient rehabilitation facilities may be a better post-acute option for stroke patients compared with skilled nursing facilities, according to a new study.

University of Texas researchers found that IRF patients had greater improvements in physical mobility and self-care functions when compared to patients who were discharged to SNFs.

Investigators said the decision-making process in selecting post-acute care services is “heavily influenced by non-clinical factors,” and the findings indicate the “need to carefully manage discharge to post-acute care based on the patient’s needs and potential for recovery.”

The investigation included 99,185 stroke patients who received post-acute care services at a SNF or IRF between Jan. 2013 and Nov. 2014. Researchers used Medicare claims data to compare the assessments.

The findings were published Wednesday in JAMA.

Choosing a Rehab Facility

This is extremely simple, ignore all the blathering below. 

1. How many of your stroke patients get 100% recovered?
2. List all the protocols for rehab you use and their efficacy.
3. If 'All strokes are different, all stroke recoveries are different' comes out. Run, run away, they know absolutely nothing about stroke rehab.

http://www.flagstaffbusinessnews.com/choosing-a-rehab-facility/
You or one of your family members are in the hospital following an injury, illness or surgery and the physician or surgeon says it’s time to leave the hospital but rehabilitation or additional care is needed before going home. Some conditions that may require short- or long-term care at a rehabilitation facility include stroke; disabling diseases such as Parkinson’s disease or multiple sclerosis; brain and spinal cord injuries; orthopedic injuries or surgery; amputation; ventilator and breathing support; post-surgery recovery; acute illness and infection; and general wound care.  
Depending on resources, facility options, and the extent and length of rehabilitation and care needed, most people will either go to a skilled nursing facility that provides rehabilitation services or a long-term or short-term rehabilitation hospital.  
Staff at these specialized care centers may include nurses; physical, occupational and speech therapists; social workers; dietitians; a physician medical director; and other specialized medical staff as needed. 

Differences Between a Hospital, Skilled Nursing Facility or Acute Inpatient Rehabilitation Hospital 
What is the difference between a hospital, acute (short-term) rehabilitation hospital, long-term rehabilitation hospital and a skilled nursing facility? The differences have to do with the level of care provided, the length of care needed and the type of injury, illness or diagnosis of the patient. Here is some information on each type of care facility listed above: 

Acute-Care Hospitals provide constant, short-term treatment for a severe injury, an episode of illness or urgent medical condition. The patient is under the direct care of a physician. Most acute-care hospitals perform surgery and therefore provide short-term (days) post-surgery care. In medical terms, care for acute health conditions is the opposite of long-term care or care for chronic (ongoing) conditions. Length of stay is typically days, but may be longer depending on patient needs. 

Skilled Nursing Facilities (SNF) provide both short-term and long-term care for the elderly and/or those who have an illness or injury who require daily medical care, help with routine tasks, supervision and assistance. When around-the-clock care is required, a SNF may be the best option. Traditionally, the patient’s care is overseen by a physician, but a physician does not see the patient on a daily basis, as is the case in a hospital. SNFs provide physical, occupational and speech therapy, as well as nursing care. Medicare reports the average length of stay is 41 days.  

Short-Term Acute Inpatient Rehabilitation Hospitals can help speed the recovery process following surgery (most often an orthopedic surgery such as joint replacement or spine repair) or an extended hospital stay. Short-term rehabilitation focuses on rebuilding strength, retraining muscles, regaining speech and rewiring the brain. Treatment plans are individualized and most patients participate in two to three hours of physical and occupational therapy a day. Medicare reports the average length of stay is 12 days.  

Rehabilitation in Northern Arizona 
The highest quality rehabilitation care is available right here in Northern Arizona – no need to leave home. The newly opened Rehabilitation Hospital of Northern Arizona located on McMillian Mesa is the only rehabilitation hospital in the region, serving all of Northern Arizona. The 40-bed rehabilitation hospital provides intensive rehabilitation services to people recovering from disabling diseases or injuries, such as strokes, brain, spinal cord and orthopedic injuries. For more information, visit rhna.ernesthealth.com or call 928-774-7070. Follow on Facebook at Rehabilitation Hospital of Northern Arizona. 


By Richard Holt, D.O. 
Richard Holt, D.O., is the medical director at the Rehabilitation Hospital of Northern Arizona. Dr. Holt specializes in helping patients recover from injury or disease and live the highest quality of life possible.

 

Many Older Patients Report No Improvement in Functioning After Rehabilitation Services

For the stroke patients there really should be little expectation for benefit. There are no protocols with efficacy ratings so guidelines are being used which are pretty much worthless. Since 'Only 10% of patients get fully recovered', why would you expect recovery in older patients?
http://dgnews.docguide.com/many-older-patients-report-no-improvement-functioning-after-rehabilitation-services?

May 9, 2018

By Ed Susman

ORLANDO, Fla -- May 9, 2018 -- About 1 in 4 patients sent to receive rehabilitation services such as physical, occupational or speech therapy report that they didn’t receive any benefit from the services, according to a study presented here at the 2018 Annual Meeting of the American Geriatrics Society (AGS).

Among 519 patients aged 65 years and older from the National Health and Aging Trends Study, 25% of patients who received rehabilitation services in nursing home or inpatient settings reported no improvement in functioning.

Of the 372 patients in the study, 85 had experienced a stroke, 39 had Alzheimer’s disease or dementia, 78 patients had depression, and about 40% of the patients reported impairments in the ability to perform activities of daily living.

“We need to develop objective measures of improvement in function because it appears that one of the factors in these self-reported outcomes is that lack of improvement is associated with lower levels of education,” said Adam Simning, MD, Strong Memorial Hospital, and University of Rochester, Rochester, New York. “It seems like there may be some kind of cognitive thing going on in the perception of improvement. It seems that if people believe that are getting better, they feel better too.”

In analysing the socioeconomic demographics and adjusting for multiple factors, the researchers found that patients who did show improvement tended to have achieved higher levels of education, have lower levels of impairment in the ability to perform activities of daily living, have longer periods of rehabilitation services, and received in-home rehabilitation services.

The database used to gather the information was unable to determine if the patient was in a rehabilitation service offered by a nursing home, in the in-hospital setting or in a dedicated rehabilitation facility.

Dr. Simning suggested that health literacy might play a role in perceived advantages of rehabilitation.

He noted that the study is continuing, with 2-year results to be reported soon.

[Presentation title: Self-Reported Improvement in Functioning Following Rehabilitation in a Hospital, Nursing Home, or Rehabilitation Facility. Abstract C123]

Integrated Rehab Consultants Grows Revenue to $21 Million by Filling Critical Need in Skilled Nursing Facilities Physiatrist Oversight of Rehab Shortens Stay; Reduces Costs

Nowhere in here do they ever mention results. How many patients got 100% recovered? They may be making money but that doesn't mean the patients are getting what they want, which is 100% recovery.
https://newswise.com/articles/integrated-rehab-consultants-grows-revenue-to-21-million-by-filling-critical-need-in-skilled-nursing-facilities

Article ID: 678821
Released: 1-Aug-2017 12:05 PM EDT
Source Newsroom: PS Medical Marketing

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Economics, Healthcare, Nursing, Psychology and Psychiatry, Local - Illinois

Newswise — Chicago-based Integrated Rehab Consultants (IRC) has grown its gross revenue from $63,000 since its inception in 2010 to more than $21 million in just six years by providing physicians for rehab oversight to improve patient care and significantly reduce cost for patients and insurers.  IRC achieved profitability in its first year and each subsequent year while self-funding its own growth at an exponential pace:
Year               Revenue                   %growth
2010               $   63,000     
2011               1,197,000                  1,800%
2012               2,791,000                     133%
2013               5,145,000                     84%
2014               8,464,000                     64%
2015            15,898,000                      88%
2016   .        21,394,000                      34%
IRC is on track for gross revenue of $25 million for the year ending December 31, 2017.
Starting with just one physiatrist (rehabilitation physician) in Chicago in 2010, IRC now supplies 100+ physicians to 300+ high quality Skilled Nursing Facilities (SNFs) in 22 states coast-to-coast and CEO Amish Patel, DO, has his sights set even higher.
“Integrated Rehab Consultants’ growth has been totally self-funded to date,” Dr. Patel noted.  “However, we see a tremendous opportunity for additional growth and expansion into psychiatry using a similar business model.”
IRC is successfully filling a critical need in nursing care today. Increasingly, especially among older adults, insurance providers (including Medicare) are discharging patients who need short-term rehabilitation after a stroke or orthopedic surgery, such as a knee replacement, to SNFs, rather than more costly in-patient rehab facilities, to get them in shape before returning home.
According to MedPAC, the average stroke patient stay in a SNF costs $8,905, as opposed to $34,196 in an inpatient rehab facility.
However, many lower-cost SNFs do not have the highly qualified staff to direct the most efficient rehab for these patients. IRC fills the gap by providing physiatrists to oversee patient rehab. The physicians’ fees are covered by Medicare or other patient insurance.

Physiatrist Oversight Shortens Rehab Stay
When a physiatrist is involved to provide more frequent patient visits, focus exclusively on rehab and oversee a physical therapy plan, patients’ length of stay is decreased. According to a recent Coker Group study (2015), SNFs with an IRC physiatrist on staff lowered their average patient length of stay by 11 percent.
Discharging patients from SNFs more quickly pleases everyone: patients, facilities, hospitals and insurance providers. Families are happy to see loved ones come home, facilities are able to free up beds for more acute (and more profitable) patients, hospitals are seeing fewer re-admissions and insurers prefer the lower-cost option.
IRC, the largest provider of physiatrists to SNFs nationwide, was founded by Dr. Amish Patel, a board-certified, Chicago-based physiatrist. As a young physiatrist, he noticed more rehab patients going to SNFs as opposed to other care settings and found that the SNFs weren’t equipped to care for this type of patient. He contracted with other physiatrists across the country and matched them with SNFs to provide rehab oversight. He continues to treat patients in the Chicago area while serving as the company’s CEO.

Post-Acute SNF Care Often Not Cost-Effective

With anything even close to resembling a great stroke association, followup research would occur to create a stroke protocol about when to do hospital release and followup rehabilitation. But since we have fucking failures of stroke associations we will continue to know nothing about what to do. Our stroke medical professionals don't give a shit since the effects of this lack of policy/protocol only affects stroke survivors. There is no blowback to them, no financial penalty for not getting survivors 100% recovered.
 https://www.medpagetoday.com/nursing/Nursing/66956?

Hospitals did better by focusing care on getting patients well enough to go home

• by Christopher Cheney, HealthLeaders Media July 30, 2017

New research on the cost-effectiveness of inpatient care at hospitals compared to skilled nursing facility (SNF) found that hospitals spending intensively on inpatient care and sending patients home rather than to a SNF generated lower one-year mortality rates than hospitals that spend more intensively on post-acute-care at SNFs.
The study used a standard technique for assessing hospital performance, the study's lead author said.
"When you compare hospitals, the big concern is [that] they treat different patients, which makes it very difficult to compare outcomes or how hospitals treat people. But now, we have a new way of comparing very similar patients who go to different hospitals," said Joseph J. Doyle, Jr.
Doyle is a professor of applied economics at the Massachusetts Institute of Technology. He and colleagues at MIT and Vanderbilt University are using Medicare ambulance-service claims data to compare spending and other performance measures at hospitals.
The study Doyle published this month in the Journal of Health Economics, "Uncovering Waste in U.S. Healthcare: Evidence from Ambulance Referral Patterns," examined average 90-day spending on more than 1.5 million Medicare patients.
"We characterized the types of hospitals that get better outcomes. [They] tend to be more intense on the inpatient side. It doesn't necessarily have to be length of stay. Hospitals with better outcomes could be doing more inpatient procedures, for example," Doyle said.
"These hospitals treat patients more intensively during their inpatient stay, then they send people home instead of sending them to SNFs."
More Research Needed
While this finding is provocative, more research is required to draw conclusions on the relative cost-effectiveness of inpatient care versus SNF care, he said. "We are able to characterize the hospitals that get good outcomes, but it's a leap to say we should all mimic the type of care that is given in those hospitals."
"Maybe the hospitals that spend more intensively on inpatient care and send patients home have better doctors and better nurses; it's possible that there are many characteristics of hospitals that result in that type of treatment profile."
In addition to further research to determine whether other hospitals can replicate the mortality outcomes of hospitals with an inpatient-care-intense treatment profile, more research is necessary to examine the cost-effectiveness of SNF care, Doyle said. "This spotlight is suggesting that we should take a close look at post-acute-care."
Comparing the treatment outcomes of patients who are sent home rather than to a SNF after inpatient care is prime area for future research.
"For patients where it is not obvious whether they should go home or go to a SNF, we should have studies that either historically or, even better, prospectively, randomize those patients to either go with home-health care or go to a SNF ... If we send more people home, do we achieve better outcomes or not?"
In addition to the tantalizing findings about inpatient care and SNF care, Doyle's latest research casts doubt about earlier comparative research conducted on hospital performance.
"There is a large literature that suggests it really does not matter what hospital a patient goes to for care, in terms such as survival rates from a heart attack. We are concerned that earlier hospital comparisons did not take into account that the patients were different. We say it does matter where you go," Doyle said.
"If it doesn't matter where you go, then people could say high-intensity hospitals are wasteful."
This report is brought to you by HealthLeaders Media.

• Primary Source

  Journal of Health Economics

  Source Reference: Doyle JJ, et al " Uncovering waste in US healthcare: Evidence from ambulance referral patterns" J Health Econ 2017; DOI: 10.1016/j.jhealeco.2017.03.005.