readmission? - after subacute care K. Singler 21th September 2017 - PowerPoint PPT Presentation

How to prevent early & unplanned hospital readmission? - after subacute care – K. Singler 21th September 2017

CONFLICT OF IN INTEREST DIS ISCLOSURE I have no potential conflict of interest to report. K. Singler

The way.... A&E/ Acute Acute care illness ICU

The way.... A&E/ Acute Acute care illness ICU

The way.... A&E/ Subacute care/ Acute Transitional discharge Acute care illness care ICU rehabilitation

Hospital readmisson after post-acute rehabilitation – a quality indicator? 2013:The Centers for Medicare and Medicaid Services (CMS) identified 30-days readmission as national quality indicator for inpatient ehabilitation facilities. Lichtman JH, Leifheit-Limson EC, Jones SB et al. Stroke 2010;41:2525-2533. Federal Register. Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2014; Washington DC; Federal Register.42 CFR Part 412;78:89

Risk of readmisson after post-acute rehabilitation Impairment category Readmission rate - 736.536 patients Lower extremity joint 5.8 % replacement - mean age 78.0 (SD=7.3) years Lower extremity 9.4 % - female 62.5% fracture - living with someone prior to hosp. 65.7% Stroke 12.7 % - ≥ one rehab.comorbidity 27.9% Debility 18.8 % - mean LOS 12.4 (SD=5.3) days Neurological 17.4 % disorders Brain Dysfunktion 16.4 % Ottenbacher KJ, Karmakar A, Graham JE et al. JAMA 2014;311(6):604-614

Rates of hospital readmission 30- days readmission rate 11.8% (95%CI, 11,7%, 11.8%) after discharge 23 % of PAC episodes within 30- days of hospital discharge Ottenbacher KJ, Karmakar A, Graham JE et al. JAMA 2014;311(6):604-614 Mor V, Intrator O, Feng Z et al. Health Aff 2010;29:57-64.

Reasons for readmisson after post-acute rehabilitation Reasons for readmission Site of rehabilitation: Heart failure - rural vs. urban Urinary tract infection - hospital based vs. freestanding Pneumonia (Septicemia) Motor and cognitive functioning Nutritional and metabolic disorders Esophygitis, gastroenteritis & Early assessment of functional status digestive disorders Ottenbacher KJ, Karmakar A, Graham JE et al. JAMA 2014;311(6):604-614

Predictors for 30-days rehospitalization Unplanned rehospitalization rate only 4% LOS Polypharmacy Functional status Morandi A, Bellelli G, Vasilevskis EE. J Am Med Dir Assoc 2013; 14(10): 761 – 767

Factors associated with early readmission (≤ 7days) Characteristics OR (95% CI) LOS (index stay) >8 days 0.60 (0.56, 0.64) Discharge diagnosis: MI 1.54 (1.35, 1.75) +1 day in hospital Pneumonia 1.14 (1.03, 1.23) risk of early readmission Number of chronic conditions >6 0.85 (0.76, 0.91) decreased by 2% Prior hospitalization within 1 year 1.10 (1.09, 1.11) (OR 0.98 [CI 0.97 – 0.98]) Private insurance 1.43 (1.32, 1.59) Rural area 1.47 (1.33, 1.61) Size of hospital 0.78 (0.71, 0.86) Teaching status of hospital 0.88 (0.81, 0.96) Horney C, Capp R, Boxer R, Burke RE. JAGS 2017; 65:1199-1205

Comorbidity indices vs. function Comorbidity Index Impairment group • Charlson CI functional status • Stroke } • Tier comorbidity • Joint replacement as predictor of • Functional CI • Lower extremity readmission • Elixhauser CI fracture • Hierarchical Condition Category Shih SL, Gerrard P, Goldstein R et al. J Gen Intern Med 2015;30:1688 – 1695. Kumar A, Karmarkar AM, Graham JE et al. J Gerontol A Biol Sci Med Sci 2017;72(2):223-228.

The way.... A&E/ Subacute care/ Acute Transitional discharge Acute care illness care ICU rehabilitation Assessment of functional status Geriatric assessment

Functional status (FS) and hospitalization Risk factors for short-term functional recovery • Acute illness and hospitalization are crucial events • Older age • 30% do not recover their premorbid FS • Physical and cognitive frailty  Incrased risk of death • Severity of medical illness • Prehospitalization FS  Prolonged short- and long-term disablity • Functional dynamics  Institutionalization Sleiman I, Rozzini R, Barbisoni P et al. J Gerontol A Biol Sci Med Sci 2009;64:659 – 663 Portegijs E, Buurman BM, Essink-Bot ML et al. J Am Med Dir Assoc 2012;13:569.e1 – 569.e7 Boyd CM, Landefeld CS, Counsell SR et al. J Am Geriatr Soc 2008;56:2171 – 2179.

Risk factors for short-term functional recovery . • Older age Functional status ? • Physical and cognitive frailty • Severity of medical illness • Prehospitalization FS functional changes around • Functional dynamics Acute Illness acute illness and hospitalization ! Gill TM, Allore HG, Holford TR, Guo Z. JAMA 2004;292:2115 – 2124; Mudge AM, O’Rourke P, Denaro CP. J Gerontol A Biol Sci Med Sci 2010;65:866 – 872;

Functional changes across the illness continuum 1- month after hospitalization: D = Decline S = Stable I = Improvement Zaslavsky O, Zisberg A, Shadmi E. J Gerontol A Biol Sci Med Sci 2015;70:381-6.

Functional changes across the illness continuum S – S S - I D - I D - S S - D Magic word: In-hospital improvement ?

The way.... A&E/ (Sub) Acute care/ Acute discharge illness ICU Early rehabilitation Assessment of functional status

Hospitalization Process Effects on Functional Outcomes and Recovery (HoPE-FOR) Zisberg et A et al. J Am Geriatr Soc 2015;63:55-62.

HoPE-FOR Variable FD discharge FD 1-month follow up In-hospital mobility -0.62, <.001 -0.36, <.001 In-hospital continence care -0.58, <.001 -0.28, <.001 In-hospital medication sedative load 0.16, <.001 0.07, .07 Hospital environment -physical -0.16, <.001 -0.11, .003 -human -0.14, <.001 -0.03, .42 FD= Functional decline

In-hospital mobility – functional decline Physical outcomes eg. Delirium, pain etc Psychological outcomes eg. Anxiety, depression Early mobilization Social outcomes Organisational outcomes  50% to 70% of people in the hospital do not walk outside their room  Current study 48% of participants reporting confinement to their room Ostir GV, Berges IM, Kuo YF et al. J Am Geriatr Soc 2013;61:551-557 Kalisch BJ, Lee S, Dabney BW. J Clin Nurs 2014;23:1486-1501

early Acute rehabilitation care Singler K, Biber R, Wicklein S. Z Gerontol Geriatr 2011;44(6):368-74 Biber R, Singler K, et al. Arch Orthop Trauma Surg 2013;133:1527-31

The way.... rehabilitation process as needed A&E/ (Sub) Acute care/ Acute discharge rehabilitation illness ICU Early rehabilitation Assessment of functional status OPS 8-550.x

Early geriatric rehabilitation - Effectiveness and feasibility - Martinez-Velilla et al. Kosse et al. Articles included 17 15 (multidiscipl. vs usual care + exercise) Functional outcome significant improvement Improvement on functional tests up to 12 months (4) LOS -- Reduced by multidisciplinary programs Discharge destination -- Less discharge to nursing home Costs Costeffective Feasibility No adverse side effects safe Adherence rate -- Variation between studies Martínez-Velilla N, Cadore L, Casas-Herrero Á et al. J Nutr Health Aging 2016;20(7):738-51. Kosse NM, Dutmer AL, Dasenbrock L, Bauer JM, Lamoth CJ. BMC Geriatr 2013;13:107

Key messages • Rehospitalization from post acute care is common • Individual risk factors – hospital processes • In-hospital mobility, continence care, nutrition play an important role • Early rehabilitation (led by geriatricians) is a promising solution Patient centred care