Emergency department interventions that could be conducted in subacute care settings for patients with nonemergent conditions transported by paramedics: a modified Delphi study.

BACKGROUND: As the number of patients with nonemergent conditions who are transported by paramedics continues to increase in Ontario, redirecting specific patients to subacute settings may be more beneficial and suitable for both patients and emergency departments. We aimed to evaluate whether emergency department interventions conducted on patients with nonemergent conditions who are transported by paramedics could be conducted in subacute health centres. METHODS: We conducted a RAND/UCLA modified Delphi study in Ontario between Oct. 13 and Dec. 19, 2020. We used purposive sampling to recruit practising emergency and primary care physicians for an expert panel. We abstracted interventions given to adult patients with nonemergent conditions (18 yr of age or older) who were transported by paramedics to an emergency department from the National Ambulatory Care Reporting System (NACRS) database (Jan. 1, 2014, to Mar. 31, 2018). Participants in the expert panel rated the suitability of the 150 most frequently recorded emergency department interventions from the NACRS database, for completion in subacute health care centres. We set consensus at 70% agreement. RESULTS: We invited 25 physician experts, 21 of whom consented to participate; 20 physicians completed round 1, and 18 physicians completed both rounds. After 2 rounds, consensus was reached on 146 (97.3%) interventions; 103 interventions (68.7%) were suitable for subacute centres, 43 (28.7%) for only the emergency department and 4 (2.6%) did not receive consensus. For subacute centres, all 103 interventions were rated for urgent care centres; walk-in medical centres were applicable for 46 (30.6%) interventions and clinics led by nurse practitioners for 47 (31.3%) interventions. INTERPRETATION: Most interventions provided to patients with nonemergent conditions transported by paramedics to emergency departments were identified as suitable for urgent care clinics, with one-third being suitable for either walk-in medical centres or clinics led by nurse practitioners. This study has potential to inform a patient classification model for paramedic-initiated redirection of patients from emergency departments, although further contextualization is required for this to be implemented in clinical practice. STUDY REGISTRATION: ID ISRCTN22901977.

Linking AM-PAC Cognition to PROMIS Cognitive Function.

OBJECTIVE: To link the Activity Measure for Post-Acute Care (AM-PAC) Applied Cognition to the Patient-Reported Outcomes Measurement Information System (PROMIS) Cognitive Function, allowing for a common metric across scales. DESIGN: Cross-sectional survey study. SETTING: Outpatient rehabilitation clinics. PARTICIPANTS: Consecutive sample of 500 participants (N=500) aged ≥18 years presenting for outpatient therapy (physical, occupation, speech). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: AM-PAC Medicare and Generic Cognition short forms and PROMIS Cognitive Function items representing the PROMIS Cognitive Function item bank. RESULTS: The calibration of 25 AM-PAC cognition items with 11 fixed PROMIS cognitive function item parameters using item-response theory indicated that items were measuring the same underlying construct (cognition). Both scales measured a wide range of functioning. The AM-PAC Generic Cognitive assessment showed more reliability with lower levels of cognition, whereas the PROMIS Cognitive Function full-item bank was more reliable across a larger distribution of scores. Data were appropriate for a fixed-anchor item response theory-based crosswalk and AM-PAC Cognition raw scores were mapped onto the PROMIS metric. CONCLUSIONS: The crosswalk developed in this study allows for converting scores from the AM-PAC Applied Cognition to the PROMIS Cognitive Function scale.

Mixed-Methods Approach to Understanding Determinants of Practice Change in Skilled Nursing Facility Rehabilitation: Adapting to and Sustaining Value With Postacute Reform.

BACKGROUND AND PURPOSE: Postacute care reform is driving physical and occupational therapists in skilled nursing facilities (SNFs) to change how they deliver care to produce better outcomes in less time. However, gaps exist in understanding determinants of practice change, which limits translation of evidence into practice. This study explored what determinants impacted change in care delivery at 2 SNFs that implemented a high-intensity resistance training intervention. METHODS: We used a mixed-methods, sequential explanatory design to explain quantitative findings using qualitative methods with a multiple-case study approach. Quantitative data were collected on therapists' attitudes toward evidence-based practice and aspects of intervention implementation. We conducted focus groups with therapists (N = 15) at 2 SNFs, classified as either high- (SNF-H) or low-performing (SNF-L) based on implementation fidelity and sustainability. RESULTS AND DISCUSSION: Determinants of SNF rehabilitation practice change included the organizational system, team dynamics, patient and therapist self-efficacy, perceptions of intervention effectiveness, and ability to overcome preconceived notions. A patient-centered system, positive team dynamics, and ability to overcome preconceived notions fostered practice change at SNF-H. While self-efficacy and perception of effectiveness positively impacted change in practice at both SNFs, these determinants were not enough to overcome challenges at SNF-L. To adapt to changes and sustain rehabilitation value, further research must identify the combination of determinants that promote application of evidence-based practice. CONCLUSIONS: This study is the first step in understanding what drives change in SNF rehabilitation practice. As SNF rehabilitation continues to face changes in health care delivery and reimbursement, therapists will need to adapt, by changing practice patterns and adopting evidence-based approaches, to demonstrate value in postacute care.

Implications and Experiences in Postacute Care-Rehabilitation, Long-Term Acute Care, and Skilled Nursing.

Postacute care is a term used to describe a group of health care providers, caring for patients outside of traditional acute care. The populations served and measures of outcomes are similar, but the services provided may vary by type of setting and individual provider. Managing through the coronavirus disease-2019 (COVID-19) pandemic has been both a challenge and an opportunity to demonstrate the vital role of postacute providers in the health care continuum. National media outlets have highlighted emergency departments, critical care areas, and start-up COVID units in acute care hospitals treating critically ill patients battling COVID-19. Stories of nursing homes in crisis over the rapid spread of COVID-19 have saddened readers of newspapers and social media alike. Postacute providers have experienced the pandemic alongside the acute care hospitals in ways that have highlighted the flexibility of postacute care, challenged leaders to lead with intensity, and demonstrated their importance in the continuum of care. Through a series of interviews with postacute care leaders, this article explores the response to the pandemic from the perspective of providers in postacute care settings.

Patients discharged from higher-quality skilled nursing facilities spend more days at home.

OBJECTIVE: To evaluate the association of skilled nursing facility (SNF) quality with days spent alive in nonmedical settings ("home time") after SNF discharge to the community. DATA SOURCES: Secondary data are from Medicare claims for New York State (NYS) Medicare beneficiaries, the Area Health Resources File, and Nursing Home Compare. STUDY DESIGN: We estimate home time in the 30- and 90-day periods following SNF discharge. Two-part zero-inflated negative binomial regression models characterize the association of SNF quality with home time. DATA EXTRACTION METHODS: We use Medicare claims data to identify 25 357 NYS fee-for-service Medicare beneficiaries aged 65 years and older with an SNF admission for postacute care who were subsequently discharged to home in 2014. PRINCIPAL FINDINGS: Following 30 and 90 days after SNF discharge, the average home time is 28.0 (SD = 6.1) and 81.6 (SD = 20.2) days, respectively. A number of patient- and SNF-level factors are associated with home time. In particular, within 30 and 90 days of discharge, respectively, patients discharged from 2- to 5-star SNFs spend 1.2-1.5 (P < .001) and 3.2-4.3 (P < .001) more days at home than those discharged from 1-star (lowest quality) SNFs. CONCLUSIONS: Improved understanding of what is contributing to differences in home time could help guide efforts into optimizing post-SNF discharge outcomes.

Rapid Telehealth-Centered Response to COVID-19 Outbreaks in Postacute and Long-Term Care Facilities.

Purpose: The vulnerability of postacute and long-term care (PA/LTC) facility residents to COVID-19 has manifested across the world with increasing facility outbreaks associated with high hospitalization and mortality rates. Systematic protocols to guide telehealth-centered interventions in response to COVID-19 outbreaks have yet to be delineated. This article is intended to inform PA/LTC facilities and neighboring health care partners how to collaboratively utilize telehealth-centered strategies to improve outcomes in facility outbreaks. Methods: The University of Virginia rapidly developed a multidisciplinary telehealth-centered COVID-19 facility outbreak strategy in response to a LTC facility outbreak in which 41 (out of 48) facility residents and 7 staff members tested positive. This strategy focused on supporting the facility team remotely using rapidly deployed technologic solutions. Goals included (1) early identification of patients who need their care escalated, (2) monitoring and treating patients deemed safe to remain in the facility, (3) care coordination to facilitate bidirectional transfers between the skilled nursing facility (SNF) and hospital, and (4) daily facility needs assessment related to technology, infection control, and staff well-being. To achieve these goals, a standardized approach centered on daily multidisciplinary virtual rounds and telemedicine consultation was provided. Results: Over a month since the outbreak began, 18 out of 48 (38%) facility residents required hospitalization and 6 (12.5%) died. Eleven facility residents have since returned back to the SNF after recovering from their hospitalization. No staff required hospitalization. Conclusions: Interventions that reduce hospitalizations and mortality are a critical need during the COVID-19 pandemic. The mortality and hospitalization rates seen in this PA/LTC facility outbreak are significantly lower than has been documented in other facility outbreaks. Our multidisciplinary approach centered on telemedicine should be considered as other PA/LTC facilities partner with neighboring health care systems in responding to COVID-19 outbreaks. We have begun replicating these services to additional PA/LTC facilities facing COVID-19 outbreaks.

[Post-acute and rehabilitation care in young patients with multiple comorbidities: An observational study]. / Soins de suite et réadaptation (SSR) de Médecine Interne pour sujets jeunes polypathologiques : étude observationnelle d'une structure pilote.

INTRODUCTION: A unique structure devoted to post-acute and rehabilitation care for patients under 75 with multiple comorbidities has been created within the Department of Internal Medicine, Bichat Hospital, Paris. We aim to report on demographic factors, clinical characteristics and outcomes of patients hospitalized in this pilot structure. METHODS: All consecutive adult patients admitted between May 2017 and May 2018 were retrospectively reviewed. RESULTS: Analysis was performed on 61 (61 [24-75] years-old) admitted patients. The median length of hospital stays was 108 [13-974] days. At admission, the median Charlson comorbidity index was 6 [0-12] predicting a 10-year survival of 21 [0-99]%. Most patients were unemployed (83.6%) and had very low-income (< national minimum wage in 65.6% of cases). At hospital discharge, most patients (85.4%) were able to return home. The complete resolution of health problems occurred in most cases (65.6%) and was associated with a lower probability of both hospital readmission and death 1-year after discharge. CONCLUSION: The structure served a high percentage of patients with major and complex health needs but limited access to care due to individual disabilities, low-income and underinsured status. However, despite major health disorders, functional limitations, and vulnerability, admission improved patient outcomes and reduced excess hospital readmissions in most cases.

Solving the COVID-19 Crisis in Post-Acute and Long-Term Care.

Our nation's nursing home industry has been in need of overhaul for decades-a situation made all the more evident by COVID-19. AMDA-The Society for Post-Acute and Long-Term Care Medicine is dedicated to quality in post-acute and long-term care process and outcomes. This special article presents 5 keys to solving the COVID-19 crisis in post-acute and long-term care, related to policy, collaboration, individualization, leadership, and reorganization. Taking action during this crisis may prevent sinking back into the complacency and habits of our pre-COVID-19 lives.

Policy Recommendations Regarding Skilled Nursing Facility Management of Coronavirus 19 (COVID-19): Lessons from New York State.

To provide policy recommendations for managing Coronavirus 19 (COVID-19) in skilled nursing facilities, a group of certified medical directors from several facilities in New York state with experience managing the disease used e-mail, phone, and video conferencing to develop consensus recommendations. The resulting document provides recommendations on screening, protection of staff, screening of residents, management of Coronavirus 19 positive and presumed positive cases, communication during an outbreak, management of admissions and readmissions, and providing emotional support for staff. These consensus guidelines have been endorsed by the Executive Board of the New York Medical Directors Association and the Board of the Metropolitan Area Geriatrics Society.

How a Barcelona Post-Acute Facility became a Referral Center for Comprehensive Management of Subacute Patients With COVID-19.

The COVID-19 pandemic's greatest impact is among older adults. Management of the situation requires a systemic response, and post-acute care (PAC) can provide an adequate mix of active treatment, management of associated geriatric syndromes and palliative care, both in the acute phase, and in post-COVID-19 recovery. In the region of Catalonia, Spain, selected PAC centers have become sites to treat older patients with COVID-19. Referrals come from the emergency department or COVID-19 wards of the acute reference hospitals, nursing homes, or private homes. We critically review the actions taken by Parc Sanitari Pere Virgili, a PAC facility in Barcelona, to manage the pandemic, including its administration, health care, communication, psychological support, and ethical frameworks. We believe that the strategies we used and the lessons we learned can be useful for other sites and countries where similar adaptation of existing facilities may be implemented.

The War on COVID-19 Pandemic: Role of Rehabilitation Professionals and Hospitals.

The global outbreak of coronavirus disease 2019 has created an unprecedented challenge to the society. Currently, the United States stands as the most affected country, and the entire healthcare system is affected, from emergency department, intensive care unit, postacute care, outpatient, to home care. Considering the debility, neurological, pulmonary, neuromuscular, and cognitive complications, rehabilitation professionals can play an important role in the recovery process for individuals with coronavirus disease 2019. Clinicians across the nation's rehabilitation system have already begun working to initiate intensive care unit-based rehabilitation care and develop programs, settings, and specialized care to meet the short- and long-term needs of these individuals. We describe the anticipated rehabilitation demands and the strategies to meet the needs of this population. The complications from coronavirus disease 2019 can be reduced by (1) delivering interdisciplinary rehabilitation that is initiated early and continued throughout the acute hospital stay, (2) providing patient/family education for self-care after discharge from inpatient rehabilitation at either acute or subacute settings, and (3) continuing rehabilitation care in the outpatient setting and at home through ongoing therapy either in-person or via telehealth.

Are Stroke Survivors Discharged to the Recommended Postacute Setting?

OBJECTIVE: To examine the processes and barriers involved in providing postdischarge stroke care. DESIGN: Prospective study of discharge planners' (DP) and physical therapists' (PT) interpretation of factors contributing to patients' discharge destination. SETTING: Twenty-three hospitals in the northeastern United States. PARTICIPANTS: After exclusions, data on patients (N=427) hospitalized with a primary diagnosis of stroke between May 2015 and November 2016 were examined. Of the patients, 45% were women, and the median age was 71 years. DPs and PTs caring for these patients were queried regarding the selection of discharge destination. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Comparison of actual discharge destination for stroke patients with the destinations recommended by their DPs and PTs. RESULTS: In total, 184 patients (43.1%) were discharged home, 146 (34.2%) to an inpatient rehabilitation facility, 94 (22.0%) to a skilled nursing facility, and 3 (0.7%) to a long-term acute care hospital. DPs and PTs agreed on the recommended discharge destination in 355 (83.1%) cases. The actual discharge destination matched the DP and PT recommended discharge destination in 92.5% of these cases. In 23 cases (6.5%), the patient was discharged to a less intensive setting than recommended by both respondents. In 4 cases (1.1%), the patient was discharged to a more intensive level of care. In 2 cases (0.6%), the patient was discharged to a long-term acute care hospital rather than an inpatient rehabilitation facility as recommended. Patient or family preference was cited by at least 1 respondent for the discrepancy in discharge destination for 13 patients (3.1%); insurance barriers were cited for 9 patients (2.3%). CONCLUSIONS: Most stroke survivors in the northeast United States are discharged to the recommended postacute care destination based on the consensus of DP and PT opinions. Further research is needed to guide postacute care service selection.

Beneficios de una unidad de mediana estancia en la rehabilitación de adultos mayores dependientes / Benefits of a subacute care unit in the rehabilitation of frail dependent older adults

Las Unidades de Mediana Estancia (UME) se definen como un recurso institucional con camas de hospitalización para pacientes ancianos, en donde ‒una vez superada la fase aguda de la enfermedad‒ sea posible efectuar un tratamiento a medio plazo, con recursos rehabilitadores, atención médica y cuidados de enfermería, todo ello con el propósito de conseguir la recuperación funcional y la reinserción en la comunidad. El objetivo de este trabajo fue efectuar un estudio cuasi experimental con propio individuo control antes-después con el fin de describir las características basales de los pacientes ingresados en la UME con objetivos de rehabilitación, así como su ganancia funcional luego de la intervención, medida como la diferencia entre el índice de Barthel al alta (valor final) y al ingreso en la UME (valor basal). Para ello se incluyeron 122 personas y se obtuvo como principal resultado una ganancia funcional positiva de 40 puntos y un parámetro de eficacia (ganancia funcional/días de internación) de 1,18. Los resultados obtenidos se consideran, de acuerdo con la literatura, como efectivos y eficaces. (AU)

Subacute Care Units are defined as an institutional resource with hospital beds where once a patient overcomes the acute phase of a disease, it is possible for him to undergo a rehabilitation treatment with the objective of achieving functional recovery and reintegration into the community. The purpose of this paper was to carry out a quasi-experimental before and after study where the subjects serve as their own controls, in order to describe the baseline characteristics of the patients admitted to the subacute care unit with rehabilitation objectives, as well as their functional gain after the intervention, measured as the difference between the Barthel index at discharge (final value) and admission to the EMU (baseline value). For this, 122 people were included, obtaining as main results a positive functional gain of 40 points (p <0.001) and an efficiency parameter (functional gain / days of hospitalization) of 1.18, considering the results obtained according to the literature as effective and efficient. (AU)