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 SNF Rehabilitation In The Limelight

 

 

​Skilled Nursing Facilities (SNFs) provide more rehabilitation to elders than any other post-acute care setting. With Medicare SNF stays numbering over 2 million a year (not counting those provided in Medicare Advantage plans), the majority of which involve some amount of rehabilitation services, it is about time we started to focus on SNF rehabilitation quality. And the Centers for Medicare & Medicaid Services (CMS) measures in Nursing Home Compare will do just that with the addition of “Percentage of Short-stay Residents Who Were Successfully Discharged to Community” and “Percentage of Short-stay Residents Who Made Improvements in Function.”

Based on two decades of national studies of rehabilitation in SNFs for elderly Medicare beneficiaries in fee-for-service and managed care organizations, the time has arrived for evaluating rehabilitation on outcomes. I’ve participated in numerous studies that investigated SNF outcomes, including both community discharge and functional improvement, for stroke, hip fracture, and medical/surgical diagnoses. Beginning in 2007, the Medicare Payment Advisory Commission initiated research programs to develop methods for reporting national risk-adjusted rates of community discharge, and more recently Minimum Data Set-based functional outcomes and improvement.

The community discharge measures developed in these programs are similar to the recent CMS community discharge measure, in which a readmission within 30 days of community discharge renders the discharge “unsuccessful,” and it is not counted in the rate. Exclusions and risk adjustment methods differ to some extent among the methods, leading to somewhat different average rates. The CMS average risk-adjusted community discharge was 54 percent in its most recently reported Nursing Home Compare result. A methodology that incorporates exclusions based on whether a care transition succeeds or fails is consistent with other CMS value-based initiatives. It puts much more emphasis on the quality of discharge decisions and post-discharge follow-up.

CMS’ functional improvement measure uses self-performance in three activities of daily living (ADLs) from the MDS: transfer, locomotion on unit, and locomotion in corridor. Other researchers study self-performance in bed mobility, transfer, and ambulation in an effort to cover the range of mobility impairments that are prevalent in SNFs. Investigations have also included rates of no decline in these mobility ADLs, recognizing that many short-stay residents are on a somewhat downward trajectory by the time they are admitted to a SNF, where significant improvement is not predicted.

The existing body of research indicates that rehabilitation outcomes are not driven entirely by resident characteristics and the available discharge options. Strong relationships between the rate of community discharge and therapy, nurse hours per resident day, and after-risk adjustment for resident characteristics and geography have been demonstrated. Similarly, both mobility improvement and no decline were associated with therapy levels and certified nurse assistant hours per resident day.

So, let’s applaud the addition of these measures. They highlight positive outcomes of SNF care, a nice balance for prevention measures such as those that focus on adverse events and readmission. And perhaps most importantly, attention will shift to looking for new ways to improve rehabilitation outcomes and care transition success. 
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