1. Choosing the right level of post- acute care for stroke patients Randie M. Black-Schaffer, M.D., M.A. Division of Stroke and Neurology, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston MA

2. What characteristics distinguish patients who go to Inpatient Rehabilitation Hospitals (IRFs) from those who go to Skilled Nursing Facilities (SNFs) for post-acute stroke care? Does IRF care lead to better outcomes than SNF care? Two questions

3. FACTORS that predict acute discharge disposition Age Severity of impairment Functional level after stroke Cognition Urinary continence FACTORs not considered in the literature Motivation Patient goals Hakkennes, SJ, et al. Selection for Inpatient Rehabilitation after Acute Stroke: A Systematic Review of the Literature. Arch Phys Med Rehabil 2011 Hakkennes, SJ, et al. Selection for Inpatient Rehabilitation after Acute Stroke: A Systematic Review of the Literature. Arch Phys Med Rehabil 2011

4. Impact of Levels of Service: How Much is Postacute Care Use Affected by Its Availability? Buntin, MB, et al, Health Services Research, 2005 All Medicare pts in hospital 1999 for stroke, hip fx, Jt replacement Results: – IRF vs SNF related to distance – Number of facilities in the patient’s area – SNF or IRF related to acute facility

5. State Variation in Stroke Discharge Destination (2002-2004) Top 10 IRF users (FFS Medicare) State Discharge Rank Discharge Rank Any IRF as a Rank to IRF to SNF Inpatient % of Inpatient Nevada 30% (1) 15% (50) 50% 59% (1) Arkansas 28% (2) 20% (47) 49% 57% (2) Louisiana 27% (3) 14% (51) 52% 53% (5) Oklahoma 26% (4) 19% (48) 49% 53% (3) Arizona 24% (5) 21% (44) 46% 53% (4) Pennsylvania 23% (6) 30% (21) 54% 43% (14) North Dakota 23% (7) 27% (34) 50% 45% (10) Kansas 23% (8) 21% (43) 45% 50% (6) Texas 22% (9) 21% (46) 49% 46% (8) New Hampshire22%(10)27%(33)50%45%(11) Kramer A, Holthaus D., et al. Study of Stroke Post-Acute Care and Outcomes: Final Report. Aurora, CO. Division of Health Care Policy and Research, University of Colorado at Denver and Health Sciences Center, 2006. http://aspe.hhs.gov/daltcp/reports/2006/strokePAC.htm

6. State Variation in Stroke Discharge Destination (2002-2004) Bottom 10 IRF users (FFS Medicare) State Discharge Rank Discharge Rank Any IRF as a Rank to IRF to SNF Inpatient % of Inpatient Virginia 15% (42) 30% (20) 45% 33% (38) Minnesota 14% (43) 35% (4) 50% 28% (47) Florida 14% (44) 33% (10) 48% 30% (46) Alabama 14% (45) 28% (30) 43% 32% (41) Nebraska 13% (46) 29% (23) 47% 28% (48) Vermont 13% (47) 30% (19) 43% 30% (45) Iowa 13% (48) 29% (22) 42% 30% (44) Connecticut 12% (49) 40% (1) 56% 22% (50) Oregon 11% (50) 33% (8) 45% 25% (49) Maryland 4% (51) 35% (3) 39% 10% (51) Kramer A, Holthaus D., et al. Study of Stroke Post-Acute Care and Outcomes: Final Report. Aurora, CO. Division of Health Care Policy and Research, University of Colorado at Denver and Health Sciences Center, 2006. http://aspe.hhs.gov/daltcp/reports/2006/strokePAC.htm

7. Stein J, et al. Predicting Rehab Care after Acute Stroke 736 pts at 22 acute hospitals in NECC, 2010-2011 Ischemic and hemorrhagic stroke IRF disposition from acute more likely than SNF if – Younger (P<.001) – Pre-stroke mRS 0-1 (P=.004) – Acute care Barthel Index 25-40 (P=.004), or 45-60 (P=.018) Home more likely than IRF/SNF if – Barthel Index 85-100 – Lower pre-stroke mRS (P<.001) – Higher Short Portable Mental Status score (P<.001) – Lower NIHSS (P<.001)

8. Factors associated with IRF vs SNF placement Younger age Higher functional level Continent Better cognitive status IRF nearby IRF related to acute hospital

10. PAL (Post Acute Levelling) Tool Domains The Post Acute Leveling (PAL) Tool looks at the following:  Patient Age  Major Driver of Post Acute Care  Physician Need  in visits per week  Nursing Need  in hours per day  Estimated Length of Stay  Rehabilitation Needs  in hours per day  Program  Specialty Needs  Social, Payor, and Medication issues.

11. Are outcomes better with IRF or SNF post-acute care for stroke?

12. Outcomes and Costs After Hip Fracture and Stroke: A Comparison of Rehabilitation Settings Kramer, AM, et al. JAMA 1997 CharacteristicRehab (N=292)SNF (N=193) Age75.881.2P=.001 Willing caregiver9353P=.001 Institutionalized PTA 111P=.001 Hemiparesis1431P=.001 Comorbidities1.571.87P=.05 Incontinence4559P=.001 Acute LOS10.716.1P=.001 Function on admission to post- acute care (BI) 8.05.3P=.001 MMSE2315P=.001

13. Outcomes and Costs After Hip Fracture and Stroke: A Comparison of Rehabilitation Settings Kramer, AM, et al. JAMA 1997 Stroke patients: 292 to IRF, 193 to SNF LOS at IRF 28 days; LOS SNF 56 days “Study findings are consistent with enhanced outcomes for elderly patients with stroke treated in rehabilitation hospitals but not for patients with hip fracture.” IRF stroke patients more likely to be in community at 6 mo. than SNF patients (OR 3.3; CI 1.5-7.2)

14. Does Postacute Care Site Matter? Chan L, Sandel ME, Jette AM, et al. Arch PMR 2013 Hypothesis: Pts with stroke receiving IRF care would have better 6 mo. Functional outcomes than those who received postacute care in SNF, HH/OP. 222 stroke pts at 4 acute hospitals Evaluation at DC from acute care and 6 mo. AM-PAC Activity Measure for Post Acute Care - functional status NIHSS - stroke severity mRS – pre-stroke function mCharlson - comorbidities

15. Chan L, et al. 2013 4 groups: – IRF: N= 66 – SNF: N= 29 – HH/OP only: N=48 – No PAC: N=79 Intensity of therapy per Kaiser Foundation Health Plan: – IRF : 3 hrs/day for 6 days per wk – SNF: 1.3 hrs/day for 5 days per wk

16. Chan L, et al: Results Controlling for – Age, BMI, baseline function, pre-stroke mRS, – mCharlson Index, hx prior stroke Patients who went to an IRF made greater gains in mobility, ADL, and cognition measured at 6 mo. compared to those who went to SNF.

17. Chan L, et al: interpretation Pts in IRFs have greater access to MDs, RNs Higher intensity of rehab therapy Often within an acute hospital Greater pt/fam education, care coordination, DC planning

18. Dobson Davanzo & Associates. Assessment of Patient Outcomes of Rehabilitative Care Provided in IRF and After Discharge. 2014. SNF vs IRF utilization Medicare pts 2005-2009 – Changes over time for 13 conditions Longitudinal outcomes for 2 years after – Mortality – Days at home – Acute readmissions – ER visits

19. IRF Utilization 2005-2009

20. Dobson/Davanzo: Propensity Score matching Patients matched for: – Age – Gender – Race – Condition – Procedure codes – Diagnosis codes – Charges by dept. Patients matched for: – Age – Gender – Race – Condition – Procedure codes – Diagnosis codes – Charges by dept. Patients not matched for: – Prestroke function – Function on admission to rehab – Severity of impairment – Severity of comorbidities Patients not matched for: – Prestroke function – Function on admission to rehab – Severity of impairment – Severity of comorbidities

21. Stroke Outcomes Dobson/Davanzo 2014

22. Comments “The contribution of this study is that the propensity score matching of IRF and SNF patients controls for observed differences in patient characteristics, thereby isolating the impact of the PAC setting.” Patients not matched re functional level or impairment

23. Patients may go to multiple levels of Post Acute Care after Stroke Acute Care LTAC IRF Home Acute Care LTAC SNF Home Acute Care IRF SNF Home Acute Care SNF IRF Home

24. Patient Trajectory through Post-Acute Care Acute Care. 60 yo female s/p thalamic hemorrhage with L hemiplegia. PEG placement led to abdominal sepsis. She suffered DVT in all 4 limbs, HO in left hip. Transferred to LTAC. Antibiotics completed, drains removed, po intake resumed, PEG removed, hip pain managed. Transferred to IRF. A&O x 3, able to participate, poor endurance. Mobility limited by L hip pain and hemiplegia. Transfers mod A of one at discharge. Walking 30 feet with mod-max A at discharge. HO pain diminished. Discharged home with home care services. Acute CareLTACIRFHome Days636964Day 196

25. Conclusions IRF outcomes better than SNF for initial stroke rehab Widespread selection bias to send younger, healthier patients to IRF, therefore Claims of long term health benefits of IRF vs. SNF should be viewed with caution Multiple PAC levels of care for a single patient common

26. Thank you! rblackschaffer@partners.org Division of Stroke and Neurology, Department of Physical Medicine and Rehabilitation, Harvard Medical School