Functional Status Across Post-Acute Settings is Associated With 30-Day and 90-Day Hospital Readmissions.

OBJECTIVE: To examine the association between cocalibrated functional scores across post-acute care settings and the subsequent risk of hospital readmission. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: We analyzed 781,021 fee-for-service Medicare beneficiaries discharged to either inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), or home health agencies (HHA) after an acute hospital stay for stroke (N = 143,277), lower extremity joint replacements (512,577), and hip/femur fracture (125,167) between January 1, 2013, and August 31, 2014. MEASURES: Functional items from IRF-PAI, MDS, and OASIS were categorized into self-care and mobility domains. We cocalibrated admission functional scores across post-acute settings and divided scores into 4 functional levels using quartiles (Q1-Q4, with Q4 representing the most independent function). The primary outcomes were 30-day and 90-day hospital readmissions (yes/no) after an initial post-acute stay. RESULTS: Patients who were more dependent in self-care and mobility at the initial post-acute setting were significantly more likely to experience hospital readmission [eg, hazard ratios of 30-day readmission in stroke: 1.54 (95% confidence interval [CI] 1.47-1.61), 1.18 (95% CI 1.14-1.23), and 1.12 (95% CI 1.08-1.16) for Q1, Q2 and Q3, compared to Q4]. We found similar results for risk of 90-day hospital readmission across impairment conditions. CONCLUSIONS AND IMPLICATIONS: Patients who were more functionally dependent at the initial post-acute setting had a higher risk to readmit to the hospitals after discharging from the post-acute setting for 30 and 90 days, compared with patients who were more functionally independent. This finding is consistent across impairment conditions and post-acute settings. Future research should determine effective strategies of maintaining and facilitating functional performance across post-acute settings to optimize long-term patient outcomes.

Association of Occupational and Physical Therapy With Duration of Prescription Opioid Use After Hip or Knee Arthroplasty: A Retrospective Cohort Study of Medicare Enrollees.

OBJECTIVE: To establish whether nonpharmacologic interventions, such as occupational and physical therapy, were associated with a shorter duration of prescription opioid use after hip or knee arthroplasty. DESIGN: This retrospective cohort study used data from a national 5% Medicare sample database between January 1, 2010 and December 31, 2015. SETTING: Home health or outpatient. PARTICIPANTS: Adults 66 years or older with an inpatient total hip (n=4272) or knee (n=9796) arthroplasty (N=14,068). INTERVENTIONS: We dichotomized patients according to whether they had received any nonpharmacologic pain intervention within 1 year after hospital discharge (eg, occupational or physical therapy evaluation). Using Cox proportional hazards, we treated exposure to nonpharmacologic interventions as time dependent to determine if skilled therapy was associated with duration of opioid use. MAIN OUTCOME MEASURES: Duration of prescription opioid use. RESULTS: Median time to begin nonpharmacologic interventions was 91 days (95% confidence interval [CI], 74-118d) for hip and 27 days (95% CI, 27-28d) for knee arthroplasty. Median time to discontinue prescription opioids was 16 days (hip: 95% CI, 15-16d) and 30 days (knee: 95% CI, 29-31d). Nonpharmacologic interventions delivered with home health increased the likelihood of discontinuing opioids after hip (hazard ratio [HR], 1.15; 95% CI, 1.01-1.30) and knee (HR, 1.10; 95% CI, 1.03-1.17) arthroplasty. A sensitivity analysis found these estimates to be robust and conservative. CONCLUSIONS: Occupational and physical therapy with home health was associated with a shorter duration of prescription opioid use after hip and knee arthroplasty. Occupational and physical therapy can address pain and sociobehavioral factors associated with postsurgical opioid use.

Association of Social Behaviors With Community Discharge in Patients with Total Hip and Knee Replacement.

OBJECTIVES: Understand the association between social determinants of health and community discharge after elective total joint arthroplasty. DESIGN: Retrospective cohort design using Optum de-identified electronic health record dataset. SETTING AND PARTICIPANTS: A total of 38 hospital networks and 18 non-network hospitals in the United States; 79,725 patients with total hip arthroplasty and 136,070 patients with total knee arthroplasty between 2011 and 2018. METHODS: Logistic regression models were used to examine the association among pain, weight status, smoking status, alcohol use, substance disorder, and postsurgical community discharge, adjusted for patient demographics. RESULTS: Mean ages for patients with hip and knee arthroplasty were 64.5 (SD 11.3) and 65.9 (SD 9.6) years; most patients were women (53.6%, 60.2%), respectively. The unadjusted community discharge rate was 82.8% after hip and 81.1% after knee arthroplasty. After adjusting for demographics, clinical factors, and behavioral factors, we found obesity [hip: odds ratio (OR) 0.81, 95% confidence interval (CI) 0.76-0.85; knee: OR 0.73, 95% CI 0.69-0.77], current smoking (hip: OR 0.82, 95% CI 0.77-0.88; knee: OR 0.90, 95% CI 0.85-0.95), and history of substance use disorder (hip: OR 0.55, 95% CI 0.50-0.60; knee: OR 0.57, 95% CI 0.53-0.62) were associated with lower odds of community discharge after hip and knee arthroplasty, respectively. CONCLUSIONS AND IMPLICATIONS: Social determinants of health are associated with odds of community discharge after total hip and knee joint arthroplasty. Our findings demonstrate the value of using electronic health record data to analyze more granular patient factors associated with patient discharge location after total joint arthroplasty. Although bundled payment is increasing community discharge rates, post-acute care facilities must be prepared to manage more complex patients because odds of community discharge are diminished in those who are obese, smoking, or have a history of substance use disorder.

Policy and Payment Changes Create New Opportunities for Occupational Therapy in Acute Care.

IMPORTANCE: Changes in health care policy and payment over the past decade have resulted in a greater emphasis on cost effectiveness, quality outcomes, and the health care consumer's experience. Payers' response to the new policies and their expectations have created expanded opportunities for occupational therapy practitioners in health care overall but particularly in acute care hospitals. OBJECTIVE: The objective of this article is to empower occupational therapy directors, practitioners, educators, and students to be proactive in a rapidly changing acute care setting. EVIDENCE REVIEW: Research on policy and payment changes since the passage of the Patient Protection and Affordable Care Act (Pub. L. 111-148) was synthesized with evidence related to occupational therapy practice and education. FINDINGS: Occupational therapy practitioners in acute care environments are experiencing expanded roles in optimizing patient readiness for safe community discharge, decreasing lengths of stay, and protecting them from hospital-acquired conditions. CONCLUSIONS AND RELEVANCE: Policy and payment initiatives reward health care organizations for the added value occupational therapy practitioners bring to acute care teams. WHAT THIS ARTICLE ADDS: This article details how occupational therapy practitioners can advance consumer satisfaction, outcomes, and efficiency in acute care, which can lead to increased recognition of the vital role that occupational therapy can play, thus leading to expanded opportunities.