Rehabilitation Intensity and Patient Outcomes in Skilled Nursing Facilities in the United States: A Systematic Review

Abstract

Objective Exponential increases in rehabilitation intensity in skilled nursing facilities (SNFs) motivated recent changes in Medicare reimbursement policies, which remove financial incentives for providing more minutes of physical therapy, occupational therapy, and speech therapy. Yet there is concern that SNFs will reduce therapy provision and patients will experience worse outcomes. The purpose of this systematic review was to synthesize current evidence on the relationship between therapy intensity and patient outcomes in SNFs. Methods PubMed, Medline, Scopus, Embase, CINAHL, PEDro, and COCHRANE databases were searched. English-language studies published in the United States between 1998 and February 14, 2020, examining the relationship between therapy intensity and community discharge, hospital readmission, length of stay (LOS), and functional improvement for short-stay SNF patients were considered. Data extraction and risk of bias were performed using the American Academy of Neurology (AAN) Classification of Evidence scale for causation questions. AAN criteria were used to assess confidence in the evidence for each outcome. Results Eight observational studies met inclusion criteria. There was moderate evidence that higher intensity therapy was associated with higher rates of community discharge and shorter LOS. One study provided very low-level evidence of associations between higher intensity therapy and lower hospital readmissions after total hip and knee replacement. There was low-level evidence indicating higher intensity therapy is associated with improvements in function. Conclusions This systematic review concludes, with moderate confidence, that higher intensity therapy in SNFs leads to higher community discharge rates and shorter LOS. Future research should improve quality of evidence on functional improvement and hospital readmissions. Impact This systematic review demonstrates that patients in SNFs may benefit from higher intensity therapy. Because new policies no longer incentivize intensive therapy, patient outcomes should be closely monitored to ensure patients in SNFs receive high-quality care.

Detraining Slows and Maintenance Training Over 6 Years Halts Parkinsonian Symptoms-Progression

“…The drugs are still the primary symptom-moderators in people with PD (PwPD), as the lesion surgeries and deep brain stimulation cannot halt the progression of the underlying neurodegenerative processes (4). Physical exercise has been also used as an adjuvant to the drugs to reduce the motor and nonmotor PD-symptoms and improve quality of life (2,3,(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19). The potency of exercise is revealed by the 21 year delay in the clinical manifestation of PD in the physically active individuals (20).…”

“…When exercise is enriched with multi-sensory stimuli, the improvements in the motor and non-motor symptoms can be long-lasting (6,22,23). Indeed, high-intensity exercise can enhance the processes beyond those impacted by levodopa (Ldopa) medications (7,9,16,17,(24)(25)(26)(27)(28)(29). Because improvements in the symptoms outlast the exercise period during detraining, exercise might have the potential to slow not only symptom-but disease-progression (7).…”

“…Because improvements in the symptoms outlast the exercise period during detraining, exercise might have the potential to slow not only symptom-but disease-progression (7). Accordingly, therapy-intensity predicted the length of hospital stay, hospital readmission, and functional improvements (9). However, the results are inconsistent, as improvements in the symptoms can still be independent of exercise duration, frequency, and intensity even if PwPD are of the same age, gender, and disease stage.…”

Therapy Assistant Staffing and Patient Quality Outcomes in Skilled Nursing Facilities

“…SNFs may respond to PDPM with a variety of process decisions related to therapy staffing. For example, despite evidence that higher intensity rehabilitation and higher overall therapy staffing have been linked to improved quality outcomes such as higher rates of patient functional improvement and successful community discharge (Jette et al, 2004(Jette et al, , 2005Jung et al, 2016;O'Brien et al, 2018;Prusynski, Gustavson, et al, 2021), SNFs may also choose to lower costs by providing fewer therapy minutes overall, which could impact both therapist and assistant staffing (Livingstone et al, 2019). Early evidence has in fact shown early declines in national therapy staffing after PDPM implementation, with assistant staffing declining at sharper rates compared with therapist staffing (McGarry et al, 2021;Prusynski, Leland, et al, 2021).…”

“…This study examines associations between proportions of therapy assistant versus therapist staffing and three rehabilitation-sensitive quality outcomes: patient functional improvement, community discharge, and hospital readmissions. We will also examine therapy assistant staffing in the context of therapy intensity, as PDPM shifts incentives for therapy intensity in addition to staffing, and prior studies suggest therapy intensity is positively associated with quality (Prusynski, Gustavson, et al, 2021).…”