1. Evaluating IMPACT (Level 5 – Evaluating)

As patients continue their recovery, post-acute care (PAC)safely transitions them out of the acute-care hospital. There arefour PAC settings: skilled nursing facilities (SNF), long-term carehospitals (LTCHs), inpatient rehabilitation facilities (IRFs), homehealth agencies (HHAs).

Patients in these settings have similar conditions, such asstrokes and hip replacements. However, Medicare pays differentprices depending upon the setting (Medicare Payment AdvisoryCommission 2014, 171). For a patient’s continued recovery andoptimal outcome, does the choice of PAC setting matter? Two sets ofresearchers investigated this question. One set investigated thefunctional recovery for patients who had had a stroke (Chan et al.2013).   Another set investigated the functional recoveryfor patients who had had a hip fracture repaired (Mallinson et al.2014).

Chan and colleagues performed a long-term study on 222 patientswho had had a stroke. The patients had received care from fourdifferent acute care hospitals in one integrated delivery system(IDS). The patients also received their postacute care fromsettings in the IDS. The IDS offered three types of PAC settings:SNF, IRF, and HHA. In addition, patients could receive out-patientcare in the IDS. The researchers used a standardized instrument,the Activity Measure for Post Acute Care (AM-PAC), to determine thepatients’ functional status. The researchers scored the patientsfunctional status twice: first immediately upon discharge from theacute care hospital and second six months after discharge and afterreceiving postacute care. The researchers’ results showed:

• Patients who received their postacute care in an IRF had atleast eight-point higher improvements in mobility, self-care, andcognition, than patients who received their postacute care in aSNF.
• Patients who received their postacute care in an IRF also hadstatistically significant improvements in Applied Cognitioncompared to those patients who only received home health combinedwith outpatient services.

Chan and colleagues concluded that “patients with a stroke maymake more functional gains if they receive some of their postacutecare in an IRF compared to other sites” (Chan et al. 2013, 629).Deutsch’s commentary on the research of Chan and colleagues notedthat comparing outcomes across postacute care is difficult becausethe PAC sites use different data sets (2013, 631-632).

           Mallinson and colleagues investigated the outcomes of patientsafter hip fracture repair. Facilities from three types of PACsettings participated in the research. Eventually, the researchersreviewed the care of 181 patients at 18 PAC providers. These PACproviders were four IRFs, six SNFs, and eight HHAs. After beingtrained on the data collection instrument, nurses at each sitecollected data using the IF functional independence measure (FIM).The researchers’ results showed, controlling for patients’characteristics, severity, comorbidities, and services:

• IRF and HHA patients had lower self-care function at dischargerelative to SNF patients
• HHA patients had, on average, a two-week longer length of staythan SNF patients
• SNF patients had, on average, a nine-day longer length of stayand IRF patients

Mallinson and colleagues concluded that outcomes varied amongsettings “depending upon whether self-care or mobility was theoutcome of focus” (Mallinson et al. 2014, 209).

DeJong’s commentary on the research of Mallinson and colleaguesnoted that the absence of a common PAC patient assessmentinstrument requires workarounds (2014). Researchers can use asite-neutral instrument, such as the AM-PAC or they can use anexisting PAC-site-specific instrument. Both workarounds requiretraining on the instrument for all or some of the data collectorsand require special data collection outside of routineprocedures.

Questions

1.  List the data collectioninstrument for PAC settings discussed in the case

2.   What PAC setting ismissing from the previously described research investigations? Whatis that setting’s data collection instrument?

3.   Both Deutsch and DeJongnote problems caused by the lack of a common data set across PACsettings. How has Congress addressed this problem?

4.   Workarounds requirespecial training and special data collection outside routineprocedures. Why are these workarounds a problem for researchers?Does Congress’ solution address this problem?

5.   How could you or yourfamily benefit from a common data collection instrument across PACsettings?