Amid regulatory pressures to move closer to a one-size-fits-all payment system across postacute care settings, a massive new study sponsored by APTA and the American Occupational Therapy Association is calling for a more careful approach. The analysis of 1.4 million episodes of rehab in skilled nursing facilities, inpatient rehab facilities, and home health agencies found that while rehab is strongly associated with significant improvements in function no matter the postacute setting, actual patient needs demand care that’s more tailored to each setting. Bottom line: Rehab works best when it can be adapted to the care environment and individual patients.

What the Study Covered

The study, known as Therapy Outcomes in Post-Acute Care Settings, aka TOPS, used data from the U.S. Centers for Medicare & Medicaid Services related to 1.4 million Medicare cases involving patients who were hospitalized and later discharged to postacute care, or PAC, in an IRF, SNF, or via a home health agency.

Researchers tracked Medicare beneficiaries who entered their first PAC setting after hospital discharge between Jan. 1, 2015, and Dec. 31, 2016, recording hours of physical and occupational therapy received during their initial episode of care, as well as assessments of functional improvements (dressing, walking/locomotion, toileting, bathing, transferring, and feeding), and instances of rehospitalization within 30 days of acute care discharge. Researchers also collected demographic information and patient numbers related to three major diagnoses: stroke, congestive heart failure, and joint replacement. The prevalence of Alzheimer’s disease/dementia and depression was also included in the study.

The data used in the study had not been made available by CMS before — APTA and AOTA call TOPS a "first of its kind" analysis that has "implications for postacute payment system reforms and can serve as a baseline for future studies." Dobson DaVanzo and Associates was commissioned to conduct the research.

Study Participants

Among the patients included in the study, approximately 693,000 beneficiaries were discharged to SNFs, 552,000 to home health settings, and 197,000 to IRFs. Women outnumbered men in all three settings, comprising 62% of the study population overall, with 60% in home health, 65% in SNFs, and 57% in IRFs. In terms of age groups receiving therapy, the largest age group in home health was between 65 and 74 (35%), with SNFs tending to have more patients between 75 and 84 (35%), and IRFs skewing to the 85 and older cohort (38%). Participants were predominantly white (between 85% and 86% in each setting).

Findings

Results of the study, available in summary and chartbook form, led to three major findings: that PAC patients have distinct characteristics and complex comorbidities in each setting, that the intensity of physical therapy and occupational therapy services is associated with improved ability to do everyday activities, and that people who received the fewest minutes of therapy were at the highest risk for hospital readmission regardless of PAC setting.

Among the data supporting the findings:

• The prevalence of Alzheimer’s disease and other dementia varied among settings, with the SNF population highest, at 45%, followed by patients in IRFs (31%) and home health (20%).
• Four in 10 IRF patients were admitted to the ICU during their acute care stay, compared with 29% of patients in SNFs and 24% of patients receiving home health services.
• PAC settings also varied when it came to the presence of various diagnoses: People who had experienced stroke made up about half (48%) of the IRF population, compared with 32% and 20% in SNFs and home health, respectively. Home health was the most common setting for joint replacement recovery, at 59% of the population, compared with 33% in SNFs and 8% in IRFs. Congestive heart failure was associated with 48% of SNF patients and 45% of home health patients studies, but only 7% of IRF patients.
• On the six-element functional status assessment used in the study — dressing, walking/locomotion, toileting, bathing, transferring, and feeding — home health patients recorded the highest scores at admission, averaging 21 out of a possible 36. SNF patients averaged 14 points, and IRF patients averaged 11 points.
• The actual amount of therapy received varied both within and across settings, with home health patients receiving between fewer than 1.6 hours and up to 30 hours during their first episode of care. SNF patients ranged from a low of 6.3 hours or fewer to 219 hours; IRF patients received from 13 hours or fewer up to 85 or more hours.
• Researchers divided each setting’s therapy hours received into low, typical, and high-intensity groupings to track the relationship between therapy intensity and functional gains, and in each case, they found a strong connection between increased hours of therapy and improvements in function.

In home health, the average functional gain was 2.27 times higher for those in the high-intensity group compared with the low-intensity group. In both the SNF and IRF settings, the most dramatic improvement occurred between the low-intensity and typical-intensity groups, with improvements more or less the same between the typical and high-intensity groups.

For SNF patients, the average functional gain was 1.92 times higher for the typical intensity group compared with the low-intensity group. IRF patients in the typical intensity group registered functional improvements that were, on average, 1.47 times higher than the low-intensity group.

• Hospital readmissions were similarly positively affected by therapy intensity from low to typical, with home health dropping from 8.5% to 5.8%; SNFs falling from 26.30% to 17.70% (and 15.4% among the high-intensity group); and IRF moving from 29.8% in the low intensity group to 13.9% in the typical-intensity group.

Message to CMS: Take a Thoughtful Approach to any Payment Changes

APTA and AOTA believe the results of the study point to the need to be wary of payment changes that would gloss over the distinct rehab challenges presented by patients in each PAC setting. The considerations also need to be guided by another factor brought into clear focus in the TOPS study: Rehabilitative therapy works well in each setting.

"The findings of the TOPS study imply that CMS should move carefully and thoroughly when researching and developing a unified PAC prospective payment system, a system that may disadvantage patients with high rehabilitation needs," said APTA President Sharon Dunn, PT, PhD, in a joint statement from APTA and AOTA. "CMS must take care to monitor the level of therapy provided in PAC settings, in case new payment incentives inadvertently or negatively impact the therapeutic benefit provided to Medicare beneficiaries, or diminish the therapy services and approaches distinct to each PAC setting."

"The TOPS study provides clear evidence that occupational therapy and physical therapy services improve patient outcomes across all PAC settings," the organizations write in the study summary. "Findings consistently indicate a high potential for harm to patients who receive the fewest minutes of therapy. These findings highlight the importance of matching delivery of therapy services to patient needs."