Strategies for Identifying and
Decreasing Readmissions for
Inpatient Rehabilitation
Pamela Roberts, PhD, OTR/L, SCFES, FAOTA, CPHQ, FNAP
Cedars‐Sinai Medical Center
California Hospital Association‐Center for Post Acute Care
Annual Conference
Huntington Beach, California
January 29, 2015
Critical Elements: The Road to
Inpatient Rehabilitation
Compliance
Risk Factors for Readmission
Readmissions
• Unmet need for new ADL disabilities after return home from the hospital is particularly vulnerable to readmissions • Patients’ functional needs after discharge should be evaluated and addressed Reference: The Gerontologist, Vol 53(3), 454‐461.Readmissions
Functional status on Admission to CIIRP is strongly associated with readmission before planned discharge from CIIRP. Efforts to reduce hospital readmissions should consider patient functional status as an important and potentially modifiable risk factor.Readmissions
Approximately 11% of SCI patients experience Return to Acute (RTAC) during the course of rehabilitation for a variety of medical and surgical reasons. RTAC’s are associated with longer rehabilitation length of stay.Readmissions
Efforts to reduce readmissions to acute care should include greater scrutiny of older, lower functioning patients with burn injury who are evaluated at admission to inpatient rehabilitation.Readmissions
Reference: Roberts P, DiVita M, Riggs R, Niewczyk P, Bergquist B, & Granger CV (2014). Risk factors for discharge to an acute care hospitalFrom inpatient rehabilitation among stroke patients. PMR, 6: 50‐55. • Retrospective study of stroke 783 stroke patients from 2008‐2012 admitted to IRF • Examined 60 who returned to acute care hospital • Two significant risk factors were low motor FIM and enteral feeding • Trends but not significant • Younger age • Longer onset time from stroke to IRF admit • Presence of a tiered comorbidity Reference: Asher A, Roberts PS, Bresee C, Zabel G. Riggs R, and Rogatko A (In press). Transferring inpatient rehabilitation facility cancer patients back to acute care (TRIPBAC). PM&R. Among post‐acute rehabilitation facilities providing services to Medicare fee‐for‐ service beneficiaries, 30‐day readmission rate ranged from 5.8% for patients with lower extremity joint replacement to 18.8% for patients with debilityOttenbacher KJ, Karmarkar A, Graham JE, Kuo F, Deutsch A, Reistetter TA, Snih SA, and Granger CV (2014). Thirty‐day hospital Readmission following discharge from postacute rehabilitation in fee‐for‐service medicare patients. JAMA; 311(6): 604‐614.
Higher motor and cognitive functional status were associated with lower hospital readmission rates across six impairment categories (stroke, lower extremity fracture, lower extremity joint replacement, debility, neurologic disorders and brain dysfunction
Quality Measure for
Readmissions for IRFs
• NQF #2502 All‐Cause Unplanned Readmission Measure
for 30 days Post Discharge from Inpatient Rehabilitation
Facilities
•
Measure estimates the risk‐standardized rate of
unplanned, all‐cause readmissions for patients
discharged from an IRF who were readmitted to
short‐stay acute‐care hospital or a long‐term care
hospital within 30 days of an IRF discharge
• Measure is based on data for 24 months of IRF discharges to
non‐hospital post‐acute levels of care or to the community
Quality Measure for
Readmissions for IRFs
Calculation:
• Predicted number of readmissions at the facility divided
by the expected number of readmissions for the same
patients multiplied by the mean rate of readmission in the
population
Quality Measure for
Readmissions for IRFs
• Exclusions:
• IRF patients who died during the IRF stay • IRF patients less than 18 years old • IRF patients who were transferred at the end of a stay to another IRF or short‐term acute care hospital • Patients who were not continuously enrolled in Part A FFS Medicare for the 12 months prior to the IRF stay admission date, and at least 30 days after IRF stay discharge date • Patients who did not have a short‐term acute‐care stay within 30 days prior to an IRF stay admission date • IRF patients discharged against medical advice (AMA) • IRF patients for whom the prior short‐term acute‐care stay was for nonsurgical treatment of cancer • IRF stays with data that are problematic (e.g., anomalous records for hospital stays that overlap wholly or in part or are otherwise erroneous orCritical Elements: The Road to
Inpatient Rehabilitation
Compliance
Strategies to Prevent
Readmissions
Practical Strategy Considerations
• Standardized IRF “SBAR” hand‐off
• Lack of standardization of hand‐off for:
Bladder and bowel function/management
Pain management
Completion of acute Care Plans
Lines/Drains/Airways
Tests/procedures completed prior to admission
Skin/Pressure Ulcers
Out of bed/activity level
Transfer level, use of special eqiupment/technique
Dangers of Discharge
Initiatives to Reduce Readmissions
• MiPAD
• Medical Passport
• Follow‐up telephone
calls within 24 hours
• Physician
Assistant/Nurse
Practitioner assisting
recent CSMC discharges
in medical oversight
• Frailty Assessment
•
Foundation identifying
“Frail” outpatients to
prevent admissions and if
admitted to prevent
readmissions
•
Medication Reconciliation
(source verification)
throughout the continuum
•
Case Manager throughout
the continuum
Inpatient Rehabilitation
Multidisciplinary Information
and Personal Assistance Diary
(MiPAD)
•
Goal: Improve information and education
throughout the continuum of care
•
Tool used to have all education in one place
including triggers to include certain
information
1. Introduction A) Handbook B) Group Therapy C) Team Members D) Survey 2. My Condition A) Diagnosis Specific Packet B) Health and Well‐Being C) Medications 3. My Safety A) Precautions B) Safety in the Home C) Disaster Preparedness 4. My Discharge a) Home Exercise Program b) Equipment c) Training d) Family Conference 5. My Contacts a) Medical Passport b) Support Services c) Business Card HolderMiPad
(Multidisciplinary information and Personal AssistanceDiary)
