Enhanced Medical Rehabilitation Increases Therapy Intensity and Engagement and Improves Functional Outcomes in Postacute Rehabilitation of Older Adults: A Randomized-Controlled Trial

Abstract

Objectives For millions of disabled older adults each year, post-acute care in skilled nursing facilities (SNFs) is a brief window of opportunity to regain enough function to return home and live independently. Too often this goal is not achieved, possibly due to therapy that is inadequately intense or engaging. This study tested Enhanced Medical Rehabilitation, an intervention designed to increase patient engagement in, and intensity of, daily physical and occupational therapy sessions in post-acute care rehabilitation. Design Randomized controlled trial of Enhanced Medical Rehabilitation versus standard-of-care rehabilitation. Setting Post-acute care unit of a skilled nursing facility in St Louis, MO. Participants 26 older adults admitted from a hospital for post-acute rehabilitation. Intervention Based on models of motivation and behavior change, Enhanced Medical Rehabilitation is a set of behavioral skills for physical and occupational therapists (PT/OT) that increase patient engagement and intensity, with the goal of improving functional outcome, through: (1) a patient-directed, interactive approach, (2) increased rehabilitation intensity, and (3) frequent feedback to patients on their effort and progress. Measurements Therapy intensity: assessment of patient active time in therapy sessions. Therapy engagement: Rehabilitation Participation Scale. Functional and performance outcomes: Barthel Index, gait speed, and six-minute walk. Results Participants randomized to Enhanced Medical Rehabilitation had higher intensity therapy and were more engaged in their rehabilitation sessions; they had more improvement in gait speed (improving from 0.08 to 0.38 meter/sec vs. 0.08 to 0.22 in standard of care,p=0.003) and six-minute walk (from 73 to 266 feet vs. 40 to 94 feet in standard of care, p=0.026), with a trend for better improvement of Barthel Index (+43 points vs. 26 points in standard of care, p=0.087), compared to participants randomized to standard-of-care rehabilitation. Conclusion Higher intensity and patient engagement in the post-acute rehabilitation setting is achievable, with resultant better functional outcomes for older adults. Findings should be confirmed in a larger randomized controlled trial.

Hospital Readmission From Post-Acute Care Facilities: Risk Factors, Timing, and Outcomes

“…Impaired functional status was associated with the highest risk of readmission in our study; evidence of its impact on patient outcomes in other settings supports this finding. (18,41–45) However, little is known about which patients benefit from skilled rehabilitation therapies,(46) which therapies to utilize,(47–49) or when therapy is most effectively delivered. (50) This has important downstream cost implications as patients who fail to rehabilitate may be confined to nursing homes for long-term care.…”

Initiation of Antidepressant Medication After Hip Fracture in Community-Dwelling Older Adults

“…This is not a surprising finding, given that a psychiatric consultant may feel the need to recommend an antidepressant in the case of an emotionally distressed or behaviorally disturbed patient. Nevertheless, given the current uncertainty regarding the risk-benefit ratio of antidepressants in this population and the potential for harm, psychiatrists can take the lead in recommending non-pharmacologic interventions 45,46 or simply watchful waiting.…”

Stroke rehabilitation

“…Patients with stroke after the acute phase are referred either to independent rehabilitation centers or NFs based on sociodemographic and economic factors such as age, general conditions, and level of impairment 28. A small, but well-designed RCT from a single NF in St. Louis in the United States of America (USA), included 26 older patients 29. Patients were randomized to enhanced medical rehabilitation or standard-of-care rehabilitation.…”