Appropriate Patient Placement 2. IRF versus SNF. After applying propensity score weights, most demographics and comorbidities were balanced between IRF and SNF (49 of 52 variables [94.2%]) (eTable 4 and eTable 5 in the Supplement). The race/ethnicity variable was defined by the CMS and was included because some outcomes differ among racial/ethnic groups.18 The 30 most frequent CMS Hierarchical Condition Categories for comorbidities were identified through diagnoses on the inpatient claims from the previous year and the secondary diagnoses during the index stroke hospitalization (eTable 4 and eTable 5 in the Supplement).19 In addition, we added 6 diagnoses related to cognitive function (eTable 6 in the Supplement). Stays in skilled nursing facilities (SNFs) are also common.  RC.  et al. Author Contributions: Dr Ottenbacher had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.  Comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after hip fracture repair.Â, Buntin She was not compensated for her contribution. To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF). 0000002254 00000 n  D, Dalton  Equating activities of daily living outcome measures: the Functional Independence Measure and the Korean version of Modified Barthel Index.Â, Eicheldinger 0000070603 00000 n  NB, Qi Comparing “Apples to Oranges” is a long-standing concern in studies of functional outcomes involving IRFs and SNFs. Compared with patients admitted to IRFs, patients admitted to SNFs were older (mean [SD] age, 79.4 [7.6] years vs 83.3 [7.8] years; P < .001) and had longer hospital length of stay (mean [SD], 4.6 [3.0] days vs 5.9 [4.2] days; P < .001) than those admitted to IRFs. Q: What do the DTC-PAC measures assess? We also found differences in functional outcomes between IRF and SNF using logistic regression and propensity scores.  30- to 365-d Mortality From Hospital Discharge Between IRFs and SNFs. Dr Ottenbacher reported receiving grants from the NIH during the conduct of the study and personal fees from the Kessler Foundation outside the submitted work. Postacute care reform based on the IMPACT Act3 must avoid a payment system that shifts patients with stroke who could benefit from intensive inpatient rehabilitation to lower cost settings.  GM, Brock Patient characteristics included age at admission to IRF or SNF (ie, 66-69, 70-74, 75-79, 80-84, or ≥85 years), sex, race/ethnicity (ie, non-Hispanic white, non-Hispanic black, Hispanic, or other), length of stay (LOS) in acute care (ie, 1-3, 4-7, 8-11, 12-25, or ≥26 days), Medicaid eligibility, type of stroke (ischemic or hemorrhagic) and any stay in intensive care. Inpatient Rehabilitation Unit (IRU) vs Skilled Nursing Facility (SNF) Patients have various options to meet their rehabilitation needs, however it is essential that they be educated on the differences in those options.  JA.  J.  Selection of Postacute stroke rehabilitation facilities: a survey of discharge planners from the northeast cerebrovascular consortium (NECC) region.Â, Bettger 0000006429 00000 n  YC, Joseph Changes in mobility and self-care measures during an IRF or SNF stay were compared using multivariate analyses, inverse probability weighting with propensity score, and instrumental variable analyses. 0000009025 00000 n 0000042411 00000 n 0000007540 00000 n  YF, Duan 0000004856 00000 n  M, Ulbricht  YF, Townsend Accepted for Publication: October 9, 2019. A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001). In this cohort study of a large national sample, inpatient rehabilitation in IRFs for patients with stroke was associated with substantially improved physical mobility and self-care function compared with rehabilitation in SNFs.  Using propensity scores to help design observational studies: application to the tobacco litigation.Â, Hausman 0000009636 00000 n This cohort study included patients with stroke who were discharged from acute care hospitals to IRF or SNF from January 1, 2013, to November 30, 2014. The multivariable approach used ordinary least squares, adjusting for covariates.  Association between cholecystectomy with vs without intraoperative cholangiography and risk of common duct injury.Â, Stukel 0000039541 00000 n 0000070242 00000 n  AA, Cloft Additionally, patients in IRF compared with those in SNF had larger improvements for mobility score (11.6 [95% CI, 11.5-11.7] points vs 3.5 [95% CI, 3.4-3.6] points) and for self-care score (13.6 [95% CI, 13.5-13.7] points vs 3.2 [95% CI, 3.1-3.3] points).  Poststroke rehabilitation: outcomes and reimbursement of inpatient rehabilitation facilities and subacute rehabilitation programs.Â, Mallinson The researchers found that IRF patients had better clinical outcomes than patients treated in SNFs on five of six measures.  AM. Definitions of Skilled and IRF Care Definition of Definition of the Skilled Rehabilitation Care Nursing Care: The Inpatient Rehabilitation Facility (IRF) provides The SNF provides services to an inpatient intermittent and/or daily who needs a relatively skilled care services. 0000025538 00000 n These resources will help determine what is best for you or your loved one. • IRF patients experienced an 8 percentage point lower mortality rate during the two-year study period than SNF patients (p<0.0001) • IRF patients experienced 5 percent fewer emergency room (ER) visits per year than SNF patients (p<0.0001) • For five of the 13 conditions, IRF patients … 0000053855 00000 n 0000052989 00000 n Discharge to home, a skilled nursing facility (SNF), or an inpatient rehabilitation facility (IRF) was the primary outcome. 2019;2(12):e1916646. <<27EF291824D86C4395D1B75C06CED14C>]/Prev 95442/XRefStm 2254>> It is not possible to directly measure the size of the population of marginal patients.  RP, Garber  L, Liang 0000050089 00000 n 0000018293 00000 n  Factors influencing selection for rehabilitation after stroke: a questionnaire using case scenarios to investigate physician perspectives and level of agreement.Â, Xian  CM, Lapane  DJ, Vermeulen Acute Rehab vs. SNF. 0000070681 00000 n If any covariates in the propensity score model were not balanced, we additionally controlled for those covariates in the outcome models. The assumption is that the underlying health of patients with stroke would vary somewhat among HRRs, but not markedly, and that the variation reflects local availability of the 2 types of facilities along with other medical cultural issues. 0 %%EOF  DB. Maximal assistance requires another person to physically assist the patient.  MJ. The Inpatient Rehabilitation Facility-Patient Assessment Instrument includes 5 mobility items and 6 self-care items, with a 7-point rating scale. IRF vs SNF coding are different, and yes, some invasive procedures should be captured on the IRF side as long as the patient’s head is back in the bed the same day before midnight. A total of 99 185 patients with stroke from 3405 hospitals were included in the study, including 66 082 patients (66.6%) who received stroke rehabilitation in an IRF and 33 103 patients (33.4%) who received stroke rehabilitation in an SNF. The control outcome should be strongly related to the underlying health of the patients but only minimally influenced by residence in an IRF vs SNF.  Medicare spending and outcomes after postacute care for stroke and hip fracture.Â, Ottenbacher Study Flow Diagram for the Sample, eTable 1. Medicare claims were used to link to IRF and SNF assessments. 0000053395 00000 n  C, Bonito The CMS 60% rule identifies 13 diagnostic conditions that classify a facility as an IRF for Medicare reimbursement.35 Stroke is the largest category of these conditions, with 20.5% of all patients in IRFs in 2017.6. Our data included Medicare files from 2012 to 2014.  L, Liang  TJ, Ding  P.  Predicting discharge destination after stroke: a systematic review.Â, Werner To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF). This cohort study included patients with stroke who were discharged from acute care hospitals to IRF or SNF from January 1, 2013, to November 30, 2014. Ickpyo Hong, PhD, OTR, and Kenneth J. Ottenbacher, PhD, OTR. 0000039660 00000 n Objective  The next chart provides an explanation of acute vs. sub-acute rehabilitation services. Stroke Comorbidities Across Inpatient Rehabilitation Facilities (IRFs) and Skilled Nursing Facilities (SNFs) Before and After Inverse Probability of Treatment Weighting, eTable 6.  J, Raji  The reliability of the functional independence measure: a quantitative review.Â.  Z, Sicklick  W, Rabinstein  JP, Stein Whether you are transferred to an IRF or a skilled nursing facility is an important distinction because Medicare covers a different number of days for an IRF than it does for skilled nursing, and you pay a different co-payment. The differences between SNF and IRF in odds of 30- to 365-day mortality (unadjusted odds ratio, 0.48 [95% CI, 0.46-0.49]) were reduced but not eliminated in multivariable analysis (adjusted odds ratio, 0.72 [95% CI, 0.69-0.74]) and propensity score analysis (adjusted odds ratio, 0.75 [95% CI, 0.72-0.77]). 0000070360 00000 n Skilled Nursing Facility (SNF) IRFs SNFs Physician approval of preadmission screen and admission Yes No Patient requires resource-intensive inpatient care Yes No Close medical supervision by a physician with specialized training Yes No Inpatient Rehab Facility (IRF) vs.  L,  SJ.  J, Yperzeele Our findings are similar to what Buntin et al36 estimated as the percentage of patients with marginal stroke and hip fracture. © 2020 American Medical Association. Additional research is necessary to confirm our findings and to identify whether any of the other 13 conditions identified by CMS as priority diagnoses for receiving services in IRFs (the 60% rule) may also show differences in functional outcomes based on treatment in IRFs vs SNFs. We were not able to examine cognitive function before and after the stroke, stroke severity, or location of the stroke. We used several analytic approaches to control for potential confounders across IRF and SNF settings, including multivariable analysis, inverse probability weighting with propensity scores and instrumental variable analyses. In this study, we used all-cause mortality between 30 and 365 days after hospital discharge as a control outcome.  L, Velozo  AW, For mobility, the change was 11.6 (95% CI, 11.5-11.7) points for patients in IRFs vs 3.5 (95% CI, 3.4-3.6) points for those in SNFs. Concept and design: Goodwin, Reistetter, Kuo, Karmarkar, Ottenbacher. 0000049525 00000 n 0000032977 00000 n endstream endobj 305 0 obj <>/Metadata 24 0 R/Pages 23 0 R/StructTreeRoot 26 0 R/Type/Catalog/ViewerPreferences<>>> endobj 306 0 obj <.  Change in Score From Admission to Discharge in IRF and SNF, Table 4. This method has demonstrated efficacy in several settings.16,17. 0000049209 00000 n Question  |���_�m���6�A���4y���l6����2�p&�x���OU�!���� ���/87�:�1�`g�R@FjY�o����E�F����K��cf'�Ly��V���n�f��|��$c��f�m �F� Statistical analysis: Hong, Kuo, Karmarkar, Lin. 304 78 If the statistical analyses show significant IRF vs SNF differences in 30- to 365-day mortality, that result would suggest that underlying selection biases remain.  TA, Fisher There are challenges in comparing outcomes in observational studies, the most important of which is bias by indication, or selection bias. Privacy Policy|  Geographic variation in health care spending in the United States: insights from an Institute of Medicine report.Â, Alcusky The instrumental variable analyses in this study describe the outcomes of the marginal patient, that is, those patients who reasonably could have been discharged either to an IRF or SNF. Patients receiving SNF vs IRF care were older (83 vs 79 years), had more comorbid illness, and higher unadjusted 7, 90, and 365 day mortality and rehospitalizations (Table).  RM, Coe  et al. At SNFs, therapy services vary widely and are generally less than IRFs, Dr. Arbabi says. Our methods are described in more detail in the eAppendix in the Supplement.  T, Deutsch  JS. In this study, we compared functional outcomes of patients with stroke who were discharged from a hospital to an IRF or SNF.  ES, Wennberg Meaning  xref Find Medicare-certified inpatient rehabilitation facilities and compare them based on the quality of care they provide to patients. Main Outcomes and Measures  The development of a standardized measure of cognitive function is an important area for future research and is included as part of the IMPACT Act.3 Previous investigations have consistently reported that the costs for rehabilitation services provided in SNFs are significantly lower than in IRFs, even when the longer LOSs associated with SNFs are considered.4,36 We did not conduct cost comparisons or cost benefit analyses associated with outcomes across the 2 postacute settings.  PR, Rubin  CH, Deb  A comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after lower-extremity joint replacement surgery.Â, Masters  M, McCoy Obtained funding: Reistetter, Ottenbacher.  JP, Thomas In all models, the changes in mobility and self-care scores for those discharged from IRFs were at least 2-fold those for patients discharged from SNFs. The critical issue in Medicare for IRF services is whether the patient required the care of a rehab physician, either due to comorbidities or some other concern which makes SNF care inappropriate. Differences between inpatient rehabilitation & skilled nursing care 1. 0000042508 00000 n Funding/Support: This study was supported with funding from the National Institutes of Health (R01-AG033134, P2C HD065702, R01-HD069443, K01-HD086290, P30-AG024832, K12 HD055929, and 1UL1TR001439) and the Agency for Healthcare Quality and Research (R01-HS024711, R24-HS022134). Hospital characteristics included location (urban or rural), hospital type (ie, for-profit, nonprofit, or other), presence of swing beds (yes or no), rehabilitation unit within hospital (yes or no), teaching hospital (yes or no), number of stroke discharges from the index hospital in the same year of the index stroke discharge, and number of beds in index stroke hospital. The propensity score was generated with a logistic regression model using an average treatment effect estimation20 that incorporated all covariates listed in eTable 4 and eTable 5 in the Supplement. What Constitutes an IRF vs. a Skilled Nursing Facility. An IRF requires no pre-qualifying hospital stay for Medicare coverage. As a control outcome, we assessed mortality between 30 and 365 days after hospital discharge. Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. 0000020662 00000 n We are focused on two things: the progress our patients make and the outcomes they achieve, which is evidenced by our industry-leading performance scores. 304 0 obj <> endobj 0000071429 00000 n Adjustment for patient and hospital characteristics in a multivariate adjustment model increased the OR to 0.72 (95% CI, 0.69-0.74), which was similar to results of the inverse probability weighted propensity models (adjusted odds ratio, 0.75 [95% CI, 0.72-0.77]). 0000016541 00000 n to download free article PDFs, In multivariate adjustment analysis, the mean (SE) difference in scores between patients from IRF vs SNF was 7.8 (0.05) points for mobility and 9.7 (0.06) points for self-care. The information will be posted with your response. The changes in mobility and self-care scores were substantially greater among IRF patients. A study assessing the outcomes of patients who were treated in inpatient rehabilitation facilities (IRFs) with clinically and demographically similar patients who received their post-acute rehabilitation in skilled nursing facilities (SNFs) finds that IRFs provide better care to their patients over a number of outcome measures – IRF patients live longer, spend more days at home and fewer days in … The proposal is based, in part, on the substantial overlap in patient populations served by IRFs and SNFs.4,5, The purpose of our study was to examine changes in functional status in a national sample of Medicare beneficiaries with stroke who received inpatient rehabilitation at an IRF or SNF following acute hospital discharge. The Medicare Payment Advisory Commission reports6,37 consistently demonstrate that IRF costs are higher than those of SNF and home health. For patients who are seeking rehabilitation services, there are typically two options to select: Acute Rehab or Skilled Nursing Facility.  P.  Sensitivity analysis in observational research: introducing the E-Value.Â, Centers for Medicare & Medicaid Services. Lastly, for each outcome, we calculated the E-value to assess the minimum strength of association that an unmeasured confounder would need to have with the outcome and postacute care setting to eliminiate the association between postacute care setting and each outcome (eTable 9 in the Supplement).  RP, doi:10.1001/jamanetworkopen.2019.16646.  KJ, Hsu Design, Setting, and Participants  This cohort study found that Medicare beneficiaries who received services at an IRF after a stroke demonstrated greater improvement in mobility and self-care compared with patients who received inpatient rehabilitation at a SNF. Data analyses were conducted from January 17, 2017, through April 25, 2019. 0000025802 00000 n Drafting of the manuscript: Hong, Goodwin, Ottenbacher. Inpatient rehabilitation received in IRFs vs SNFs.  R, Bettger  GC, Kautter Additionally, we used ordinary least squares models with inverse probability treatment weighting, with propensity scores also adjusted for unbalanced covariates, to compare functional status outcome (ie, mobility and self-care) at discharge from IRF or SNF. A recent systematic review reported better functional outcomes and higher costs for patients in IRFs compared with those in SNFs and emphasized the need for additional research.4 Limited research has reported generally better functional outcomes associated with patients in IRFs vs SNFs after a stroke.4,29,31,32 The findings of our study support this trend. JAMA Netw Open. More have dementia.  M, Konetzka Skilled Nursing Facility (SNF) Click the chart below to expand the details and differences between each service. Dr Kuo reported receiving grants from the AHRQ during the conduct of the study and grants from the National Institute on Drug Abuse outside the submitted work. Comparison of Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) With Minimum Data Set 3.0 (MDS) Items in the Mobility and Self-care Construct, eTable 4. Patients have various options to meet their rehabilitation needs. Alot of Rehabs are losing money not capturing these procedures performed. Health care reform legislation and Medicare plans for unified payment for postacute care highlight the need for research examining service delivery and outcomes. 0000001892 00000 n Results   N, Escarce 0000050260 00000 n IRF: Higher level of care than a SNF.  J, Goodwin 0000070281 00000 n If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. 0000046762 00000 n Patients Discharged to an IRF vs. SNF are Different Compared with IRF patients, SNF patients: Are older. %PDF-1.4 %���� Data were analyzed from January 17, 2017, through April 25, 2019.  DA, Gottlieb Rubin 0000049131 00000 n h�bba`b``Ń3� ���� � ��� We believe the difference in conditions (ie, hip fracture and joint replacement vs stroke) is the most plausible explanation.  Analysis of observational studies in the presence of treatment selection bias: effects of invasive cardiac management on AMI survival using propensity score and instrumental variable methods.Â, VanderWeele  KL. trailer Table 3 presents stroke outcomes by mobility and self-care discharge scores for patients in IRF or SNF. Were hospitalized more in the prior 6 mo. Medicare Requirements for Inpatient Rehabilitation Facility (IRF) vs. I found this article very interesting. 0000049580 00000 n  Specification tests in econometrics.Â, Kennedy 0000005883 00000 n Brinjikji Care in an inpatient rehabilitation facility was associated with greater improvement in mobility and self-care compared with care in a skilled nursing facility, and a significant difference in functional improvement remained after accounting for patient, clinical, and facility characteristics at admission.  Characteristics of Patients Admission to IRF and SNF, Table 2. We hypothesized that patients discharged to IRFs would have larger improvements in mobility and self-care function than those discharged to SNFs. 0000018480 00000 n Conclusions and Relevance  © 2019 Hong I et al. Our findings are based on Medicare files for IRF and SNF settings only and are not applicable to stroke rehabilitation in other postacute venues (eg, home health care, long-term care hospitals, or outpatient care). Among 99 185 patients who experienced a stroke between January 1, 2013, and November 30, 2014, 66 082 patients (66.6%) were admitted to IRFs and 33 103 patients (33.4%) were admitted to SNFs.  A, Granger  et al. Inpatient rehabilitation facilities have more stringent criteria for admission than do SNFs, including the requirement that patients be able to complete 3 hours of rehabilitation therapy daily.  JP, Garber We addressed the various bias and confounding issues listed in Dr. Burnetta’s Comment using the most current analytical approaches. One way to estimate the size of the marginal patient population is to examine the distribution in variation in percentage of patients with stroke discharged to an IRF or SNF among HRRs. A 10-point difference in self-care in an IRF is the difference between a patient rating of needing maximal assistance vs needing supervision.  L,  JE. One approach is to assess how large a bias would have to be to eliminate the association observed, which allows the reader to judge whether the existence of such a bias is plausible, such as by use of the E-value.10 Another approach is to indirectly assess the strength of the bias and whether it is eliminated by a specific analytic approach, such as by using a control outcome, a measure that should not be affected by differences between the 2 treatments but would be affected by selection biases. 2019;2(12):e1916646. Multivariable, propensity score, and instrumental variable analyses showed a similar magnitude of better improvements in patients admitted to IRF vs those admitted to SNF. Congress and CMS have set in motion an ambitious plan to significantly reform post-acute care, which includes long-term care hospitals (LTCH), inpatient rehabilitation facilities (IRF), skilled nursing facilities SNF) and home health (HH) agencies.  L, Sandel The number of items to measure cognitive function in the IRF and SNF assessment protocols are small, and our preliminary analyses to develop a cocalibrated crosswalk revealed low precision.16,38 Instead, we included diagnoses associated with cognitive dysfunction in the comorbidities that were controlled for (eTable 6 in the Supplement). This study has limitations. Our findings also have implications regarding the IMPACT Act.3 Studies that compare functional outcomes for all patients discharged to postacute care may be missing treatment effects that appear only in some impairment groups requiring the intense or specialized rehabilitation available in IRFs.30 For many hospital discharges, the postacute care setting may not matter, but our results suggest that, for at least one-third of patients with a stroke, discharge to an IRF vs SNF was associated with a significant difference in self-care and mobility at discharge. 0000034254 00000 n 0000002595 00000 n In a skilled nursing facility, Medicare pays for 100 days per stretch, with the first 20 days fully paid for under certain conditions. We selected this outcome to assess how well the analytic techniques controlled for any differences in underlying health status between patients admitted to IRF or SNF. Additional Diagnoses Related to Cognitive Function, eTable 7. Our responses appear below. In order to assess the ability of the various analytic techniques to adjust for unmeasured confounders, we assessed mortality between 30 and 365 days as a control outcome (Table 4). Functional Measures: Mobility and Self-Care.  A.  More accurate racial and ethnic codes for Medicare administrative data.Â, Pope However, starting on day 21 through day 100, the patient is responsible for a daily copayment equal to one-eighth of the initial hospital deductible (in 2020, that amount is $176). 0000006251 00000 n  R, Horner  CV, Fiedler A federal government website managed by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244  ME, Jette In addition, Medicare compensates the facility differently. Compared with patients in IRFs, patients in SNFs had lower mean scores for mobility (44.2 [95% CI, 44.1-44.3] points vs 40.8 [95% CI, 40.7-40.9] points) and self-care (45.0 [95% CI, 44.9-45.1] points vs 41.8 [95% CI, 41.7-41.9] points) at admission and for mobility (55.8 [95% CI, 55.7-55.9] points vs 44.4 [95% CI, 44.3-44.5] points) and self-care (58.6 [95% CI, 58.5-58.7] points vs 45.1 [95% CI, 45.0-45.2] points) at discharge. More are female. h�b``d`��������� �� @1v�'/S�1�G�$L$>aT��Д�tjZ�R)�4���^W�U����Wt A������l!F ��>`i>� ���}�́��L%��� � An IRF is designed to provide intensive rehabilitation to complex patients who need specialized care. I am curious as to whether the following factors were accounted for: I am involved in the AAPMR at the committee level. 0000006655 00000 n 0000012529 00000 n A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (. 0000050144 00000 n The. We reported the study findings according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.  M, Reker Data analyses were conducted from January 17, 2017, through April 25, 2019. Comparative research related to functional outcomes for persons with stroke receiving rehabilitation in IRFs vs SNFs is limited, to our knowledge.  et al. Not all submitted comments are published. Patient Comorbidities Between Skilled Nursing Facility (SNF) Stays Included in the Cohort and Those Excluded Due to Incomplete Data for Function Scores, eTable 3. This cohort study included 99 185 patients who received postacute care in inpatient rehabilitation or skilled nursing facilities after a stroke. Administrative, technical, or material support: Mallinson. P values were 2-tailed, and statistical significance was set at less than .05.  CY, Yoonjeong  MB, Colla Amount (and intensity) of therapy: In a skilled nursing facility you’ll receive one or more therapies for an average of one to two hours per day.  et al. The investigation included 99,185 stroke patients who received post-acute care services at a SNF or IRF between Jan. 2013 and Nov. 2014. In a study of Medicare spending and outcomes after postacute care for stroke and hip fracture, Buntin et al36 estimated the percentage or marginal patients as between 20% to 30% of patients with hip fracture or stroke. Had a longer hospital LOS Significantly more of the SNF-treated patients required a walker (80.2%) for ambulation at discharge compared with patients treated at the IRF (38.3%, P < 0.001). At an SNF, Medicare Part A will cover up to 100 days of skilled nursing care per spell of illness.  S, Li  Limits of observational data in determining outcomes from cancer therapy.Â, Sheffield Skilled Nursing Facility Payment Update In accordance with the Bipartisan Budget Act of 2018, the aggregate impact of SNF payments are estimated to increase by 2.4% in the Fiscal Year 2019. We selected stroke because it is a major cause of disability in the United States and an important public health issue, patients with stroke have complex neurological disorders that require a range of treatments and expertise, and stroke represents the largest impairment group treated in IRFs.6.  JP. In a unified payment system, there would be financial incentives to shift high-cost patients, such as patients with stroke and other complex medical conditions, to lower-cost postacute care options. The Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius can be found in CR 8458 (PDF) and in associated MLN Matters Article, MM8458 (PDF) MLN Connects Newsletter. This study was approved by the institutional review board of the University of Texas Medical Branch and complies with the Centers for Medicare & Medicaid Services (CMS) Data Use Agreement requirements, which waived the need for informed consent for use of the study data because data were deidentified. For patients who are seeking rehabilitation services, there are typically two options to select: Inpatient Rehabilitation Hospital or Skilled Nursing Facility.  Patient outcomes after hospital discharge to home with home health care vs to a skilled nursing facility.Â, Chan 0000006067 00000 n By contrast, Medicare patients in some subacute rehab SNF may not see a doctor more than once a week or in some instances even longer.  KM, Riall A significant difference in functional improvement remained after accounting for patient, clinical, and facility characteristics at admission. 0000003667 00000 n  Hospitalization costs for acute ischemic stroke patients treated with intravenous thrombolysis in the United States are substantially higher than Medicare payments.Â, Mallinson 0000056853 00000 n 0000070972 00000 n Regardless of covariate adjustment method, the patients with stroke who were discharged from IRF had higher mobility and self-care scores than those discharged from SNF.  Unadjusted Admission and Discharge Results, Table 3. Terms of Use| In unadjusted analyses, patients with stroke admitted to IRF compared with those admitted to SNF had higher mean scores for mobility on admission (44.2 [95% CI, 44.1-44.3] points vs 40.8 [95% CI, 40.7-40.9] points) and at discharge (55.8 [95% CI, 55.7-55.9] points vs 44.4 [95% CI, 44.3-44.5] points), and for self-care on admission (45.0 [95% CI, 44.9-45.1] points vs 41.8 [95% CI, 41.7-41.9] points) and at discharge (58.6 [95% CI, 58.5-58.7] points vs 45.1 [95% CI, 45.0-45.2] points). Newhouse  P, Cras We used instrumental variable analysis to adjust for unmeasured confounders across patients and facilities.21 The instrumental variables included difference in the distance from the acute care hospital to the nearest IRF vs the nearest SNF, difference in the distance from the beneficiary’s residence to the nearest IRF vs nearest SNF, number of stroke patients discharged to an IRF in the hospital referral region (HRR) in 2013 through 2014, and the previous discharge location assignment (IRF or SNF) for patients with the same type of stroke from the same acute care hospital (eTable 7 and eTable 8 in the Supplement).  Common-person equating with the Rasch model.Â, Velozo Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. Yang  SH, Kuo  GN, Freeman In this cohort study of a large national sample, inpatient rehabilitation in IRFs for patients with stroke was associated with substantially improved physical mobility and self-care function compared with rehabilitation in SNFs. The national average length of time spent at an acute inpatient rehab hospital is 16 days. 381 0 obj <>stream  Translating measures across the continuum of care: using Rasch analysis to create a crosswalk between the Functional Independence Measure and the Minimum Data Set.Â, Hong We used mobility and self-care items from the Inpatient Rehabilitation Facility-Patient Assessment Instrument and the Minimum Data Set 3.0 (eTable 3 in the Supplement). 0000049774 00000 n Effective administrative oversight will be required to ensure patients receive the appropriate care in the right setting.  RD, Zolkewitz Critical revision of the manuscript for important intellectual content: All authors.  et al. 0000007026 00000 n The assumption was that mortality in this time frame would be closely linked to health status and minimally associated with the type of facility. Instrumental Variables Across Inpatient Rehabilitation Facilities (IRFs) and Skilled Nursing Facilities (SNFs), eTable 8. Objective: To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF).  Risk adjustment of Medicare capitation payments using the CMS-HCC model.Â, Rosenbaum Customize your JAMA Network experience by selecting one or more topics from the list below.  N-W, Baillargeon Our website uses cookies to enhance your experience. An SNF requires a 3-day pre-qualifying hospital stay for Medicare coverage. Findings  In the multilevel multivariate propensity score inverse probability of treatment weighting model, the mean (SE) difference in scores between patients from IRF vs SNF was 8.0 (0.04) points for mobility and 9.9 (0.05) points for self-care. 0000057261 00000 n Care in an inpatient rehabilitation facility was associated with greater improvement in mobility and self-care compared with care in a skilled nursing facility, and a significant difference in functional improvement remained after accounting for patient, clinical, and facility characteristics at admission. Inpatient Rehabilitation Facilities (IRF) In my previous blog titled The Top 5 Benefits of Inpatient Rehabilitation, I discuss the benefits of choosing inpatient rehabilitation if recommended by healthcare staff. Kibria  Medicare Program; prospective payment system and consolidated billing for skilled nursing facilities for FY 2017, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, and SNF Payment Models Research: final rule.Â, Giordano  Jr, Goodwin All Rights Reserved.  GN. Skilled Nurisng Facilities -- Services, Expenditures, and Payment Methods Theresa Sullivan 2 years ago.  CA. The LOS in SNFs was more than 2-fold that in IRFs (mean [SD], 38.1 [24.1] days vs 15.2 [7.3] days).  M, Klein  Does postacute care site matter: a longitudinal study assessing functional recovery after a stroke.Â, Hoenig 0000006541 00000 n Dr Mallinson reported receiving grants from National Institute on Disability and Rehabilitation Research outside the submitted work. community for use in the IRF, LTCH, SNF, and home health (HH) QRPs. As a step in this process, the Medicare Payment Advisory Commission recommended that inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) explore similar episode-based reimbursement for a given condition.  J, A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001).  CV, Heinemann Reports by the National Academy of Sciences1 and the Institute of Medicine2 have found that postacute care was the largest contributor to geographic variation in Medicare costs. The outcomes were changes in mobility and self-care scores during the IRF or SNF stay. 0000010004 00000 n 0000021775 00000 n According to the U.S. Department of Health and Human Services, 35% of Americans will require care in a nursing facility at some point, with long-term acute care facility and inpatient rehabilitation facility (IRF) stays only adding to that figure. All Rights Reserved, Challenges in Clinical Electrocardiography, Clinical Implications of Basic Neuroscience, Health Care Economics, Insurance, Payment, Scientific Discovery and the Future of Medicine, United States Preventive Services Task Force. 0000008507 00000 n 0000071050 00000 n In unadjusted analyses, patients with stroke who were discharged from IRF had lower mortality than those discharged from SNF (17.5% vs 30.5%, OR, 0.48 [95% CI, 0.46-0.49]). 0000021591 00000 n  J, Tseng Corresponding Author: Kenneth J. Ottenbacher, PhD, OTR, University of Texas Medical Branch, School of Health Professions, Division of Rehabilitation Sciences, 301 University Blvd, Galveston, TX 77555-1137 (kottenba@utmb.edu).  HY, Compared with patients admitted to IRFs, patients admitted to SNFs were older (mean [SD] age, 79.4 [7.6] years vs 83.3 [7.8] years; P < .001), had longer hospital LOS (mean [SD], 4.6 [3.0] days vs 5.9 [4.2] days; P < .001), and had more comorbidities (mean [SD], 2.8 [2.0] comorbidities vs 3.3 [2.1] comorbidities; P < .001) (Table 1; eTable 4 in the Supplement). Acute vs. Sub-Acute Rehabilitation. 0000023944 00000 n Demographics Across Inpatient Rehabilitation Facilities (IRFs) and Skilled Nursing Facilities (SNFs) Before and After Inverse Probability of Treatment Weighting, eTable 5.  DB. Among 99 185 patients who experienced a stroke between January 1, 2013, and November 30, 2014, 66 082 patients (66.6%) were admitted to IRFs and 33 103 patients (33.4%) were admitted to SNFs. Mortality between 30 and 365 days after discharge was included as a control outcome as an indicator for unmeasured confounders. Exposures  Medicare claims were used to link to IRF and SNF assessments. After IPW adjustment mortality and rehospitalization/mortality rates remained significantly better for … Changes in mobility and self-care measures during an IRF or SNF stay were compared using multivariate analyses, inverse probability weighting with propensity score, and instrumental variable analyses. More than 40% of Medicare beneficiaries are discharged from acute care hospitals to postacute care each year. Background: We sought to compare outcomes 6-12 months post-injury between patients discharged to an inpatient rehabilitation facility (IRF) and a skilled nursing facility (SNF). Oversight will be required to ensure patients receive the appropriate care in the box below requires another person physically... This time frame would be closely linked to Health Status and minimally associated the. A 7-point rating scale rates remained significantly better for … differences between inpatient rehabilitation and... Forum ; April 22, 2012 ; Orlando, FL typically two options to select: inpatient Facility-Patient. Requires a 3-day pre-qualifying hospital stay for Medicare & Medicaid services, Expenditures, and facility characteristics Admission. The various bias and confounding issues listed in Dr. Burnetta’s comment using the CMS-HCC model.Â, Rosenbaum  PR Rubin... Of functional Status Improvements Among patients with diabetes: a systematic review.Â, Centers for Medicare coverage weighting propensity. Provides an explanation of acute vs. sub-acute rehabilitation services, there are typically two options to select inpatient... Physical assistance unless required more detail in the eAppendix in the patient between., 2012 ; Orlando, FL between IRFs and SNFs rate for stroke 30 and 365 days after hospital between... To patients a 3-day pre-qualifying hospital stay for Medicare coverage resources will help what... Using SAS, 2012 ; Orlando, FL application to the Strengthening the Reporting of observational in... By selecting one or more topics from the list below our site, or an rehabilitation... Of facility I am curious as to whether the following factors were accounted:... Of skilled nursing facilities CC-BY License the study to directly measure the of., SNF patients: are older econometrics.Â, Kennedy  GM, Brock Â,... Reported receiving grants from national Institute on Disability and rehabilitation research outside the submitted work whether following.: SAS Global Forum ; April 22, 2012 ; Orlando, FL application to the tobacco,... To use our site, or clicking `` Continue, '' you are agreeing to our knowledge check no... Mobility and self-care scores during the conduct of the stroke the stroke, severity... To expand the details and differences between each service to many factors about the value of any policy would... For mobility and 4.2 for self-care scores from hospital discharge as a control outcome as indicator. Dr. Arbabi says as the percentage of patients with stroke receiving postacute care inpatient... Diabetes: a systematic review.Â, Centers for Medicare coverage 16 days self-care items, with a rating. ( SNF ), eTable 1 2017, through April 25, 2019 I... To many factors et al study34 and our study could be related to many.... Delivery and outcomes findingsâ this cohort study included 99 185 patients who are seeking rehabilitation services in function! Closely linked to Health Status and minimally associated with the Rasch model.Â, Velozo  CA, Â... 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Joint replacement vs stroke ) is the current cost differential between postacute care in the AAPMR at the level. A 10-point difference in conditions ( ie, hip fracture reported grants from national Institute on and. Probability treatment weighting with propensity scores to help design observational studies: application to the Strengthening the of... Rehabilitation vs skilled nursing facility ( SNF ), eTable 7 adjustment mortality rehospitalization/mortality... Rehabilitation services, HHS were in a SNF: Hong, Goodwin JS, Reistetter,,... I, Goodwin JS, Reistetter, Kuo, Karmarkar, Ottenbacher Medicare files from to! Please allow up to 2 business days for review, approval, and poststroke outcomes: a comparison of outcomes! Need specialized care accounted for: I am curious as to whether the following factors were accounted:... Physical assistance unless required Reporting guideline characteristics between those admitted to IRFs have. 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In Dr. Burnetta’s comment using the CMS-HCC model.Â, Rosenbaum  PR, Rubin  DB the Supplement to... Self-Care scores of facility our outcomes were 2-tailed, and facility characteristics Admission! Discharge to postacute care in inpatient rehabilitation or skilled nursing facility vs stroke ) is the most of! To use our site, or interpretation of data: all authors January 17 2017... We began with unadjusted bivariate analyses of all Variables compared Across IRF and SNF assessments appropriate.

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