Access to Post-Acute Care for Persons who Need Rehabilitation .

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Access to Post-Acute Care for Persons who Need Rehabilitation. Trudy Mallinson, Ph.D., OTR/L Rehabilitation Institute of Chicago Northwestern University. Post-Acute Care Providers that Provide Rehabilitation Services. Inpatient Rehabilitation Facilities (IRFs)
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Access to Post-Acute Care for Persons who Need Rehabilitation Trudy Mallinson, Ph.D., OTR/L Rehabilitation Institute of Chicago Northwestern University

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Post-Acute Care Providers that Provide Rehabilitation Services Inpatient Rehabilitation Facilities (IRFs) Skilled Nursing Facilities (SNFs) Home Health Agencies (HHAs) Long-Term Care Hospitals (LTCHs) Other suppliers: Outpatient Comprehensive Outpatient Rehabilitation Facilities Adult Day Care

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Post-intense Care Rehab Settings Medicare affirmation necessities fluctuate by PAC setting e.g. IRFs (3 hrs treatment/day, 24hr therapeutic supervision, 75% manage), SNFs (24hr nursing, restricted MD, treatment hrs not determined) However, a significant part of the recovery mind gave is comparable crosswise over settings and, Many patients could possibly be dealt with in more than one setting

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Medicare Expenditures In the mid 1980s, mind gave in post-intense care settings was viewed as a financially savvy other option to developed doctor\'s facility remains By the mid 1990s, mind in post-intense care settings, including IRFs, SNFs, and HHAs had turned into the quickest developing zone of the Medicare program

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Medicare spending for post-intense care has expanded by more than $33 billion. Add up to Medicare installments from 1986 to 1996 by supplier sort (in billions)

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HHA IPS (1997) HHA PPS (2000) SNF PPS (1998) IRF PPS (2002) LTCH PPS (2002) Medicare Spending for Post-Acute Care, by setting, 1992-2001 MedPAC, 2003

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PAC PPS Comparison MedPAC, 2002

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Early Impact of PAC PPSs SNFs Percentage of patients accepting to a great degree large amounts of treatment diminished; rate getting moderate levels expanded (White, 2003) HHAs Significant decrease in number of offices 1997-2000 (NAHC, 2001) however # of visits was a great deal more seriously lessened (Liu et al, 2003; McCall, 2003) Hospital-based HHAs made minimum diminishments (McCall, 2003) Therapy visits as % of scene expanded 9% in 1997 to 23% in 2001, (MedPAC, 2003)

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Early Impact IRF PPS Continued decrease in ALOS of Medicare patients in IRFs from 15.4 days (RAND) in 1999 to 13.2 in 2002 ( eRehabData) . UDSmr reports, Am J PM&R , 1996 - 2002

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Early Impact the IRF PPS expands weight to diminish LOS CMS distributes normal CMGt LOS (for reasons for ascertaining short stay patients) These LOS seem to have been translated as far as possible on LOS

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Average LOS (2002) = 22.3 days Published (1999) Transfer LOS = 33 days ALOS for CMG 0114 (Severe stroke, no comorbidities) 2002 Based on eRehabData releases, 2002 (n=2,157)

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Function at release inclines down with LOS (2002-Q1 2004) eRehabData, 2004

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2 focuses = clinically important change (Deutsch, 2002; Buchanan; 2003) Discharge to group drifts down eRehabData, 2004

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2 focuses = clinically significant change (Deutsch, 2002; Buchanan; 2003) Discharge to organization slants up eRehabData, 2004

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Greater effect on people with interminable inabilities? eRehabData, 2004

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Does this mirror an adjustment in pattern? UDSmr reports, Am J PM&R , 1996 - 2002 eRehabData, 2004

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Post-intense Care PPS Under PPS, every PAC setting has an interesting technique for repayment Creates non-nonpartisan motivators for get to and benefit arrangement. For instance, the inpatient restoration framework (IRF PPS), a settled per scene installment, makes motivations to decrease length-of-stay while the gifted nursing framework (SNF PPS), an altered outlay rate, makes motivators to lessen day by day costs however not length-of-remain.

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Substitutability of Settings Lack of clear clinical rules about which patients are most fittingly administered to in which PAC setting Differing repayments may have made it favorable for suppliers to concede or potentially exchange patients inside the PAC settings of their own association, paying little respect to patient need. (MedPAC, 2003)

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Patterns of PAC Use also, pre-PPS, 19-22% of all PAC patients get mind in at least 2 PAC settings successively (Gage, 1999). Nothing is thought about: examples of PAC use crosswise over settings the expenses connected with specific examples how suppliers have adjusted examples of PAC use because of changing money related motivators

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Issues to Understand Defining Access to PAC Who gets conceded Timing, force and term of administration (inside IRF) Multiple PAC use inside a scene of care Use of non-conventional, extender settings

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Issues to Understand Provider Responses to PPS Tightening affirmation criteria to confine access to extreme or capricious patients; Restricting administrations day by day, amid the scene, or by decreased length-of-stay; Unbundling of administrations i.e. substituting PAC "extender" administrations, for example, day recovery for the later segment of care; Increasing utilization of LTCH and wellbeing net doctor\'s facilities as destinations of restoration; Increasing utilization of numerous segments of the PAC continuum in a solitary scene of care e.g. SNF to IRF to HHC

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Issues to comprehend Access to post-intense care is connected with: Patient variables: Diagnosis, utilitarian status, social support, age Market (office) components: Geographic locale, supply and responsibility for and, oversaw mind entrance

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Early Impact of IRF-PPS NIDRR HSR DRRP on Medical Rehabilitation - 5 year ponder, H133A030807 Aim 1: Organization of Med. Restoration Tom Prince, Elizabeth Durkin Aim 2: Access To Medical Rehabilitation Trudy Mallinson, Larry Manheim Aim 3: Patient Outcomes Allen Heinemann, Debbie Dobrez Aim 4: Comorbidities Debbie Dobrez, Anne Deutsch

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Aim 1 - Organization Examine closings, mergers, acquisitions Impact of market elements on rebuilding Impact of IRF attributes (unit or detached, revenue driven status and so on) on rebuilding How reactions to weights are made (subjective) Aim 2 - Access Examine changes in sort and seriousness of patients admitted to IRFs Examine changes in PAC use (crosswise over scene) Effects more noteworthy for IRFs that are NFP, incorporated with doctor\'s facility, high pre-PPS costs in respect to expected PPS incomes NIDRR HSR DRRP

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Available Databases for IRF Medicare Provider of Service File Hospital Cost Reports Beneficiary Files Proprietary eRehabData UDSmr

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Other issues affecting access to IRFS LMRPs (Local Medical Review Policies) Now LCDs, created and upheld by Fiscal Intermediaries (FIs) 75% control Previously not authorized, numerous offices don\'t at present go along Both of these will have a far more prominent effect on access to IRFs than PPS

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Longer-term issues What recovery is (black box), for whom recovery is powerful Confounds issues of get to in light of the fact that can\'t characterize who will do best specifically PAC settings Do understanding results differ crosswise over post intense care settings and what are the expenses connected with the results? What level of joining over the PAC-LTC continuum is expected to encourage the most suitable treatment choices?

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What is NIDRR? National Institute of Disability and Rehabilitation Research Organizationally situated inside the Office of Special Education Resources inside the Department of Education Variety of subsidizing components Field started, Centers - Research and Training, Engineering and Research, Fellowships

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Health Services Research – Disability and Rehabilitation Research Project on Medical Rehabilitation (H133A030807) Acknowledgments

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The End

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