Measuring Rehabilitation Intensity in Ontario Beth Linkewich - PowerPoint PPT Presentation

Measuring Rehabilitation Intensity in Ontario Beth Linkewich (Beth.Linkewich@sunnybrook.ca) Toronto Stroke Networks, Sunnybrook Health Sciences Centre Ruth Hall (Ruth.Hall@ices.on.ca) Ontario Stroke Network, Institute for Clinical Evaluative Sciences Ryan Metcalfe (Rehab@cihi.ca) Canadian Institute for Health Information May 9, 2017 Presentation to Central South cihi.ca @cihi_icis Rehabilitation Intensity Forum

Rehab Intensity (RI) Following Stroke • Increased activity and environmental stimulation is important to neurological recovery after stroke. • Stroke best practices recommend a minimum of 3 hours of therapy per-patient- day in inpatient rehabilitation [1]. • The Ontario Stroke Network (OSN) partnered with the Canadian Institute for Health Information (CIHI) and Ontario’s MOHLTC to include mandatory collection of RI data as part of the National Rehabilitation Reporting System (NRS) from April 2015 onward. • The OSN and regional stroke networks have worked with rehabilitation programs to support implementation and quality assurance. [1] Lindsay, M.P., Gubitz, G., Bayley, M. et al. (2010). Canadian Best Practice Recommendations for Stroke Care (Update 2010). On behalf of the Canadian Stroke Strategy Best Practices and Standards Writing Group. Ottawa, ON, Canadian Stroke Network. Retrieved from: www.strokebestpractices.ca 2

Definition of Rehabilitation Intensity • Rehabilitation Intensity is defined as: The amount of time that a patient is engaged in active, goal-directed, face to face • rehabilitation therapy, monitored or guided by a therapist, over a seven day/week period. • Physical, functional, cognitive, perceptual and social goals to maximize the patient’s recovery * Measuring Rehabilitation Time in the National Rehabilitation Reporting System (NRS): # minutes of rehabilitation intensity (defined above) for OT, PT, S-LP, OTA, PTA, CDA * Ontario Stroke Network, 2012.

Rehabilitation Intensity Requires a Cultural Shift • Shift in thinking from therapist time spent providing the therapy to the patient time spent actively engaged in and receiving therapy. • “Bigger picture” experience • Setting up the environment for success I am very busy all day long, but what are the stroke patients doing all day? How can we provide the most minutes of therapy AND maintain a complex Volunteers stimulating environment? Groups

Rehabilitation Intensity Calculations Rehabilitation Intensity = Total Rehab Time (minutes) Active Rehab LOS (days) Rehab Time with an OT (# Days from Admit to Date Ready for Discharge) Rehab Time with a PT – (Service Interruption Days) ______________________________________ Rehab Time with an SLP = Active Rehab LOS Rehab Time with an OTA Rehab Time with a PTA + Rehab Time with a CDA _____________________ = Total Rehab Time At a facility or Average Rehab Intensity = Sum [Rehab Intensity per client] Number of clients geographic level: 5

Methodology & Data Quality 5,102 stroke discharges from Ontario facilities in 2015-2016 ~ 95% had valid, non-zero values coded in one or more of the rehab time fields – i.e., full or partial rehab time captured Top and bottom 1% (according to total number of minutes per day ) were discarded from analysis 4,763 stroke rehab episodes 6

Data Availability/Quality Issues 4.7% of records had only ‘0’, Proportion of Stroke Records Excluded ‘999’, ‘9999’, or ‘99999’ 30 Records Excluded from Analysis (%) coded and were excluded 25 from analysis 20 Large regional variation 15 (0 - 25.5%) 10 Q1 (12.6%) much worse than 5 subsequent quarters (3.5% or 0 less) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 LHIN (Rank Ordered) 7 Source: National Rehabilitation Reporting System, 2015–2016, Canadian Institute for Health Information.

What does the data tell us? 8

Who is Providing Therapy? Prevalence of Each Therapy Type, 2015-2016  PT and OT most Proportion of Clients Treated (N total = 4,763) 97% common 95% 100% 90% 81% 78% 75% 80% 70%  CDA least common 60% 50% 40%  12.4% of clients served 30% 18% 20% by all provider types 10% 0% PT OT PTA OTA SLP CDA Therapy/Provider Type 9 Source: National Rehabilitation Reporting System, 2015–2016, Canadian Institute for Health Information.

How Much 1:1 Therapy Do Clients Receive? Average Minutes/Day by Therapy Type Total = 65.5 min/day • Amount increased over (Target = 180 min/day) quarters: 63.1 (Q1) – 66.5 1.7 PT (Q4) min/day 7.2 OT • Therapy assistants account 20.2 7.7 SLP for 25% of therapy OTA • Less than 1% of clients 9.9 meeting the therapy-per-day PTA target 18.9 CDA 10 Source: National Rehabilitation Reporting System, 2015–2016, Canadian Institute for Health Information.

How Much 1:1 Therapy Do Clients Receive? Median Therapy Minutes per Day by • 61.5 min/day of 1:1 therapy Therapy Type during the period of “active rehabilitation” Total = 61.5 PT 5.4 • Amount increased over OT 5.7 19.1 quarters: 57.4 (Q1) – 63.6 (Q4) SLP min/day 5.0 OTA • 180 min/day target is being PTA met by approx. 1% of clients CDA 17.5 11

How Much 1:1 Therapy Do Clients Receive? Average amount of Average Rehab per Day by Therapy Type therapy is greater 25 when you only look 20.9 19.8 Average 20.2 calculated from 18.9 20 at those clients Minutes per day (mean) all clients receiving that type of 15 13.1 therapy 9.9 9.9 9.7 Average 10 8.8 e.g., People that 7.7 calculated from 7.2 only those received therapy clients receiving 5 that particular from CDA received 1.7 therapy type 9.7 min/day; all 0 PT OT SLP OTA PTA CDA clients together (n=4608) (n=4542) (n=3593) (n=3718) (n=3870) (n=847) received 1.7 min/day Therapy Type (n=Number of clients receiving that therapy type) 12 Source: National Rehabilitation Reporting System, 2015–2016, Canadian Institute for Health Information.

Regional Variation in Rehab Intensity? Average Minutes/Day by LHIN 100 90 Minutes per day (Mean) 80 70 Provincial mean = 65.5 min/day 60 50 Much variability between 40 regions (37.3 – 89.1 min/day) 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 LHIN 13 Source: National Rehabilitation Reporting System, 2015–2016, Canadian Institute for Health Information.

Rehab Intensity by Resource Utilization Group (loosely… “severity”) 80 Rehab Intensity by RPG 71.9 68.7 68.4 Discharges by Rehab Patient Group 70 Rehab Time per Day (minutes) 63.6 61.9 59.9 (RPG) 60 53.9 4% 50 14% 1100 9% 40 1110 Mean 8% 30 1120 Median 20 1130 27% 14% 10 1140 1150 0 1100 1110 1120 1130 1140 1150 1160 1160 Rehab Patient Group (RPG) 24% Decreasing Resource Utilization (“Severity”) Most therapy per day provided to “most severe” RPG; Least therapy per day provided to “least severe” RPG 14 Source: National Rehabilitation Reporting System, 2015–2016, Canadian Institute for Health Information.

Next… We grouped clients based on Rehab Intensity (minutes of 1:1 therapy per day) into 4 groups (quartiles) and compared groups 15

This is what the groups (RI Quartiles) look like 120 110.1 RI min per day 103.2 100 Therapy Minutes Per Day Group 4 receives more 72.9 80 72.5 than twice the amount 51.7 of therapy of Group 2, 60 51.9 Median and approx. four times Mean 40 what Group 1 receives 28.2 27.2 20 0 1 2 3 4 Group (RI Quartile) 16 Source: National Rehabilitation Reporting System, 2015–2016, Canadian Institute for Health Information.

Age Age by RI Quartile 78 77 76 74.6 Clients receiving more 74 74 73 therapy per day are Age (years) 72.2 71.3 72 71 younger Median 69.4 70 Mean 68 66 64 27 min/day 52 min/day 73 min/day 110 min/day Group (RI Quartile) 17 Source: National Rehabilitation Reporting System, 2015–2016, Canadian Institute for Health Information.

Total Function Change Average Total Function Change by RI Quartile 35 28.6 30 Total Function Score Change (mean) 25.9 Clients that receive the most 23.0 25 therapy per day have the 19.1 most function change over 20 the course of their stay 15 10 5 0 27 min/day 52 min/day 73 min/day 110 min/day Group (RI Quartile) 18 Source: National Rehabilitation Reporting System, 2015–2016, Canadian Institute for Health Information.

So… more therapy per day results in more function change… right? 19

Active Rehab LOS Efficiency Active LOS Efficiency by RI Quartile 1.40 Clients receiving the most 1.19 1.16 1.10 1.20 1.01 therapy per day are Active Rehab LOS Efficiency 1.03 1.00 achieving a greater overall 0.94 1.00 0.83 FIM/LOS efficiency than 0.80 those receiving the least Median 0.60 therapy per day, despite Mean 0.40 having longer rehab stays 0.20 0.00 27 min/day 52 min/day 73 min/day 110 min/day Group (RI Quartile) 20 Source: National Rehabilitation Reporting System, 2015–2016, Canadian Institute for Health Information.

Active Rehab LOS Clients receiving most therapy per 35 Active LOS by RI Quartile day are staying ~5 29.4 28.2 30 days longer than 26.2 24.7 26 26 those receiving least 24 25 Active LOS (days) 21 therapy per day, on 20 average Median 15 Mean So… these clients 10 are receiving more therapy per day over 5 more days 0 27 min/day 52 min/day 73 min/day 110 min/day i.e. (Rehab Intensity) Group (RI Quartile) x (Active LOS) 21