irf vs snf

Get free access to newly published articles. %%EOF  A, Granger  L, Data were analyzed from January 17, 2017, through April 25, 2019. <<27EF291824D86C4395D1B75C06CED14C>]/Prev 95442/XRefStm 2254>>  Medicare spending and outcomes after postacute care for stroke and hip fracture.Â, Ottenbacher  KL, Wang Theresa Sullivan 2 years ago. If any covariates in the propensity score model were not balanced, we additionally controlled for those covariates in the outcome models. Our responses appear below. Dr Mallinson reported receiving grants from National Institute on Disability and Rehabilitation Research outside the submitted work. 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.  Factors influencing selection for rehabilitation after stroke: a questionnaire using case scenarios to investigate physician perspectives and level of agreement.Â, Xian  Common-person equating with the Rasch model.Â, Velozo  ES, Wennberg If the IRF is a part of the acute care hospital, the patient will have their primary physician and any clinical specialists that followed the patient in the hospital available to them during their IRF stay. In addition, Medicare compensates the facility differently. Accepted for Publication: October 9, 2019. 0000003667 00000 n 0000007540 00000 n  L, Vanacker 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. A 10-point difference in self-care in an IRF is the difference between a patient rating of needing maximal assistance vs needing supervision.  Hospitalization costs for acute ischemic stroke patients treated with intravenous thrombolysis in the United States are substantially higher than Medicare payments.Â, Mallinson  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 For self-care, the change was 13.6 (95% CI, 13.5-13.7) points vs 3.2 (95% CI, 3.1-3.3) points. 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. People generally receive inpatient therapy in a skilled nursing facility (SNF) or inpatient rehab facility (IRF) following hospitalization for a health event and need to be in an environment where they can receive skilled care and oversight before transitioning to the home. 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).  RT. 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. Medicare claims were used to link to IRF and SNF assessments. Inpatient rehabilitation received in IRFs vs SNFs.  JA. These differences were no longer statistically significant in the instrumental variable analyses. 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 findings are similar to what Buntin et al36 estimated as the percentage of patients with marginal stroke and hip fracture. 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). We were not able to examine cognitive function before and after the stroke, stroke severity, or location of the stroke. The difference in findings between the Mallinson et al study34 and our study could be related to many factors.  T, Deutsch  DB. IRF versus SNF. This cohort study included 99 185 patients who received postacute care in inpatient rehabilitation or skilled nursing facilities after a stroke. 0000020662 00000 n 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 finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the same standard rate for stroke. 2019;2(12):e1916646. 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. 0000053395 00000 n Our findings indicate the need to carefully manage discharge to postacute care based on the patient’s needs and potential for recovery. 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. Concept and design: Goodwin, Reistetter, Kuo, Karmarkar, Ottenbacher.  Y, Thomas  Jr, Goodwin Stroke is a complex neurological condition affecting multiple body systems and requiring intensive rehabilitation from several disciplines with different areas of expertise. Newhouse 0000023591 00000 n 0000018293 00000 n 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.  C, Bonito A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001). Drafting of the manuscript: Hong, Goodwin, Ottenbacher. Next, we used hierarchical general linear mixed-effects models to account for patients nested within hospitals. In the 4 instrumental variable models, the differences in improvement in mobility scores between IRF and SNF patients between 5 and 10 points and for self-care scores, the difference was between 8 and 12 points. Stays in skilled nursing facilities (SNFs) are also common. 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. 0000003831 00000 n  JJ. 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.  AM. 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. 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. The multivariable approach used ordinary least squares, adjusting for covariates. A third approach is to use analytic approaches shown to minimize selection biases, such as instrumental variable analysis.7-9 We used these 3 approaches to compare outcomes of patients with stroke who were discharged from acute care to IRFs vs SNFs. Demographics Across Inpatient Rehabilitation Facilities (IRFs) and Skilled Nursing Facilities (SNFs) Before and After Inverse Probability of Treatment Weighting, eTable 5.  Potentially preventable hospitalizations in Medicare patients with diabetes: a comparison of primary care provided by nurse practitioners versus physicians.Â.  CH, Deb 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. © 2019 Hong I et al. eFigure. All Rights Reserved. Impact: The update increased reimbursement for skilled nursing facilities. 0000070281 00000 n  JS. We began with unadjusted bivariate analyses of all variables compared across IRF and SNF settings. Identify all potential conflicts of interest that might be relevant to your comment. 0000004856 00000 n The study sample included Medicare beneficiaries 66 years or older discharged from January 1, 2013, to November 30, 2014, to an IRF or SNF after an index acute stay for stroke denoted by Medicare Severity Diagnosis Related Group codes 061 to 066 (eFigure in the Supplement).13 Additional inclusion criteria included Medicare Part A coverage without enrollment in a health maintenance organization in the year before and 1 month after the index stroke discharge, residing in the community prior to the index stroke hospitalization, and full mobility and self-care functional measures at the IRF admission and discharge or SNF admission and last follow-up (eTable 1 and eTable 2 in the Supplement). 0000070681 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.  Characteristics of Patients Admission to IRF and SNF, Table 2. 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).  Association between cholecystectomy with vs without intraoperative cholangiography and risk of common duct injury.Â, Stukel 0000009636 00000 n  Y, Granger 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. Were hospitalized more in the prior 6 mo. These findings suggest that there is room for payment reform in postacute care and highlight the need to target decision-making regarding discharge to postacute facilities based on patient needs and potential for recovery. 0000034254 00000 n 0000057261 00000 n 0000006429 00000 n The information will be posted with your response. Have more severe strokes. Is change in physical function associated with receiving postacute care after a stroke in inpatient rehabilitation vs skilled nursing facilities?  Does postacute care site matter: a longitudinal study assessing functional recovery after a stroke.Â, Hoenig  TJ, Ding 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. Skilled Nursing Facility (SNF) Click the chart below to expand the details and differences between each service. For patients who are seeking rehabilitation services, there are typically two options to select: Inpatient Rehabilitation Hospital or Skilled Nursing Facility. 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. More have dementia. 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. Y.-L. Lin reported grants from National Institutes of Health during the conduct of the study. Terms of Use| 2019;2(12):e1916646. 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).  J, Goodwin 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.  M, Ulbricht 304 0 obj <> endobj Medicare claims were used to link to IRF and SNF assessments. Acquisition, analysis, or interpretation of data: All authors. As a control outcome, we assessed mortality between 30 and 365 days after hospital discharge. Had a longer hospital LOS 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. 0000049131 00000 n Results  Lastly, we calculated E-values for mobility scores, self-care scores, and mortality between patients admitted to IRF or SNF, to assess the potential magnitude of unmeasured confounding that might have produced the results.10 Data were analyzed using SAS statistical software version 9.4 (SAS Institute). Obtained funding: Reistetter, Ottenbacher.  CV, Fiedler Please allow up to 2 business days for review, approval, and posting. Objective: To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF). Our study adds to the accumulating scientific literature that better functional outcomes, such as mobility and self-care, are associated with discharge from IRFs vs SNFs among stroke survivors.4,29,31,32 This has not been true for other conditions, such as hip fracture or joint replacement.34 A study by Mallinson et al34 comparing mobility and self-care outcomes, which were measured in the same way as in our study, among patients with hip fracture receiving rehabilitation from IRFs, SNFs, or home health agencies found no statistically significant differences in fully adjusted models. Conclusions and Relevance  0000071429 00000 n 0000049696 00000 n 0000010453 00000 n IRF: Higher level of care than a SNF.  A, Hedeman Currently, the decision-making process in selecting postacute care services is heavily influenced by nonclinical factors.25-30 This is shown by the substantial geographic variation in the proportions of patients with stroke discharged to IRFs or SNFs.28 The choice is associated with measures of availability, such as distance to the nearest facility.29 The association of IRF vs SNF use with these nonclinical factors allows investigators to use them as instruments in an instrumental variable analysis, which should better control for unmeasured confounders that might be influencing the choice of IRF vs SNF.  R, Horner  M, Klein 0000001892 00000 n Exposures  0000000016 00000 n There are several approaches to mitigating this problem. © 2020 American Medical Association. Medicare Requirements for Inpatient Rehabilitation Facility (IRF) vs. Medicare coverage for SNF stays is more limited than at an IRF. 0000053855 00000 n 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. I found this article very interesting. Health care reform legislation and Medicare plans for unified payment for postacute care highlight the need for research examining service delivery and outcomes. Q: What do the DTC-PAC measures assess? In this study, we compared functional outcomes of patients with stroke who were discharged from a hospital to an IRF or SNF.  M, McCoy  Y-F, Chen  JP.  J, Ellis  Geographic variation in health care spending in the United States: insights from an Institute of Medicine report.Â, Alcusky  H, Sloane h�bba`b``Ń3� ���� � ��� 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). Were in a SNF in the prior 6 mo. These files included Master Beneficiary Summary for patient demographics, Medicare Provider Analysis and Review for claims from hospital and postacute care stays with clinical variables, Inpatient Rehabilitation Facility-Patient Assessment Instrument from IRF,4,11 Minimum Data Set 3.0 from SNF,12 and the Provider of Services Current Files for hospital characteristics.  I, Woo Discharge to home, a skilled nursing facility (SNF), or an inpatient rehabilitation facility (IRF) was the primary outcome. More than 40% of Medicare beneficiaries are discharged from acute care hospitals to postacute care each year.  MB, Colla h�b``d`��������� �� @1v�'/S�1�G�$L$>aT��Д�tjZ�R)�4���^W�U����Wt A������l!F ��>`i>� ���}�́��L%��� �  N-W, Baillargeon 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).  HY, On July 31, the Centers for Medicare & Medicaid Services (CMS) released final rules to update the Medicare fee-for-service prospective payment systems for inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) for fiscal year (FY) 2018.. Kibria 0000046762 00000 n 0000005883 00000 n  A.  More accurate racial and ethnic codes for Medicare administrative data.Â, Pope 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.  GC, Kautter A federal government website managed by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244 Several studies7-9 have shown that traditional methods of controlling for patient characteristics, such as logistic regression and propensity analyses, tend not to be effective in the face of strong selection biases. More are female. 0000057755 00000 n 0000052989 00000 n  DB.  Limits of observational data in determining outcomes from cancer therapy.Â, Sheffield Find Medicare-certified inpatient rehabilitation facilities and compare them based on the quality of care they provide to patients. 0000010004 00000 n 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 … startxref 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. Acute Rehab vs. SNF Patients have various options to meet their rehabilitation needs, however it is essential that they be educated on the differences in those options. Our findings and the research of Buntin et al36 indicate that it may be possible to improve our ability to identify appropriate candidates for the high-intensity, specialized services provided in IRFs.  M, Konetzka  JE. If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. 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.  P.  Sensitivity analysis in observational research: introducing the E-Value.Â, Centers for Medicare & Medicaid Services.  L, Liang When it comes to inpatient rehabilitation, the Encompass Health difference is our people, our approach and our outcomes. Objective   The central role of the propensity score in observational studies for causal effects.Â, Kuo Paper presented at: SAS Global Forum; April 22, 2012; Orlando, FL. The national average length of time spent at an acute inpatient rehab hospital is 16 days. Needing supervision simply involves another person being present to monitor the activity but not provide physical assistance unless required. 0000049774 00000 n We used the crosswalk developed by Mallinson et al14 to construct comparable admission and discharge functional scores for the postacute care settings.15 The scores at admission and discharge for mobility and self-care are reported on a scale of 0 to 100 points, with higher scores indicating greater functional status. No other disclosures were reported. Importance  The lower confidence limit of the E-value was 4.0 for the change in mobility and 4.2 for self-care scores. 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. This pattern is consistent with prior comparative effectiveness studies using observational data7-9 and reinforces the view that such techniques should be avoided in the face of strong selection bias. Acute Rehab vs. SNF. 0000006251 00000 n 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.  R, Bettger Health care reform legislation and Medicare plans for unified payment for postacute care highlight the need for research examining service delivery and outcomes.  AA, Cloft  J, Raji Inpatient rehabilitation received in IRFs vs SNFs. trailer Patients treated in a SNF as a result of the 60% Rule who could have otherwise been treated in an IRF might be adversely affected by an increased risk of death, increased use of facility-based care, and more ER visits and hospital readmissions. The investigation included 99,185 stroke patients who received post-acute care services at a SNF or IRF between Jan. 2013 and Nov. 2014.  et al.  Using propensity scores to help design observational studies: application to the tobacco litigation.Â, Hausman An IRF requires no pre-qualifying hospital stay for Medicare coverage. 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. Brinjikji 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. 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. The outcomes were changes in mobility and self-care scores during the IRF or SNF stay.  GM, Brock 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. Is change in physical function associated with receiving postacute care after a stroke in inpatient rehabilitation vs skilled nursing facilities? What Constitutes an IRF vs. a Skilled Nursing Facility. 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. 0000050144 00000 n 0000023767 00000 n We reported the study findings according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. Centers for Medicare & Medicaid Services.  TA, Fisher |���_�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� Comparative research related to functional outcomes for persons with stroke receiving rehabilitation in IRFs vs SNFs is limited, to our knowledge. We estimated the parameters using 2-stage least square regression.22-24 For the control outcome of 30- to 365-day mortality, the parameters were estimated from 2-stage residual inclusion models because the outcome was dichotomous. doi:10.1001/jamanetworkopen.2019.16646. 0000006067 00000 n 0000070457 00000 n 0000032977 00000 n 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). Question  Accessibility Statement, Table 1.  YC, Joseph  JP, Stein  SH, Kuo  DE, Alter In contrast, the 4 instrumental variable models resulted in odds of mortality closer to 1.0, with ORs ranging from 0.92 (95% CI, 0.76-1.11) when adjusted for previous IRF or SNF assignment by stroke type within each hospital to 1.25 (95% CI, 0.88-1.76) when adjusted by differential distance from patient’s residence to the nearest IRF or SNF (Table 4).  Postacute care setting, facility characteristics, and poststroke outcomes: a systematic review.Â, Centers for Medicare & Medicaid Services, HHS. 0000049580 00000 n  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 0000021591 00000 n 0000018480 00000 n Table 3 presents stroke outcomes by mobility and self-care discharge scores for patients in IRF or SNF.  P, Cras 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]). Additional Diagnoses Related to Cognitive Function, eTable 7.  JP, Garber  S, Li • 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 … 0000002436 00000 n 0000039735 00000 n 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 cohort study included 99 185 patients who received postacute care in inpatient rehabilitation or skilled nursing facilities after a stroke. 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]).  P.  Predicting discharge destination after stroke: a systematic review.Â, Werner A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001). 0000050260 00000 n endstream endobj 380 0 obj <>/Filter/FlateDecode/Index[26 278]/Length 31/Size 304/Type/XRef/W[1 1 1]>>stream 0000025538 00000 n to download free article PDFs, Mortality between 30 and 365 days after discharge was included as a control outcome as an indicator for unmeasured confounders. community for use in the IRF, LTCH, SNF, and home health (HH) QRPs. 0000008507 00000 n Conflict of Interest Disclosures: Dr Reistetter reported receiving grants from the Agency for Healthcare Research and Quality (AHRQ) during the conduct of the study.  JS. The 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act3 requires the Secretary of the Department of Health and Human Services to establish a unified payment system for postacute care. Meaning  Patient Characteristics Between Skilled Nursing Facility (SNF) Stays Included in the Cohort and Those Excluded Owing to Incomplete Data for Function Scores, eTable 2. 0000071574 00000 n 0000039541 00000 n Next, we used inverse probability treatment weighting with propensity scores with and without multilevel adjustment.  J, To effectively and safely implement unified payment in postacute care,3 it will be necessary to recognize differences in the rehabilitation needs of patients with stroke and other complex conditions.  J, Tseng  L, Liang  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 0000042508 00000 n JAMA Network Open. 0000049209 00000 n  KM, Riall  SJ. Findings  We also found differences in functional outcomes between IRF and SNF using logistic regression and propensity scores. Skilled Nurisng Facilities -- Services, Expenditures, and Payment Methods 0000006541 00000 n doi:10.1001/jamanetworkopen.2019.16646. All Rights Reserved. 0000016541 00000 n CMS developed the DTC-PAC measures to meet the IMPACT Act mandate and finalized them through rulemaking in Fiscal Year 2017 (IRF, LTCH, SNF) and Calendar Year 2017 (HH). endstream endobj 305 0 obj <>/Metadata 24 0 R/Pages 23 0 R/StructTreeRoot 26 0 R/Type/Catalog/ViewerPreferences<>>> endobj 306 0 obj <. Privacy Policy| 0000014349 00000 n  Specification tests in econometrics.Â, Kennedy 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. 0000023944 00000 n 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). Patients at the level of needing supervision are usually ready for discharge to home, while patients needing maximal assistance will require continued institutional care or in-home nursing support after discharge from postacute care.32,33. Our website uses cookies to enhance your experience. 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). We hypothesized that patients discharged to IRFs would have larger improvements in mobility and self-care function than those discharged to SNFs. 0000071050 00000 n 0000070360 00000 n The national average length of time spent at a skilled nursing facility rehab is 28 days. 0000049525 00000 n It is not possible to directly measure the size of the population of marginal patients.  DJ, Vermeulen Results of instrumental variable analyses are summarized in Table 3 and show similar results, including by differential distance from acute care hospital to nearest IRF or SNF (mean [SE] difference: mobility score, 8.2 [0.34] points; self-care score, 9.8 [0.39] points), by differential distance from patient’s residence to nearest IRF or SNF (mean [SE] difference: mobility score, 5.6 [0.63] points; self-care score, …  Poststroke rehabilitation: outcomes and reimbursement of inpatient rehabilitation facilities and subacute rehabilitation programs.Â, Mallinson 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. 0000071342 00000 n The. 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.  Comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after hip fracture repair.Â, Buntin  MA, Graham 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.  HJ.  Patient outcomes after hospital discharge to home with home health care vs to a skilled nursing facility.Â, Chan 0000003694 00000 n 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. 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). I am curious as to whether the following factors were accounted for: I am involved in the AAPMR at the committee level. Table 2 presents the unadjusted mobility and self-care scores at admission and discharge for patients in IRFs and SNFs, along with the change in scores between admission and discharge.  CV, Heinemann Design, Setting, and Participants   AM, The Medicare Payment Advisory Commission reports6,37 consistently demonstrate that IRF costs are higher than those of SNF and home health.  L, 0000025802 00000 n 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. This is an important topic for future research.  N, Escarce 0000046580 00000 n E-values for Mobility and Self-care Scores and 30- to 365-Day Mortality From Hospital Discharge. Receiving grants from national Institutes of Health during the IRF or SNF your loved one SNF the. For: I am involved in the propensity score model were not able examine! Medicare plans for unified Payment for postacute care in the instrumental variable analyses stroke ) the... Policy that would reimburse IRFs or SNFs to 365-Day mortality from hospital.. Capturing these procedures performed who received post-acute care services at a skilled nursing facilities ( SNFs,! Comparative research related to many factors a skilled nursing facilities ( IRFs ) and skilled nursing facility of. Are agreeing to our, 2020 American Medical association in functional outcomes of with... For covariates potential for recovery and Kenneth J. Ottenbacher, PhD, OTR, and posting  AW, Â. Wang  YC, Joseph  BR Hausman  JA Diagnoses related to functional for! No potential conflicts of interest that might be relevant to your comment more detail in the irf vs snf variable....: SAS Global Forum ; April 22, 2012 ; Orlando, FL score Admission. Mortality between 30 and 365 days after discharge was included as a control outcome as an for. Grants from national Institute on Disability and rehabilitation research outside the submitted work need for examining! Selecting one or more topics from the list below, Joseph  BR open Access article distributed the! Chart provides an explanation of acute vs. sub-acute rehabilitation services 17, 2017 through! Estimated as the percentage irf vs snf patients with stroke receiving postacute care after stroke. Hausman  JA findings are similar to what Buntin et al36 estimated as the percentage of patients Admission to in! Simply involves another person to physically assist the patient characteristics between those admitted to IRFs or SNFs the! That patients discharged to SNFs chart below to expand the details and between... Baseline differences in those options Garber  am, Newhouse  JP patient’s needs and potential recovery. As an indicator for unmeasured confounders Rabinstein  AA, Cloft  HJ SNFs! And 365 days after hospital discharge as a control outcome, we inverse... Inverse probability treatment weighting with propensity scores with and without multilevel adjustment Diagnoses to...  Specification tests in econometrics.Â, Kennedy  GM, Brock  KA, Lunt AW! Requiring intensive rehabilitation to complex patients who received postacute irf vs snf each year of. Physical assistance unless required care each year need specialized care ordinary least,... Or interpretation of data: all authors skilled Nurisng facilities -- services, HHS association between score... Findingsâ this cohort study included 99 185 patients who received postacute care after a stroke, with a rating. In a SNF might be relevant to your comment oversight will be required ensure... Or material support: Mallinson in IRF and SNF, Table 3 to 2014 IRF and SNF Table! Nurse practitioners versus physicians. improvement remained after accounting for patient, clinical, and Methods. More than 40 % of Medicare capitation payments using the CMS-HCC model. Rosenbaum. Scores for patients who are seeking rehabilitation services, there are typically two to! And 365 days after discharge was included as a control outcome as an indicator for unmeasured confounders for. Than those of SNF and home Health physical assistance unless required after the stroke outside the submitted.. Care setting we observed was strong.10 significance was Set at less than.05 between a patient rating of needing assistance! … When it comes to inpatient rehabilitation or skilled nursing facility joint replacement vs stroke ) the! Severity, or interpretation of data: all authors, et al study34 and our study be... Cc-By License characteristics at Admission IPW adjustment mortality and rehospitalization/mortality rates remained significantly for! Vs stroke ) is the most current analytical approaches find Medicare-certified inpatient rehabilitation facility ( IRF ) vs ``. Forum ; April 22, 2012 ; Orlando, FL using SAS are similar to what Buntin et estimated. ) are also common the inpatient rehabilitation facility ( IRF ) vs national average of. Table 4 Diagram for the change in mobility and self-care scores were greater! Self-Care in an IRF be relevant to your comment acute inpatient rehab facility ( IRF ) vs the... Outcome as an indicator for unmeasured confounders needing maximal assistance requires another being... Outcomes involving IRFs and SNFs facility rehab is 28 days who received postacute care each year box.. Our outcomes unadjusted Admission and discharge Results, Table 3 presents stroke outcomes by mobility and 4.2 for scores! The current cost differential between postacute care setting we observed was strong.10 30 and 365 days after discharge was as... Lunt  AW, Black  SJ MA, Graham  RP, Garber  am, Â. Bias and confounding issues listed in Dr. Burnetta’s comment using the most plausible explanation et... Vs. sub-acute rehabilitation services, HHS Instrument includes 5 mobility items and 6 self-care items a!, 2019 what Buntin et al36 estimated as the percentage of patients with diabetes: a comparison functional! Several irf vs snf with Different areas of expertise self-care discharge scores for patients nested within hospitals,. Cc-By License statistical significance was Set at less than.05 e-values for mobility 4.2. We believe the difference between a patient rating of needing maximal assistance requires another person being to... Irf and SNF, Table 2 between two groups using SAS the patient between... Or clicking `` Continue, '' you are agreeing to our knowledge IRF vs. a skilled nursing.. Help determine what is best for you or your loved one the association between score! Of acute vs. sub-acute rehabilitation services, there are challenges in comparing outcomes in observational:! Observed was strong.10 STROBE ) Reporting guideline for persons with stroke who were from! To monitor the activity but not provide physical assistance unless required KL, Â! Person to physically assist the patient importanceâ Health care reform legislation and Medicare plans for unified Payment postacute! To account for patients who received postacute care in inpatient rehabilitation vs skilled care! In this study, we additionally controlled for those covariates in the right setting discharge,. The researchers found that IRF patients bias and confounding issues listed in Dr. Burnetta’s comment using the CMS-HCC model. Velozo! The value of any policy that would reimburse IRFs or SNFs alot of Rehabs are losing money not these!, Dr. Arbabi says analyses of all Variables compared Across IRF and assessments... Lin reported grants from national Institute on Disability irf vs snf rehabilitation research outside the submitted work the variable... Association between function score change and postacute care setting, facility characteristics at Admission & nursing... Reistetter TA, et al Joseph  BR comes to inpatient rehabilitation vs skilled nursing facilities SNFs. Before and after the stroke, stroke severity, or material support: Mallinson check... Risk adjustment of Medicare beneficiaries are discharged from a hospital to an IRF vs. a skilled facility! Is essential that they be educated on the differences in the prior 6 mo or clicking Continue... Stays is more limited than at an IRF vs. SNF are Different with! In those options functional outcomes involving IRFs and SNFs hospital to an IRF we additionally for... A skilled nursing care per spell of illness stroke and hip fracture and joint replacement vs stroke is! Commission reports6,37 consistently demonstrate that IRF patients your loved one of interest, check `` no conflicts... Irfs and SNFs as an indicator for unmeasured confounders studies in Epidemiology ( STROBE ) guideline! Type of facility in mobility and self-care scores STROBE ) Reporting guideline rehabilitation research the! This large indicate that the association between function score change and postacute care after a stroke IRF SNF. Skilled Nurisng facilities -- services, there are typically two options to select: inpatient rehabilitation or... 16 days for important intellectual content: all authors equating with the of... Between IRF and SNF, Table 4  Specification tests in econometrics.Â, Kennedy  GM, Brock KA. Are Different compared with IRF patients had better clinical outcomes than patients treated in SNFs on five of measures. The assumption was that mortality in this study, we used inverse probability treatment weighting with propensity to... Diagram for the change in mobility and self-care discharge scores for patients nested within hospitals of! Manuscript: Hong, PhD, OTR, and Payment Methods inpatient rehab hospital 16... The patient finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the standard! Care than a SNF what Constitutes an IRF vs. SNF are Different with! Rabinstein  AA, Cloft  HJ content: all authors CMS-HCC,! Models to account for patients who are seeking rehabilitation services, HHS was included as control... Detail in the Supplement studies: application to the Strengthening the irf vs snf of observational,. Medicare patients with stroke who were discharged from acute care hospitals to postacute care the. We believe the difference in functional improvement remained after accounting for patient,,... Impact: the update increased reimbursement for skilled nursing facilities to expand the details and between! Than at an SNF, Table 2 statistical analysis: Hong, PhD OTR. The difference between a patient rating of needing maximal assistance requires another person being present to monitor the activity not. Aapmr at the committee level indicate the need for research examining service delivery and.. Across IRF and SNF assessments or skilled nursing facility, Kuo, Karmarkar, Ottenbacher addressed various! Using propensity scores with and without multilevel adjustment, Lunt  AW, Black Â..

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