Re Rehabilitatio habilitation n in in lo long- ng-te term rm - - PowerPoint PPT Presentation
Re Rehabilitatio habilitation n in in lo long- ng-te term rm care care: Interventions and Inter ventions and their effec their effect on t on activities of daily living and falls activities of daily living and falls qualit quality
Caitlin McArthur PhD, MScPT, BSc(KIN) Department of Kinesiology | Aging, Health and Well-being University of Waterloo
cmcarthur@uwaterloo.ca @McArthurCaitlin
§ a) tools to determine who should receive PR services § b) which PR services have been evaluated § c) how they have been evaluated at the resident-, facility-, and system-level
§ this number is projected to double within the next 20 years1
§ more than 80% required extensive care2
§ Lack of evidence surrounding PR interventions, considerable heterogeneity in the models of delivery, staff providing, time allocated to and goals of PR interventions.5 § An overabundance of constructs has been used to evaluate PR at the resident-level (e.g., ADLs, falls, mood)5 § broad understanding of what PR interventions have been evaluated in the literature § both active and passive modalities § full spectrum of professionals who could be involved in delivering services § Which specific facility- or system-level measures (quality indicators – QIs) could be used to evaluate PR in LTC? § Few resident receive services3, receipt of services not always related to need4, significant room for improvement4 § How can we identify which residents would benefit from rehabilitation?
§ Budget base program
§ LTC home receive block funds per bed per year
§ Strict eligibility criteria
§ Discharge once therapeutic goals met
§ Additional per diem for exercise classes
After:
§ Fee for service billed directly
to OHIP
§ At the discretion of the
physical therapist, with referral from physician
Before:
§ a) tools to determine who should receive PR services § b) which PR services have been evaluated § c) how they have been evaluated at the resident-, facility-, and system-level
Research Question 2: Which outcomes have been used to evaluate them? Research Question 1: What are the characteristics of PR interventions that have been evaluated in LTC? Research Question 3: Which tools exist for decision-making around who is eligible for PR services?
McArthur C, Gibbs JC, Patel R, Papaioannou A, Neves P, Killingbeck J, Hirdes J, Milligan J, Berg K, Giangregorio L. (2017) A scoping review of physical rehabilitation in long-term care: interventions, outcomes, and tools. The Canadian Journal on Aging. 36 (4): 435-52.
Research Question 2B: Which QIs have been used to evaluate PR in LTC?
B) Grey Literature:
Publications Portal
Rehabilitation
Reviews
(PEDro)
Evaluation of Evidence database (OTseeker) Structured scoping review using Arksey and O’Malley framework6 Key concepts: LTC, PR, interventions that have been evaluated, elderly, decisions regarding resource allocation, tools to assist in decision making, and evaluation including quality indicators
Inclusion criteria7:
case-control, randomized controlled trials, quasi- randomized clinical trials or controlled clinical trials, clinical practice guidelines, systematic reviews, and relevant reports generated by policy makers.
residing in a LTC facility
Physiotherapy Association.
framework for system level decision making regarding eligibility for PR services, or describe, evaluate or provide evidence for a quality indicator used to evaluate PR
Exclusion criteria7:
been validated will be excluded (proof of face, construct, or criterion validity must be demonstrated)
clinical commentaries, abstracts
Evidence from scoping review Key points for researchers
residents, with very few specifically including non
residents with evidence of dementia, 27.3% excluded medically acute
currently in LTC (e.g., with cognitive impairment, medically complex)
physical therapist 3 - 5 days per week, 25 - 50 minutes, 10 - 18 weeks
(e.g., multidisciplinary integrated models of care)
inclusion/exclusion criteria
stay models of care (e.g., convalescent care)
quality of life less frequently used as outcome measures
including rehabilitation (e.g., relief from pain and other symptoms, active life until death)
at facility - and system - levels (e.g., use quality indicators, healthcare transitions)
eligibility were found
receive services
Key points FOR CLINICIANS Evidence from scoping review
used outcome measures to evaluate physical rehabilitation in long-term care: Performance-based measures:
Activities of daily living:
Mood:
Falls:
Quality of life:
§ facility-level measures that are used internationally to capture the structure,
process and outcomes within and between LTC homes.
§ Often publicly reported to encourage consumers to make informed decisions
around the quality of service providers and to stimulate internal quality improvement strategies within LTC homes
§ Can be used to:
§ guide clinical decision making § evaluate and report treatment effectiveness § benchmark achievements § guide and evaluate quality improvement initiatives and strategic planning § implement guideline recommendations § inform policy § set national benchmarks § determine resource allocation9
Research Question 2B: Which QIs have been used to evaluate PR in LTC?
Use the available evidence and stakeholder consultation to identify which existing or new QIs could be used to evaluate PR in LTC Consult stakeholders to identify which existing QIs could be used to evaluate PR in LTC
1.
As per scoping review in Study 1
§ Modified nominal group technique10, 11 § 14 Stakeholders from PR and LTC were asked:
“What do you think should be the quality indicators used to evaluate physical rehabilitation in long-term care?”
Omissions? Why?
QIs reported:
QIs appeared to be related to rehab:
Evidence to support use:
consensus process, 1 reported prevalence and variation, none reported sensitivity or timeframe for change
16 15 6 6 2 2 1 1 1 0 0 0 0 5 10 15 20 falls ADLs pain pressure ulcers cogniDve restraints inconDnence human health
wait Dmes medicaDon emergency infecDons Number of votes Quality indicator domain
38 28 8 7 4 3 3 2 0 0 0 0 0 0 0 5 10 15 20 25 30 35 40 ADLs falls pain quality of life inconDnence pressure ulcers restraints behaviours wait Dmes cogniDon medicaDon health infecDons emergency
Weighted ranking score Quality indicator domain Pre-meeting vote Post-meeting ranking
ulcers
be developed
§ a) tools to determine who should receive PR services § b) which PR services have been evaluated § c) how they have been evaluated at the resident-, facility-, and system-level
Objective Methods
falls QIs across LTC homes in Canada
provinces
PR and facility-level ADLs and falls QIs within LTC homes across four Canadian provinces and one territory
stratified by province
to the multivariable regression
multivariable model at p <0.01
(e.g., size, rurality) are related to QI performance
Data collection:
§ Control Variables:
§ Size of facility § Urban/rural § Health region § Neighbourhood quintile
§ Explanatory Variables – proportion of residents with:
§ receiving rehabilitation (PT/OT/SLP, nursing rehab, therapeutic rec) § Rehab potential – self-, staff-, CAP-identified § Diagnoses – dementia, Parkinson’s, stroke, multiple sclerosis, hip fracture § Other – acute care, physician visits, antipsychotic use
Early-loss % residents improved % residents declined Mid-loss % residents improved % residents declined Late-loss % residents improved % residents declined % residents declined % residents who have fallen in past 30 days Activities of daily living Falls
Risk adjusted through: restriction, indirect standardization, and stratification with direct standardization12, 13 Expressed as percentile ranking: < 20th: “excellent” 20-80th: “average” >80th: “poor”
Improved Early Loss Improved Late Loss
0.30 0.25 0.20 0.15 0.10
ALL AB BC MB ON
Better performance
0.40 0.35 0.30 0.25 0.20
ALL AB BC MB ON
Improved Mid Loss
0.20 0.15 0.10 0.05 0.00
ALL AB BC MB ON
Better performance Worse Early Loss Worse Late Loss Worse Mid Loss
0.50 0.40 0.30 0.20 0.40 0.35 0.30 0.25 0.20 0.25 0.20 0.15 0.10
ALL AB BC MB ON ALL AB BC MB ON ALL AB BC MB ON
Better performance
0.50 0.40 ALL AB BC MB ON 0.30 0.20
Worse overall ADLs
Better performance Falls
0.25 0.20 ALL AB BC MB ON 0.15 0.10
§ Nursing rehab
§ Consistent relationship with prevention of
ADL decline in Alberta
§ Worse late-, mid-, early-loss and overall
ADL performance
§ Hip fracture
§ Improved late-loss ADLs in BC § Improved mid-loss ADLs in BC and Ontario § Improved early-loss ADLs in BC § Worse early-loss ADLs in Alberta § Worse overall ADL long-form score in BC
Negative relationship Positive relationship
§ Rehab potential § CAP triggered with improved late- loss QI in Alberta
§ Multiple sclerosis
§ Worse late-loss ADLs in BC and Alberta § Worse early-loss ADLs in Alberta § Improved early-loss ADLs in BC § Falls in BC
§ PT/OT/SLP § falls QI in BC
Rehabilitation Other facility-level factors
§ Except receiving nursing rehab services in Alberta
§ a) tools to determine who should receive PR services § b) which PR services have been evaluated § c) how they have been evaluated at the resident-, facility-, and system-level
the ADL and falls QIs before and after the policy change, and in the proportion of residents receiving PR services.
percentage of residents receiving PT
change on facility-level ADL and falls QIs
Same control variables as study 3 Response variables (QIs): expressed as continuous value Rehabilitation variable: amount of PT only January 1st, 2011 to March 31st, 2015
56.6% 84.6%
Receiving no PT Receiving PT for < 45 minutes per week Receiving PT for 45 to 150 minutes per week Receiving PT for > 150 minutes per week
22.2% 18.2%
32.9% 65.8% 0.2% 0.5%
Receiving no PT Receiving PT for < 45 minutes per week Receiving PT for 45 to 150 minutes per week Receiving PT for > 150 minutes per week
Mean: 44.2 minutes, 2.5 days Median: 45.0 minutes, 3.0 days Mean: 49.1 minutes, 2.9 days Median: 45.0 minutes, 3.0 days 2010 2015 Fewer residents are receiving PT Those that receive it, receive on average the same amount
Residents receiving PT:
Improved Early Loss
0.30 0.20 0.15 0.25 0.10 Policy change 0.40 0.30 0.25 0.35 0.20 Policy change 0.15 0.10 0.05 Policy change 0.40 0.35 0.30 0.25
Improved Mid Loss Improved Late Loss Worse Mid Loss
Worse Early Loss Worse Late Loss
0.40 0.30 Policy change 0.20 0.25 0.20 Policy change 0.15 0.10
0.40 0.30 Policy change 0.25 0.45 0.35 0.18 0.14 0.12 0.20 0.16 Policy change 0.10
Worse overall ADLs Falls
PT and interaction with policy change Proportion of residents receiving: Quality indicators – proportion of residents with: worse late loss ADLs worse or remained dependent in mid loss ADLs worse or remained dependent in early loss ADLs worse ADL long form score falls in the last 30 days improved late loss ADLs improved or remained independent in mid loss ADLs improved or remained independent in early loss ADLs No PT ✗ ✗ PT for < 45 minutes
✓ ✓ ✓ ✗ ✗ PT for 45-150 minutes on 3-5 days ✓ ✓ ✓ PT for > 150 minutes
✓denotes associaDon with improved performance on the quality indicator; ✗denotes associaDon with worse performance on the quality indicator; all associaDons are with P<0.01 Note: models are adjusted for health region, facility size, income quinDle, and rurality, and their interacDon terms with the intervenDon
§ Except least time intense PT was associated with poorer performance on two of
the ADL QIs
§ except for certain areas
§ Fewer residents receiving PT overall § associated with improved performance on several ADL QIs, but worse on two
QIs
§ Develop definition of quality rehabilitation in LTC § Explore resident goals for rehab § Future interventions should:
§ Include residents who are complex § Be realistic and sustainable § Sufficiently intense § Targeted appropriately § Embed elements of rehabilitation into daily practice
§ Examine provinces/homes with superior QI performance § Develop tools to determine service eligibility to appropriately target rehab § Ensure rehab data is entered accurately into RAI 2.0
https://www.youtube.com/user/OsteoporosisLTC/playlists
Committee members:
§ Lora Giangregorio § Katherine Berg § Ashok Chaurasia § John Hirdes
BONES Lab members:
§ Rebecca Clark § Rasha El-Kotob § Rahim Manji § Jenna Gibbs § Ruchit Patel § Jeff Templeton § Christina Ziebart
h_ps://secure.cihi.ca/free_products/infosheet_ResidenDal_LTC_Financial_EN.pdf. Accessed 03/20, 2016.
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