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 are four PAC settings: skilled nursing facilities (SNF), long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), home health agencies (HHAs).

Patients in these settings have similar conditions, such as strokes and hip replacements. However, Medicare pays different prices depending upon the setting (Medicare Payment Advisory Commission 2014, 171). For a patients continued recovery and optimal outcome, does the choice of PAC setting matter? Two sets of researchers investigated this question. One set investigated the functional recovery for patients who had had a stroke (Chan et al. 2013). Another set investigated the functional recovery for patients who had had a hip fracture repaired (Mallinson et al. 2014).

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

• Patients who received their postacute care in an IRF had at least eight-point higher improvements in mobility, self-care, and cognition, than patients who received their postacute care in a SNF.
• Patients who received their postacute care in an IRF also had statistically significant improvements in Applied Cognition compared to those patients who only received home health combined with outpatient services.

Chan and colleagues concluded that patients with a stroke may make more functional gains if they receive some of their postacute care in an IRF compared to other sites (Chan et al. 2013, 629). Deutschs commentary on the research of Chan and colleagues noted that comparing outcomes across postacute care is difficult because the PAC sites use different data sets (2013, 631-632).

Mallinson and colleagues investigated the outcomes of patients after hip fracture repair. Facilities from three types of PAC settings participated in the research. Eventually, the researchers reviewed the care of 181 patients at 18 PAC providers. These PAC providers were four IRFs, six SNFs, and eight HHAs. After being trained on the data collection instrument, nurses at each site collected 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 discharge relative to SNF patients
• HHA patients had, on average, a two-week longer length of stay than SNF patients
• SNF patients had, on average, a nine-day longer length of stay and IRF patients

Mallinson and colleagues concluded that outcomes varied among settings depending upon whether self-care or mobility was the outcome of focus (Mallinson et al. 2014, 209).

DeJongs commentary on the research of Mallinson and colleagues noted that the absence of a common PAC patient assessment instrument requires workarounds (2014). Researchers can use a site-neutral instrument, such as the AM-PAC or they can use an existing PAC-site-specific instrument. Both workarounds require training on the instrument for all or some of the data collectors and require special data collection outside of routine procedures.

Questions

1. List the data collection instrument for PAC settings discussed in the case

2. What PAC setting is missing from the previously described research investigations? What is that settings data collection instrument?

3. Both Deutsch and DeJong note problems caused by the lack of a common data set across PAC settings. How has Congress addressed this problem?

4. Workarounds require special training and special data collection outside routine procedures. Why are these workarounds a problem for researchers? Does Congress solution address this problem?

5. How could you or your family benefit from a common data collection instrument across PAC settings?