Hip fracture rehabilitation: important program and outcome characteristics. Disclosure

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1 Hip fracture rehabilitation: important program and outcome characteristics Karl J. Sandin MD MPH Medical Director, Immanuel Rehabilitation Institute Assistant Professor of Surgery (trauma), Creighton University School of Medicine Board certified, Physical Medicine and Rehabilitation and Spinal Cord Injury Medicine None Disclosure 1

2 Goals and objectives Compare and contrast hip fracture rehabilitation programs offered in hospitals, nursing homes, home health, and ambulatory settings Differentiate key features of each setting Describe effect of intensity of rehabilitation service on outcomes Review International Classification of Function Medical rehabilitation Health programs and services that reduce impairment, activity limitation, and participation restriction Medical rehabilitation originated the team concept in health care in the 1950s Functional goal attainment critical piece of medical rehabilitation 2

3 International Classification of Function World Health Organization disability construct Impairment: loss of function at organ system level Activity limitation: loss of function in daily life activities Participation Restriction: loss of function in social role Modified by social/environmental and personal factors ICF example: stroke Impairment: hemiplegia, hemisensory loss, visual field loss, aphasia, dysarthria, dysphagia Activity restriction: can t dress, toilet, walk, move in bed, move from chair to bed Participation restriction: can t work, function as grandparent, volunteer in community 3

4 ICF example: hip fracture Impairment: discontinuity of bone, loss of strength and ROM about hip, pain Activity limitations: potentially quite similar to stroke example Participation restrictions: potentially quite similar to stroke example Characteristics of rehabilitation teams Multidisciplinary: PT, OT, SLP, TR,MD, RN, RD, pharmacy, with little interaction between teams or shared goal setting Interdisciplinary: team participants retain disciplinary expertise but share goal setting, treatment planning and execution Transdisciplinary: team participants blur traditional expertise boundaries with overarching focus on person served 4

5 Multi < Inter < Trans Transdisciplinary teams are believed more efficacious, but require trust, effective communication channels, and continuous education and training to function well EHRs don t transform teams Need for hip fracture rehabilitation Common condition whether fall fracture or fracture fall Substantial data about unnecessary and persistent disability after hip fracture While still substantial mortality, increased survival due to surgical excellence and improved acute care Increasing incidence of risk factors such as imbalance, cognitive disturbance, sarcopenia, poor bone health, sensory deficits 5

6 So because hip fracture is so common, we must have great evidence about best components of rehab programs WRONG! Frequency/duration/intensity Team components Outcome measurements Do we have some evidence? Yes, more therapy, earlier is better long term for decreasing disability Davanzo and Dobson: when patients are matched on demographic and clinical characteristics, rehabilitation in hospital-based rehabilitation facilities leads to lower mortality, fewer readmissions and ED visits, and more days at home than care in a nursing home for the same condition 6

7 Characteristics of after med-surg (post acute) care environments Physician Therapy Nursing Outcome Outpatient No-low Low-high No-Low Voluntary FOTO Home Health No-low Low-medium Low-medium OASIS Long-term acute care hospital (LTAC) Inpatient rehabilitation High (daily, multiple specialities) Medium-high (typically daily; at least 3 days/week) Low-medium High (3 hour minimum) High (staffing similar to ICU) Medium-high (staffing similar to medsurg) LTRAx; LTCH data set Functional Independence Measure (FIM); IRF-PAI Nursing home Low-medium Low-medium Low-medium Minimal Data Set (MDS) Is there a way to standardize this crazy scheme? Coming: Shared data outcome elements Unified, site-neutral payment Between now and then: Challenging to compare processes and outcomes 7

8 Choosing the best post med/surg program for your patient Make sure rehabilitation is happening (therapy does not equal rehabilitation) Programs and services need to address postfracture disability and pre-fracture risk factors Don t fall for the brochure. Ask to see recent quality and experience data: Falls, CAUTIs, LOS Disposition outcomes Patient experience Health and functional outcomes So you ve decided your patient should come to hospital rehab Likelihood for meaningful improvement in reasonable period of time Meaningful = level of function at end of program that allows home discharge Reasonable period hip fracture = 8 days All acute rehabilitation patients need to have preadmission screening, potentially prior authorization, and a discharge plan Mild or worse cognitive impairments are a confounder PM&R consult can help you when you are not sure about disposition type Your work is cut out for you if hip fracture patient is Medicare advantage or commercial insurance 8

9 What does acute care documentation look like to develop rationale for therapy at rehabilitation hospital intensity? Mobility domain: minimally assisted or worse in bed mobility, transfers, gait (also <50 feet) Self-care domain: minimally assisted or worse in functional transfers, dressing, hygiene Vector of progress from one treatment day to another Activity tolerance at least fair (P-F-G-E) Patient agreeable to acute care therapy What does acute care documentation look like to develop rationale for daily MD at rehabilitation hospital? It does not look like long list of comorbidities There is medical record evidence that the primary diagnosis and comorbidities are stable enough to allow safe therapy but not so stable as to not require daily physician thought and action about interventions to increase benefit of rehabilitation program 9

10 Hip fracture POD 1 PT and OT have seen hip fracture repair patient. Patient is ModA in mobility and selfcare domains. Patient WBAT on posterior hip precautions. PMH DM. Hgb 7.8. Lives alone; widowed 5 months ago. Ortho note states pain well controlled. Could patient go directly from hospital to outpatient or home health? Would substantially depend upon environmental and psychosocial factors Does she have family who can come and stay with her and provide physical assistance as she currently needs? Whose job is it in your system to figure out these what ifs? How are we going to get these carers trained to avoid injury prior to acute discharge? 10

11 Therapy need: substantial Substantial deficit in mobility and self-care Substantial way to go to become independent Nothing stated in vignette about ability to tolerate and benefit from therapy For this patient, what should therapy be? Hours/day? Days/week? Delivered individually? In group? How much by therapist compared to aide? Does she need a daily doctor? Need to consider transfusion should she desire robust therapy Standing orders for pain meds may not be adequate in robust therapy context Diabetic control may be suboptimal using standing orders if activity varying Might robust rehabilitation program tax her mood and she needs SSRI Did someone figure out if she has DM retinopathy or neuropathy as risk factors for past and future falls? How is she coping with widowhood? 11

12 So picking a disposition from acute is hard and takes work Post-acute environments are different Within post-acute environments, rehabilitation hospitals and units are the most standardized Star rating systems are invalid and unreliable Time crunches for decision making Families overwhelmed References Magaziner, J, et al. Recovery after hip fracture; interventions and their timing to address deficits and desired outcomes evidence from the Baltimore hip studies. Nestle Nutr Insti Workshop Ser 2015;83:

13 References Resnick B et al.: Rehabilitation interventions for older individuals with cognitive impairment post hip fracture: a systemic review. J Am Med Dir Assoc 2016 March; 17(3): Radosavljevic N et.al.: Hip fractures in a geriatric population rehabilitation based on patients needs. Aging and Disease. 2014;5: References Beaupre LA et.al.: Maximising functional recovery following hip fracture in frail seniors. Best Pract Res Clin Rheumatol Dec; 27(6): Pils K et.al.: Rehabilitation after hip fracture. Wien Med Wochenschr. 2013;163: Dyer SM et.al.: A critical review of the longterm disability outcomes following hip fracture. BMC Geriatrics. 2016;16:

14 References Huusko T et.al.: Randomised, clinically controlled trial of intensive geriatric rehabilitation inpatients with hip fracture: subgroup analysis of patients with dementia. BMJ Nov;321: Fernandez MA et.al.: Outcome score measurement and clinical trials for hip fracture patients. Orthopaedics and trauma. 2016;302: References Wilson H: Multidisciplinary care of the patient with acute hip fracture; how to optimise the care for the elderly, traumatised patient at and around the time of the fracture to ensure the best short-term outcome as a foundation for the best long-term outcome. Best Practice and Research Clinical Rheumatology. 2013;27:

15 References Peeters CMM et.al.: Quality of life after hip fracture in the elderly; a systematic literature review. Injury. 2016;47: Davanzo JE et.al.: Assessment of patient outcomes of rehabilitative care provided in inpatient rehabilitation facilities and after discharge. Accessed 23 Sept 2017 at Dobson%20Study/Final_Dobson_DaVanzo_Report.p df 15

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