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It has been 10 years since Jewell, Moore, and Goldstein (1) prompted clinicians, administrators, and researchers 'to define and deliver the value added by physical therapist services [in the health [...]

Objective: To assess the effectiveness of a hospital physical therapy (PT) referral triggered by scores on a mobility assessment embedded in the electronic health record (EHR) and completed by nursing staff on hospital admission. Data Sources: EHR and billing data from 12 acute care hospitals in a western Pennsylvania health system (January 2017-February 2018) and 11 acute care hospitals in a northeastern Ohio health system (August 2019-July 2021). Study Design: We utilized a regression discontinuity design to compare patients admitted to PA hospitals with stroke who reached the mobility score threshold for an EHR-PT referral (treatment) to those who did not (control). Outcomes were hospital length of stay (LOS) and 30-day readmission or mortality. Control variables included demographics, insurance, income, and comorbidities. Hospital systems with EHR-PT referrals were also compared to those without (OH hospitals as alternative control). Subgroup analyses based on age were also conducted. Data Extraction: We identified adult patients with a primary or secondary diagnosis of stroke and mobility assessments completed by nursing (n = 4859 in PA hospitals, n = 1749 in OH hospitals) who completed their inpatient stay. Principal Findings: In the PA hospitals, patients with EHR-PT referrals had an 11.4 percentage-point decrease in their 30-day readmission or mortality rates (95% CI -0.57, -0.01) relative to the control. This effect was not observed in the OH hospitals for 30-day readmission ([beta] = 0.01; 95% CI -0.25, 0.26). Adults over 60 years old with EHR-PT referrals in PA had a 26.2 percentage-point (95% CI -0.88, -0.19) decreased risk of readmission or mortality compared to those without. Unclear relationships exist between EHR-PT referrals and hospital LOS in PA. Conclusions: Health systems should consider methodologies to facilitate early acute care hospital PT referrals informed by mobility assessments. KEYWORDS functional status measurement, observational data/quasi-experiments, aging/elderly/geriatrics, health care organizations and systems, rehabilitation services What is known on this topic * The World Health Organization and The Joint Commission recommend early interdisciplinary rehabilitation, including physical therapy, in the acute care setting for patients following stroke * Patients after a stroke benefit from mobility, but hospitals experience difficulty keeping patients mobile throughout the hospital stay * Methods are needed to facilitate appropriate referral of patients to physical therapy in the acute care setting with mobility impairments What this study adds * After a stroke, patients with automated EHR-generated hospital physical therapy referrals based on mobility assessments had relatively reduced readmission or mortality rates compared to those without this referral * We found the effect of automated physical therapy referrals on readmission or mortality rates was larger in sicker patients, older adults, and older adults who returned home after a hospitalization * The relationship between acute care rehabilitation services and hospital performance metrics such as length of stay was unclear, probably because additional care comes with a cost of time, 1 | INTRODUCTION Older adults account for almost 50 percent of hospitalizations in U.S. acute care hospitals, excluding maternal and neonatal hospitalizations. (1) In 2018, 13.2 million of the 27.8 [...]

Objective. The purpose of this study was to test the reliability of the Activity Measure for Post-Acute Care (AM-PAC) '6-Clicks' mobility and activity short forms between patients and therapist proxies. As a secondary aim, reliability was examined when patients completed their self-report before versus after the therapist evaluation. Methods. Patients being seen for an initial physical therapist (N =70) or occupational therapist (N =71) evaluation in the acute care hospital completed the '6-Clicks' mobility short form (if a physical therapist evaluation) or activity short form (if an occupational therapist evaluation). Whether patients completed their self-assessment before or after the evaluation was randomized. Patient- and therapist-rated '6-Clicks' raw scores were converted to AM-PAC T-scores for comparison. Reliability was assessed with intraclass correlation coefficients (ICCs) and Bland-Altman plots, and agreement was assessed with weighted kappa values. Results. The ICCs for the '6-Clicks' mobility and daily activity short forms were 0.57 (95% CI = 0.42-0.69) and 0.45 (95% CI =0.28-0.59), respectively. For both short forms, reliability was higher when the patient completed the self-assessment after versus before the therapist evaluation (ICC =0.67, 95% CI = 0.47-0.80 vs ICC=0.50, 95% CI = 0.26-0.67 for the mobility short form; and ICC = 0.52, 95% CI =0.29-0.70 vs ICC= 0.34, 95% CI = 0.06-0.56 for the activity short form). Conclusion. Reliability of the '6-Clicks' total scores was moderate for both the mobility and activity short forms, though higher for the mobility short form and when patients' self-report occurred after the therapist evaluation. Impact. Reliability of the AM-PAC '6-Clicks' short forms is moderate when comparing scores from patients with those of therapists responding as proxies. The short forms are useful for measuring participants' function in the acute care hospital; however, it is critical to recognize limitations in reliability between clinician- and patient-reported AM-PAC scores when evaluating longitudinal change and recovery. Keywords: Activities of Daily Living, Acute Care, Measurement: Basic Theory and Science, Mobility, Introduction Many individuals in acute care hospitals experience new or worsening deficits in physical function and their ability to participate in daily activities. (1,2) Individual's functional status in the hospital [...]

Objective. Physical function is associated with important outcomes, yet there is often a lack of continuity in routine assessment. The purpose of this study was to determine data elements and instruments for longitudinal measurement of physical function in routine care among patients transitioning from acute care hospital setting to home with home health care. Methods. A 4-round modified Delphi process was conducted with 13 participants with expertise in physical therapy, health care administration, health services research, physiatry/medicine, and health informatics. Three anonymous rounds identified important and feasible data elements. A fourth in-person round finalized the recommended list of individual data elements. Next, 2 focus groups independently provided additional perspectives from other stakeholders. Results. Response rates were 100% for online rounds 1, 3, and 4 and 92% for round 2. In round 1, 9 domains were identified: physical function, participation, adverse events, behavioral/emotional health, social support, cognition, complexity of illness/disease burden, health care utilization, and demographics. Following the fourth round, 27 individual data elements were recommended. Of these, 20 (74%) are 'administrative' and available from most hospital electronic medical records. Additional focus groups confirmed these selections and provided input on standardizing collection methods. A website has been developed to share these results and invite other health care systems to participate in future data sharing of these identified data elements. Conclusion. A modified Delphi consensus process was used to identify critical data elements to track changes in patient physical function in routine care as they transition from acute hospital to home with home health. Impact. Expert consensus on comprehensive and feasible measurement of physical function in routine care provides health care professionals and institutions with guidance in establishing discrete medical records data that can improve patient care, discharge decisions, and future research. Keywords: Acute Care, Home Care Services, Measurement: Applied, Medical Informatics, Introduction Within the framework of the International Classification of Functioning, Disability and Health, physical function is the result of interaction between a person's body parts, their whole person, and their [...]

Objective. For patients diagnosed with the novel coronavirus, COVID-19, evidence is needed to understand the effect of treatment by physical therapists in the acute hospital on patient outcomes. The primary aims of this study were to examine the relationship of physical therapy visit frequency and duration in the hospital with patients' mobility status at discharge and probability of discharging home. Methods. This retrospective study included patients with COVID-19 admitted to any of 11 hospitals in 1 health system. The primary outcome was mobility status at discharge, measured using the Activity Measure for Post-Acute Care 6-Clicks basic mobility (6-Clicks mobility) and the Johns Hopkins Highest Level of Mobility scales. Discharge to home versus to a facility was a secondary outcome. Associations between these outcomes and physical therapy visit frequency or mean duration were tested using multiple linear or modified Poisson regression. Potential moderation of these relationships by particular patient characteristics was examined using interaction terms in subsequent regression models. Results. For the 312 patients included, increased physical therapy visit frequency was associated with higher 6-Clicks mobility (b = 3.63; 95% CI, 1.54-5.71) and Johns Hopkins Highest Level of Mobility scores (b = 1.15; 95% CI, 0.37-1.93) at hospital discharge and with increased probability of discharging home (adjusted relative risk = 1.82; 95% CI, 1.25-2.63). Longer mean visit duration was also associated with improved mobility at discharge and the probability of discharging home, though the effects were less pronounced. Few moderation effects were observed. Conclusion. Patients with COVID-19 demonstrated improved mobility at hospital discharge and higher probability of discharging home with increased frequency and longer mean duration of physical therapy visits. These associations were not generally moderated by patient characteristics. Impact. Physical therapy should be an integral component of care for patients hospitalized due to COVID-19. Providing sufficient physical therapist interventions to improve outcomes must be balanced against protection from viral spread. Lay Summary. Patients with COVID-19 can benefit from more frequent and longer physical therapy visits in the hospital. Keywords: Acute Care, Mobility, Patient Discharge, Delivery Patterns, Introduction The overall cumulative hospitalization rate associated with the novel coronavirus disease, COVID-19, is 120.9 per 100,000 population and continuously increasing. (1) COVID-19 is associated with varying levels of illness [...]

Objective. Therapists in the hospital are charged with making timely discharge recommendations to improve access to rehabilitation after stroke. The objective of this study was to identify the predictive ability of the Activity Measure for Post-Acute Care '6 Clicks' Basic Mobility Inpatient Short Form (6 Clicks mobility) score and the National Institutes of Health Stroke Scale (NIHSS) score for actual hospital discharge disposition after stroke. Methods. In this retrospective cohort study, data were collected from an academic hospital in the United States for 1543 patients with acute stroke and a 6 Clicks mobility score. Discharge to home, a skilled nursing facility (SNF), or an inpatient rehabilitation facility (IRF) was the primary outcome. Associations among these outcomes and 6 Clicks mobility and NIHSS scores, alone or together, were tested using multinomial logistic regression, and the predictive ability of these scores was calculated using concordance statistics. Results. A higher 6 Clicks mobility score alone was associated with a decreased odds of actual discharge to an IRF or an SNF. The 6 Clicks mobility score alone was a strong predictor of discharge to home versus an IRF or an SNF. However, predicting discharge to an IRF versus an SNF was stronger when the 6 Clicks mobility score was considered in combination with the NIHSS score, age, sex, and race. Conclusion. The 6 Clicks mobility score alone can guide discharge decision making after stroke, particularly for discharge to home versus an SNF or an IRF. Determining discharge to an SNF versus an IRF could be improved by also considering the NIHSS score, age, sex, and race. Future studies should seek to identify which additional characteristics improve predictability for these separate discharge destinations. Impact. The use of outcome measures can improve therapist confidence in making discharge recommendations for people with stroke, can enhance hospital throughput, and can expedite access to rehabilitation, ultimately affecting functional outcomes., Anew or recurrent stroke is experienced by an estimated 795,000 adults annually in the United States and often results in serious long-term disability. (1) Appropriate rehabilitation has been shown to [...]

Objective. Poor knowledge of the relationships between physical function (PF) in the hospital and patient outcomes in an inpatient rehabilitation facility (IRF) limits the identification of patients most appropriate for discharge to an IRF. This study aimed to test for independent associations between PF measured via the AM-PAC '6-clicks' basic mobility short form in the hospital and outcomes in an IRF. Methods. This was a retrospective cohort study. Primary data were collected from an acute hospital and IRF at 1 academic medical center. Associations were tested between PF at hospital admission or discharge and PF improvement in the IRF, discharge from the IRF to the community, and 30-day hospital events by estimating adjusted relative risk (aRR) using modified Poisson regression and the relative difference in IRF length of stay (LOS) using Gamma regression. Results. A total of 1323 patients were included. Patients with moderately low, (aRR = 1.50; 95% CI = 1.15-1.93), moderately high (aRR = 1.52; 95% CI = 1.16-2.01), or high (aRR = 1.37; 95% CI = 1.02-1.85) PF at hospital discharge were more likely than those with very low PF to improve their PF while in the IRF. These same patients were more likely to discharge from IRF to the community and had significantly shorter IRF LOS. Hospital-measured PF did not differentiate risk for 30-day hospital events. Conclusion. Patients with moderate--but not very low or very high--PF measured near the time of acute hospital discharge were likely to achieve meaningful PF improvement in an IRF. They also had a shorter IRF LOS so may be ideal candidates for discharge to IRF. Prospective studies with larger samples are necessary to test this assertion. Impact. Providers in the hospital should identify patients with moderate PF near the time of hospital discharge as those who may benefit most from post-acute rehabilitation in an IRF., Medicare costs on post-acute care (PAC) utilization exceeded $59 billion in 2013, nearly tripling since 2001. (1) Therefore, new policies aim to improve the value of PAC utilization in the [...]

Keywords: Health Services Administration, Models, Organizational, Evidence-Based, Practice, Health services researchers and clinical operations leaders share similar goals to resolve inefficiencies and variability in health care delivery to improve outcomes, but have traditionally conducted their work using distinct [...]