Measuring Rehabilitation Intensity in Ontario

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 Rehabilitation Intensity Forum cihi.ca @cihi_icis

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-patientday 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 Volunteers 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 stimulating environment? Groups

Rehabilitation Intensity Calculations Rehabilitation Intensity = Total Rehab Time (minutes) Active Rehab LOS (days) Rehab Time with an OT Rehab Time with a PT Rehab Time with an SLP Rehab Time with an OTA Rehab Time with a PTA + Rehab Time with a CDA = Total Rehab Time (# Days from Admit to Date Ready for Discharge) (Service Interruption Days) = Active Rehab LOS At a facility or geographic level: Average Rehab Intensity = Sum [Rehab Intensity per client] Number of clients 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 Records Excluded from Analysis (%) 30 25 20 15 10 5 0 Proportion of Stroke Records Excluded 1 2 3 4 5 6 7 8 9 10 11 12 13 14 4.7% of records had only 0, 999, 9999, or 99999 coded and were excluded from analysis Large regional variation (0-25.5%) Q1 (12.6%) much worse than subsequent quarters (3.5% or less) 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? Proportion of Clients Treated (N total = 4,763) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Prevalence of Each Therapy Type, 2015-2016 97% 95% 81% 78% 75% 18% PT OT PTA OTA SLP CDA Therapy/Provider Type PT and OT most common CDA least common 12.4% of clients served by all provider types 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 (Target = 180 min/day) 7.7 9.9 7.2 1.7 18.9 20.2 PT OT SLP OTA PTA CDA Amount increased over quarters: 63.1 (Q1) 66.5 (Q4) min/day Therapy assistants account for 25% of therapy Less than 1% of clients meeting the therapy-per-day target 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 Therapy Type Total = 61.5 5.0 5.7 5.4 17.5 19.1 PT OT SLP OTA PTA CDA 61.5 min/day of 1:1 therapy during the period of active rehabilitation Amount increased over quarters: 57.4 (Q1) 63.6 (Q4) min/day 180 min/day target is being met by approx. 1% of clients 11

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

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

Rehab Intensity by Resource Utilization Group (loosely severity ) Discharges by Rehab Patient Group (RPG) 8% 14% 9% 4% 24% 14% 27% 1100 1110 1120 1130 1140 1150 1160 Rehab Time per Day (minutes) 71.9 61.9 68.7 68.4 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. 80 70 60 50 40 30 20 10 0 63.6 59.9 53.9 1100 1110 1120 1130 1140 1150 1160 Rehab Patient Group (RPG) Rehab Intensity by RPG Decreasing Resource Utilization ( Severity ) Mean Median

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

Age 78 77 Age by RI Quartile Age (years) 76 74 72 70 68 74.6 74 72.2 73 71.3 71 69.4 Median Mean Clients receiving more therapy per day are younger 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 35 Average Total Function Change by RI Quartile Total Function Score Change (mean) 28.6 30 25.9 23.0 25 19.1 20 15 10 5 0 27 min/day 52 min/day 73 min/day 110 min/day Group (RI Quartile) Clients that receive the most therapy per day have the most function change over the course of their stay 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 Active Rehab LOS Efficiency 1.40 1.20 1.00 0.80 0.60 0.40 0.20 1.01 0.83 1.10 0.94 1.16 1.00 1.19 1.03 Median Mean Clients receiving the most therapy per day are achieving a greater overall FIM/LOS efficiency than those receiving the least therapy per day, despite having longer rehab stays 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 Active LOS (days) 35 Active LOS by RI Quartile 30 28.2 29.4 26.2 24.7 26 26 25 24 21 20 15 10 5 0 27 min/day 52 min/day 73 min/day 110 min/day Group (RI Quartile) 21 Median Mean Clients receiving most therapy per day are staying ~5 days longer than those receiving least therapy per day, on average So these clients are receiving more therapy per day over more days i.e. (Rehab Intensity) x (Active LOS)

Conclusions (data capture & therapy provided) Mandating data collection with regional implementation collaboration has resulted in strong uptake for RI data collection for stroke inpatient rehabilitation. Coding of unknown values decreased over time and is anticipated to continue decreasing. (Care should be taken to ensure that zeros are used when associated service is not provided, regardless of the need or reason.) Currently, persons with stroke in Ontario are receiving one-third the recommended therapy-per-day in inpatient rehab. Strategies to increase rehabilitation intensity are needed. 22

Conclusions (quartile analysis) Younger patients and patients with severe stroke receiving more therapy. Patients receiving greater RI have more functional gains and LOS efficiencies, despite a longer active LOS. 23

What s next? Common Opportunities Identified by Rehab Teams Focus on clinical implementation of rehabilitation intensity Take advantage of the resources available to you Whiteboard Portal Pocket card to guide inclusion Education resources under development to support a sustainability 24

Beth.Linkewich@sunnybrook.ca Rehab@cihi.ca