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

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

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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/

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How to prevent early & unplanned hospital readmission?

  • after subacute care –
  • K. Singler

21th September 2017

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CONFLICT OF IN INTEREST DIS ISCLOSURE

I have no potential conflict of interest to report.

  • K. Singler
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The way....

Acute illness

A&E/ ICU Acute care

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The way....

Acute illness

A&E/ ICU Acute care

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The way....

Acute illness

A&E/ ICU Acute care Subacute care/ rehabilitation discharge Transitional care

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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

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Risk of readmisson after post-acute rehabilitation

Impairment category Readmission rate Lower extremity joint replacement 5.8 % Lower extremity fracture 9.4 % Stroke 12.7 % Debility 18.8 % Neurological disorders 17.4 % Brain Dysfunktion 16.4 %

Ottenbacher KJ, Karmakar A, Graham JE et al. JAMA 2014;311(6):604-614

  • 736.536 patients
  • mean age 78.0 (SD=7.3) years
  • female 62.5%
  • living with someone prior to hosp. 65.7%
  • ≥ one rehab.comorbidity 27.9%
  • mean LOS 12.4 (SD=5.3) days
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Rates of hospital readmission

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.

30- days readmission rate 11.8% (95%CI, 11,7%, 11.8%) after discharge 23 % of PAC episodes within 30- days of hospital discharge

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Reasons for readmisson after post-acute rehabilitation

Reasons for readmission Heart failure Urinary tract infection Pneumonia (Septicemia) Nutritional and metabolic disorders Esophygitis, gastroenteritis & digestive disorders Site of rehabilitation:

  • rural vs. urban
  • hospital based vs. freestanding

Motor and cognitive functioning

Early assessment of functional status

Ottenbacher KJ, Karmakar A, Graham JE et al. JAMA 2014;311(6):604-614

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Morandi A, Bellelli G, Vasilevskis EE. J Am Med Dir Assoc 2013; 14(10): 761–767

Predictors for 30-days rehospitalization

Polypharmacy Functional status LOS Unplanned rehospitalization rate only 4%

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Factors associated with early readmission (≤ 7days)

Horney C, Capp R, Boxer R, Burke RE. JAGS 2017; 65:1199-1205

Characteristics OR (95% CI) LOS (index stay) >8 days 0.60 (0.56, 0.64) Discharge diagnosis: MI Pneumonia 1.54 (1.35, 1.75) 1.14 (1.03, 1.23) Number of chronic conditions >6 0.85 (0.76, 0.91) Prior hospitalization within 1 year 1.10 (1.09, 1.11) 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)

+1 day in hospital risk of early readmission decreased by 2%

(OR 0.98 [CI 0.97–0.98])

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Comorbidity indices vs. function

  • Stroke
  • Joint replacement
  • Lower extremity

fracture

  • Charlson CI
  • Tier comorbidity
  • Functional CI
  • Elixhauser CI
  • Hierarchical Condition Category

Impairment group Comorbidity Index

functional status

as predictor of readmission

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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.

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The way....

Acute illness

A&E/ ICU Acute care Subacute care/ rehabilitation discharge Transitional care

Assessment of functional status Geriatric assessment

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Functional status (FS) and hospitalization

  • Acute illness and hospitalization are crucial events
  • 30% do not recover their premorbid FS

 Incrased risk of death Prolonged short- and long-term disablity  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.

  • Older age
  • Physical and cognitive frailty
  • Severity of medical illness
  • Prehospitalization FS
  • Functional dynamics

Risk factors for short-term functional recovery

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Risk factors for short-term functional recovery

.

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;

  • Older age
  • Physical and cognitive frailty
  • Severity of medical illness
  • Prehospitalization FS
  • Functional dynamics

Acute Illness functional changes around acute illness and hospitalization ! Functional status ?

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Functional changes across the illness continuum

Zaslavsky O, Zisberg A, Shadmi E. J Gerontol A Biol Sci Med Sci 2015;70:381-6.

1- month after hospitalization: D = Decline S = Stable I = Improvement

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Functional changes across the illness continuum

S – S S - I D - I D - S S - D

Magic word: In-hospital improvement ?

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The way....

Acute illness

A&E/ ICU (Sub) Acute care/ Early rehabilitation discharge

Assessment of functional status

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Hospitalization Process Effects on Functional Outcomes and Recovery (HoPE-FOR)

Zisberg et A et al. J Am Geriatr Soc 2015;63:55-62.

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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

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In-hospital mobility – functional decline

 50% to 70% of people in the hospital do not walk outside their room  Current study 48% of participants reporting confinement to their room Early mobilization

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

Physical outcomes eg. Delirium, pain etc Psychological outcomes eg. Anxiety, depression Social outcomes Organisational outcomes

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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

Acute care early rehabilitation

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The way....

Acute illness

A&E/ ICU (Sub) Acute care/ Early rehabilitation discharge

Assessment of functional status

as needed rehabilitation

rehabilitation process

OPS 8-550.x

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Early geriatric rehabilitation

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

  • Effectiveness and feasibility -

Martinez-Velilla et al. Kosse et al. Articles included 17 15 (multidiscipl. vs usual care + exercise) Functional outcome significant improvement up to 12 months (4) Improvement on functional tests 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
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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