1. Rehabilitation and Regenerative Medicine Selecting rehabilitation level of care: Can we achieve consensus? Joel Stein, MD

2. Rehabilitation and Regenerative Medicine Disclosures None specifically related to this presentation Research support from Nexstim, Tibion, Myomo, Tyromotion Member of Scientific Advisory Board - Myomo, Inc. (uncompensated)

3. Rehabilitation and Regenerative Medicine Session Structure Introduction – Joel Stein, MD IRF vs. SNF Outcomes – Randie Black-Schaffer, MD Breakout sessions to review cases Report back from small groups Physiatry survey results re: Discharge destination – David Cormier, DO Panel Discussion – Alyse Sicklick, MD

4. Rehabilitation and Regenerative Medicine Levels of Rehabilitation Inpatient Rehabilitation Facility (IRF, Acute Rehab) Skilled Nursing Facility (SNF, Subacute Rehab) Long Term Acute Care Hospital (LTACH) Home Care Services Outpatient

5. Rehabilitation and Regenerative Medicine IRF vs. SNF: Why it matters IRF care is more expensive. (But costs of long-term care, institutionalization and dependence are externalities from payor perspective). IRF care may result in better outcomes Considerable variation in utilization of these services exists CMS, private payors, and now ACO’s will continue to seek to minimize the costs of post-acute stroke care Stroke patients represent the single largest group of patients in IRF’s – 20% of total No clear standards exist to help clinicians determine who would benefit from which type of care Where would you want your family member to receive stroke rehabilitation?

6. Rehabilitation and Regenerative Medicine Medicare FFS spending on post-acute care Data Book: Health Care Spending and the Medicare Program. MedPac, June 2012. http://www.medpac.gov/document_TOC.cfm?id=617

7. Rehabilitation and Regenerative Medicine State Variation in Stroke Discharge Destination (2002-2004) Top 10 IRF users (FFS Medicare) State Discharge Rank Discharge Rank Any IRF Rank to IRF to SNF Inpatient as a % 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

8. Rehabilitation and Regenerative Medicine State Variation in Stroke Discharge Destination (2002-2004) Bottom 10 IRF users (FFS Medicare) State Discharge Rank Discharge Rank Any IRF Rank to IRF to SNF Inpatient as a % 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

9. Rehabilitation and Regenerative Medicine How much is Postacute Care Use Affected by its Availability? Nationwide retrospective study of all Medicare patients with stroke, hip fracture or LE Joint replacements in 1999 Limited to administrative data set Clinical factors were important in whether IRF/SNF were utilized, but the selection of IRF vs. SNF was most strongly influenced by geographical proximity – both distance to nearest facility, and number of facilities in the area Buntin MB, Garten AD, Paddock S, Saliba D, Totten M, Escarce JJ. How much is Postacute care use affected by availability. Health Services Research 40:413-434, 2005.

10. Rehabilitation and Regenerative Medicine IRF vs. SNF care by Age (1999 Medicare FFS Data) 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

11. Rehabilitation and Regenerative Medicine The definitive answer: A Randomized Trial of IRF vs. SNF Most definitive answer to this question Randomize stroke patients (perhaps within a certain range of disability) to either SNF or IRF Ethical concerns Expensive Unclear who would fund Difficult to convince patients/families/clinicians

12. Rehabilitation and Regenerative Medicine Conclusions The selection of IRF vs. SNF is of substantial importance for stroke patients No clear standards exist to guide selection of post-acute rehabilitation. Non-clinical factors seem to play an important role in determining where patients get their rehab Cost pressures appear likely to drive more patients to SNF Observational studies are inherently limited in their ability to determine which is best, and who should go where Achieving consensus among rehabilitation clinicians would be an important first step.