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National Healthcare Quality Report, 2013

Functional Status Preservation and Rehabilitation

Importance

Demographics
Noninstitutionalized adults needing help of another person with activities of daily living (ADLs)xii (2011) 5.2 million (Adams, et al., 2012)
Noninstitutionalized adults needing help with instrumental activities of daily living (IADLs)xiii (2011) 9.8 million (Adams, et al., 2012)
Number of Medicare beneficiaries receiving inpatient rehabilitation facility care (2010) 371,000 (MedPAC, 2013)
Cost
Medicare payments for outpatient physical therapy (2008 est.) $3.5 billion (Ciolek & Hwang, 2010)
Medicare payments for outpatient occupational therapy (2008 est.) $928 million (Ciolek & Hwang, 2010)
Medicare payments for outpatient speech-language pathology services (2008 est.) $336 million (Ciolek & Hwang, 2010)
Medicare payments for hospital outpatient rehabilitation (2011) $4.6 billion (CMS, 2012a)
Medicare payments for inpatient rehabilitation facility care (2011) $7.0 billion (MedPAC, 2013)

Measures

A person's ability to function can decline with disease or age, but it is not always an inevitable result. Threats to function span a wide variety of medical conditions. Services to maximize function are delivered in a variety of settings, including hospitals, providers' offices, patients' homes, long-term care facilities, and other post-acute care or rehabilitation facilities.

Some health care interventions, such as promoting physical activity and social interaction, can help prevent diseases that commonly cause declines in functional status. Other interventions, such as physical therapy, occupational therapy, and speech-language pathology services, can help patients regain function that has been lost or minimize the rate of decline in functioning.

The NHQR and NHDR track several measures related to functional status preservation and rehabilitation. Three measures are highlighted in this section:

  • Improvement in mobility among home health care patients.
  • Nursing home residents needing more help with daily activities.
  • Functional Independence Measure scores among inpatient rehabilitation facility patients.

Findings

Outcome: Improvement in Mobility Among Home Health Care Patients

After an illness or injury, many patients may need temporary help getting around at home. Home health care providers can help patients get around and attend to daily activities until they recover. This can include assistance with walking and using equipment, such as a cane or wheelchair. If needed, they can also provide physical therapy to facilitate improvements in walking or moving with an assistive device.

Better quality physical therapy and support for mobility should yield more rapid improvement in a patient's ability to get around. However, mobility may not improve even when a home health agency provides good care. Progressive neurologic conditions, such as multiple sclerosis or Parkinson's disease, may impair mobility despite optimal home health care. In addition, the potential for mobility improvement may differ across patient populations referred to different home health agencies in different geographic areas.

Figure 3.14. Adult home health care patients whose ability to walk or move around improved, by age, 2010-2011

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Source: Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set (OASIS), 2010-2011.
Denominator: Adult nonmaternity patients completing an episode of skilled home health care and not already performing at the highest level at the start of the episode, according to the OASIS question on ambulation.

  • In 2011, the percentage of home health care patients who got better at walking or moving around was 57.0% (Figure 3.14).
  • In both years, patients age 85 and over were less likely than patients in other age groups to show improvement. These patients may have higher levels of disability or infirmity than younger patients that make improvements in mobility harder to achieve.
  • The 2010 top 5 State achievable benchmark was 62.5%.xiv Data are insufficient to determine time to benchmark.

Also, in the NHDR:

  • In 2011, Black, American Indian or Alaska Native (AI/AN), and Hispanic home health patients were less likely than Whites to show improvement in their ability to walk or move around.

Outcome: Nursing Home Residents Needing More Help With Daily Activities

Long-stay residents typically enter a nursing facility because they can no longer care for themselves at home. They tend to remain in the facility for several months or years. While almost all long-stay nursing home residents have limitations in their ADLs, nursing home staff help residents stay as independent as possible.xv

Most residents want to care for themselves, and the ability to perform daily activities is important to their quality of life. While some functional decline among residents cannot be avoided, high-quality nursing home care should minimize the rate of decline and the number of patients experiencing decline.

This measure uses assessments of need for help with daily activities, conducted regularly by nursing homes, to identify those residents whose need for help increased from one assessment to the next. In 2011, the patient assessment instrument for nursing homes was changed to version 3.0 of the Minimum Data Set. Many measures, including the definition of long-stay nursing home residents, changed. Estimates in this report of need for help with daily activities by nursing home residents are not comparable with estimates in previous reports.

Figure 3.15. Long-stay nursing home residents whose need for help with daily activities increased, by age and sex, 2011

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Source: Centers for Medicare & Medicaid Services, Minimum Data Set, 2011. Data are from the third quarter of the calendar year.
Denominator: All long-stay residents in Medicare- or Medicaid-certified nursing home facilities.
Note: For this measure, lower rates are better.

  • In 2011, 18.3% of long-stay nursing home residents had increased need for help with daily activities (Figure 3.15).
  • Residents ages 0-64 and 65-74 were less likely than residents age 85 and over to need increased help with daily activities.
  • The 2011 top 5 State achievable benchmark was 15%.xvi In 2011, residents ages 0-64 had a rate lower than the benchmark. Data are insufficient to determine time to benchmark.

Also, in the NHDR:

  • In all age groups, Asian or Pacific Islander (API) residents were less likely than White residents to need increased help with daily activities.

Focus on Inpatient Rehabilitation Facility Patients

Patients receive rehabilitation therapies for a range of impairments from different types of providers, inpatient and outpatient. Inpatient rehabilitation facilities (IRFs) may be standalone facilities or part of hospitals and offer intensive physical therapy services as part of rehabilitation. Patients are often sent to IRFs for rehabilitation following joint replacements and strokes. Each Medicare-certified IRF collects measures of functional status (called the Functional Independence Measure or FIM) at admission and discharge for each Medicare patient as part of the IRF Patient Assessment Instrument.

By providing information on the change in functional ability between admission and discharge, we can see how much patients have improved in functional ability during their stay in the IRFs. We restricted analyses to patients who had initial rehabilitation and were discharged to the community (home, board and care, transitional living, or assisted living) as a way of controlling for patient case mix.

Figure 3.16. Functional Independence Measure scores at admission and discharge by type of function, 2011

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Source: Centers for Medicare & Medicaid Services, Inpatient Rehabilitation Facility Patient Assessment Instrument, 2011.
Denominator: All Medicare patients in an inpatient rehabilitation facility for initial rehabilitation and discharged to the community (home, board and care, transitional living, or assisted living).
Note: Functional score ranges from 1 (worst ability) to 7 (full function). FIM motor scores cover locomotion, transfer, self-care, and sphincter control.

  • In 2011, patients admitted to IRFs had lower function in their locomotion and transfer abilities and higher function in their social cognition and communication abilities (Figure 3.16).
  • Gains in function between admission and discharge to the community were observed in all types of abilities and were largest in locomotion and transfer abilities.

Also, in the NHDR:

  • Gains in motor function between admission and discharge to the community were smaller among AI/AN and multiple-race individuals compared with White individuals.

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Supportive and Palliative Care

Importance

Demographics
Number of Medicare nursing home residents ever admitted during the calendar year (2011) 2.6 million (CMS, 2012b)
Number of Medicare fee-for-service (FFS) home health patientsxvii (2011) 3.5 million (CMS, 2012c)
Number of Medicare FFS beneficiaries using Medicare hospice services (2011) 1.2 million (CMS, 2012d)
Cost
Total costs of nursing home carexviii (2011) $149.3 billion (CMS, 2011)
Total costs of home health carexviii (2011) $74.3 billion (CMS, 2011)
Medicare FFS payments for hospice services (2011) $13.8 billion (CMS, 2012d)

Measures

Disease cannot always be cured, and functional impairment cannot always be reversed. For patients with long-term health conditions, managing symptoms and preventing complications are important goals. Supportive and palliative care cuts across many medical conditions and is delivered by many health care providers. Supportive and palliative care focuses on enhancing patient comfort and quality of life and preventing and relieving symptoms and complications.

Toward the end of life, hospice care provides patients and families with practical, emotional, and spiritual support to help cope with death and bereavement. Honoring patient values and preferences for care is also critical. Palliative and end-of-life care needs to be "capable of promising dignity, comfort, companionship, and spiritual support to patients and families facing advanced illness or dying" (National Priorities Partnership, 2008).

The NHQR and NHDR track several measures of supportive and palliative care delivered by home health agencies, nursing homes, and hospices. The five measures presented in this section reflect patient- and family-centered care, goal setting, and care planning, which are among the critical areas of care delivery identified by the Measure Applications Partnership (MAP, 2012):

  • Relief of suffering:
    • Shortness of breath among home health care patients.
    • Moderate to severe pain among nursing home residents.
  • Help with emotional and spiritual needs:
    • Right amount of emotional support among hospice patients.
  • Effective communication:
    • Enough information about what to expect among hospice family caregivers.
  • High-quality palliative care:
    • Care consistent with patient's wishes among hospice patients.

Findings

Relief of Suffering

Outcome: Shortness of Breath Among Home Health Care Patients

Shortness of breath is uncomfortable. Many patients with heart or lung problems experience difficulty breathing and may tire easily or be unable to perform daily activities. Doctors and home health staff should monitor shortness of breath and may give advice, therapy, medication, or oxygen to help lessen this symptom.

Figure 3.17. Adult home health care patients who had less shortness of breath between the start and end of a home health care episode, by age, 2002-2011

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Source: Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set (OASIS), 2002-2011.
Denominator: Adult nonmaternity patients completing an episode of skilled home health care.
Note: Starting January 1, 2010, the patient assessment instrument for home health agencies was changed to OASIS-C. Because dyspnea improvement is measured similarly in both the previous and current versions of the assessment instrument, we are presenting 2002 through 2011 trend data.

  • Between 2002 and 2011, the percentage of adult home health care patients who showed improvement in shortness of breath over the course of a home health episode increased for the total population (Figure 3.17) and for every age group.
  • The 2008 top 5 State achievable benchmark was 68%.xix At the current annual rate of increase, this benchmark could be attained overall in about 5 years. Patients ages 65-74 and 75-84 could attain the benchmark in about 4 years, while patients ages 18-64 and 85 and over would take between 5 and 7 years to attain the benchmark.

Also, in the NHDR:

  • Between 2002 and 2011, the percentage of adult home health care patients who showed improvement in shortness of breath increased for each racial/ethnic group except Hispanics.
  • From 2006 to 2011, Hispanics were less likely than Whites to show improvement in shortness of breath.

Outcome: Moderate to Severe Pain Among Nursing Home Residents

Adequate pain management is an important indicator of quality of care and quality of life. Untreated and undertreated pain are common problems among older adults living in the community and in nursing homes. Assessment and management of pain in this population is complex and is made more difficult by the high prevalence of multiple chronic conditions, dementia, and other impairments. Previous NHQRs and NHDRs have shown that many long-stay nursing home residents with moderate to severe pain receive pain medications on an as-needed basis only and that few participate in special pain management programs.

In 2011, the patient assessment instrument for nursing homes was changed to version 3.0 of the Minimum Data Set, and many measures changed. Estimates in this report of nursing home residents with pain are not comparable with estimates in previous reports.

New! Figure 3.18. Long-stay nursing home residents who have moderate to severe pain, by age and sex, 2011

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Source: Centers for Medicare & Medicaid Services, Minimum Data Set, 2011. Data are from the third quarter of the calendar year.
Denominator: All long-stay residents in Medicare- or Medicaid-certified nursing home facilities.
Note: For this measure, lower rates are better.

  • In 2011, 14.7% of long-stay nursing home residents had moderate to severe pain (Figure 3.18).
  • Residents ages 0-64, 65-74, and 75-84 were more likely than residents age 85 and over to have moderate to severe pain.
  • The 2011 top 5 State achievable benchmark was 8.1%.xx In 2011, no group had achieved the benchmark. Data are insufficient to determine time to benchmark.

Also, in the NHDR:

  • In all age groups, Black, API, and Hispanic residents were less likely than White residents to have moderate to severe pain.
  • AI/AN residents were more likely than White residents to have moderate to severe pain, especially those ages 0-64 years.

Help With Emotional and Spiritual Needs

Hospice care is generally delivered at the end of life to patients with a terminal illness or condition who desire palliative medical care; it also includes practical, psychosocial, and spiritual support for the patient and family. The goal of end-of-life care is to achieve a "good death," defined by the IOM as one that is "free from avoidable distress and suffering for patients, families, and caregivers; in general accord with the patients' and families' wishes; and reasonably consistent with clinical, cultural, and ethical standards" (Field & Cassell, 1997).

The National Hospice and Palliative Care Organization's Family Evaluation of Hospice Care survey examines the quality of hospice care for dying patients and their family members. Family respondents report how well hospices respect patients' wishes, communicate about illness, control symptoms, support dying on one's own terms, and provide family emotional support.xxi

Management: Right Amount of Emotional Support Among Hospice Patients

Dying is a stressful process, and patients at the end of life may develop depression or anxiety disorders. Health care systems and providers need to be attuned to recognizing and responding to the emotional and spiritual needs of patients with life-limiting illness and their families.

Figure 3.19. Hospice patients age 18 and over who did NOT receive the right amount of help for feelings of anxiety or sadness, by age, 2008-2012

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Source: National Hospice and Palliative Care Organization, Family Evaluation of Hospice Care, 2008-2012.
Denominator: Adult hospice patients.
Note: For this measure, lower rates are better.

  • The percentage of hospice patients whose families reported that they did not receive the right amount of help for feelings of anxiety or sadness was 9.4% in 2012 (Figure 3.19).
  • In all years, hospice patients ages 18-44 and 45-64 were less likely than patients age 65 and over to receive the right amount of emotional support.
  • The 2009 top 5 State achievable benchmark was 6.4%.xxii Overall, hospice patients are not making progress toward this goal. Improvement is observed among hospice patients ages 18-44, but at the current annual rate of improvement, the benchmark would not be achieved for about 20 years.

Also, in the NHDR:

  • In all years, Blacks, APIs, and AI/ANs were less likely than Whites and Hispanics were less likely than non-Hispanic Whites to receive the right amount of emotional support.

Effective Communication

Management: Enough Information About What To Expect Among Hospice Family Caregivers

Patients at the end of life and their families need clear information about treatment options, prognosis, advance directives, and what to expect while the patient is dying. Health care providers need to be skilled at eliciting patients' values and preferences, accepting of different cultural and religious choices, and committed to continuing care regardless of patient treatment decisions.

Figure 3.20. Hospice patients age 18 and over whose family caregivers wanted more information about what to expect while the patient was dying, by age, 2008-2012

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Source: National Hospice and Palliative Care Organization, Family Evaluation of Hospice Care, 2008-2012.
Denominator: Adult hospice patients.
Note: For this measure, lower rates are better.

  • The percentage of hospice patient family caregivers who reported that they wanted more information about what to expect while the patient was dying was 15.0% in 2012 (Figure 3.20).
  • In all years, family caregivers of hospice patients ages 18-44 and 45-64 were more likely than family caregivers of patients age 65 and over to want more information about what to expect while the patient was dying.
  • The 2008 top 6 State achievable benchmark was 11%.xxiii Overall, no progress has been made toward this benchmark. Hospice patients ages 18-44 are moving away from the benchmark.

Also, in the NHDR:

  • In all years, family caregivers of API hospice patients were more likely than family caregivers of White patients to want more information about what to expect while the patient was dying. Family caregivers of Hispanic patients were more likely than family caregivers of non-Hispanic White patients to want more information.

High-Quality Palliative Care

Management: Care Consistent With Patient's Wishes Among Hospice Patients

Hospice care should respect patients' stated goals for care. Respecting patients' goals requires shared communication and decisionmaking between providers and hospice patients and their family members and sensitivity to cultural and religious beliefs.

Figure 3.21. Hospice patients age 18 and over who did NOT receive care consistent with their stated end-of-life wishes, by age, 2008-2012

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Source: National Hospice and Palliative Care Organization, Family Evaluation of Hospice Care, 2008-2012.
Denominator: Adult hospice patients.
Note: For this measure, lower rates are better.

  • The percentage of hospice patients whose families reported that they did not receive end-of-life care consistent with their stated wishes was 5.2% in 2012 (Figure 3.21).
  • In 2011 and 2012, hospice patients ages 18-44 were less likely than patients age 65 and over to receive end-of-life care consistent with their wishes.
  • The 2008 top 5 State achievable benchmark was 3.5%.xxiv At current rates of improvement, this benchmark could not be attained overall for about 15 years. Patients ages 18-44 and 65 and over could achieve the benchmark in about 10 years. Patients ages 45-64 show no progress toward the benchmark.

Also, in the NHDR:

  • In all years, Blacks, APIs, and AI/ANs were less likely than Whites and Hispanics were less likely than non-Hispanic Whites to receive end-of-life care consistent with their wishes.

 


xii ADLs consist of basic self-care tasks, such as bathing, dressing, eating, transferring, using the toilet, and walking.
xiii IADLs consist of tasks needed for a person to live independently, such as shopping, doing housework, preparing meals, taking medications, using the telephone, and managing money.
xiv The top 5 States that contributed to the achievable benchmark are Maine, Missouri, New Jersey, South Carolina, and Utah.
xv In Olmstead v. L.C., 527 U.S. 581 (1999), the U.S. Supreme Court concluded that the unjustified institutionalization of people with disabilities is a form of unlawful discrimination under the Americans With Disabilities Act of 1990, 42 U.S.C. 12101 et seq. The Court held that States are required to provide community-based services for people with disabilities who would otherwise be entitled to institutional services when: (1) such placement is appropriate; (2) the affected person does not oppose such treatment; and (3) the placement can be reasonably accommodated, taking into account the resources available to the State and the needs of other individuals with disabilities. More information about the HHS Office for Civil Rights' Olmstead enforcement efforts is available at www.hhs.gov/ocr/civilrights/understanding/disability/serviceolmstead/index.html.
xvi The top 5 States that contributed to the achievable benchmark are Alaska, California, Illinois, Oregon, and Utah.
xvii Medicare FFS patients represent only a portion of all home health patients.
xviii Cost estimates for nursing home and home health services include only costs for freestanding skilled nursing facilities, nursing homes, and home health agencies and not those that are hospital based.
xix The top 5 States that contributed to the achievable benchmark are Georgia, Hawaii, New Jersey, Rhode Island, and South Carolina.
xx The top 5 States that contributed to the achievable benchmark are District of Columbia, Hawaii, Maryland, New Jersey, and New York.
xxi This survey provides unique insight into end-of-life care and captures information about a large percentage of hospice patients but is limited by nonrandom data collection and a response rate of about 40%. Survey questions were answered by family members, who might not be fully aware of the patient's wishes and concerns. These limitations should be considered when interpreting these findings.
xxii The top 5 States that contributed to the achievable benchmark are Alabama, Alaska, Arkansas, Kansas, and South Carolina.
xxiii The top 6 States that contributed to the achievable benchmark are Alabama, Idaho, Iowa (tie), Kansas, South Dakota (tie), and West Virginia.
xxiv The top 5 States that contributed to the achievable benchmark are Maine, Minnesota, Mississippi, New Hampshire, and Tennessee.


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Page originally created May 2014

 

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