Medicare Beneficiaries Get Few Home Visits After ICU Stay

Andrew D. Bowser

February 27, 2020


ORLANDO – Medicare beneficiaries are receiving a low number of rehabilitation visits in the early posthospitalization period after critical illness, an analysis of hospital and home health claims data suggests.

The beneficiaries, all discharged directly to home health after an intensive care unit stay, received an average of less than one visit per week in the ensuing month, while a full third received no visits at all, according to authors of the analysis, presented at the Critical Care Congress sponsored by the Society of Critical Care Medicine.

Living alone and living in a rural area were associated with significantly fewer home health rehabilitation visits, according to investigator Jason Raymond Falvey, PT, DPT, PhD, of Yale University, New Haven, Conn.

"We identified that these patients are receiving low doses of rehabilitation in home health care settings, and perhaps doses low enough to not be physiologically adequate to overcome the deconditioning and aerobic capacity concerns that these patients have," Dr. Falvey said.

These findings reflect an "underrecognition" of the importance of rehabilitation both outside and inside the hospital setting, according to Patricia J. Posa, RN, of Saint Joseph Mercy Hospital, Northville, Mich.

"We even struggle to provide sufficient rehabilitation while they're in the hospital," Ms. Posa said in an interview. "So I think that we still have a major gap in providing rehab services across the continuum, and part of that is recognizing the deficits that patients, especially our elderly patients, might be leaving the hospital with."

Medicare beneficiaries who survive a critical illness are often discharged with referrals for physical, occupational, or speech therapy, yet there are not much data on the delivery of that care or how many visits actually take place, according to Dr. Falvey.

He and coinvestigators analyzed data on 3,176 Medicare beneficiaries discharged to home health right after an acute hospitalization with an ICU stay of at least 24 hours. To do this, they linked 2012 Medicare hospital and home health claims data with Medicare demographic and patient assessment data.

They found that the beneficiaries received just 3.5 home rehabilitation visits in 30 days, while 33% had no visits on record.

The factors most strongly associated with receiving fewer rehabilitation visits, in adjusted models, included living in a rural setting, with a rate ratio (RR) of 0.87 and living alone, with an RR of 0.88.

Higher comorbidity count also was associated with fewer visits (RR, 0.98), according to the investigators.

On the other hand, Medicare beneficiaries who received more visits were more likely to be older (RR, 1.03; 1.01-1.04; for every 5 years), more likely to have higher disability scores (RR, 1.03; 1.02-1.04; per point on the Elixhauser Comorbidity Index), and more likely to have reported severe dyspnea (RR, 1.12; 1.04-1.21), according to the report.

More research will be needed to determine the appropriate number of home health rehabilitation visits for older hospitalized patients, according to Ms. Pena, a member of the Society of Critical Care Medicine's ICU Liberation initiative, which aims to free patients from the harmful effects of pain, agitation/sedation, delirium, immobility, and sleep disruption in the ICU, as well as improve patient outcomes after an ICU stay.

The literature is already fairly robust, she said, on how frequently visits are warranted following specific scenarios such as postsurgical hip or knee replacement or stroke.

"For the general hospitalized patients that are just losing function because they were sick and didn't get out of bed enough, we don't really have good data to say, 'you know, they need three visits a week, or they need two visits a week for an hour in order to improve,' " she said, "so the science is still not caught up with the frequency."

In the absence of data, the number of visits may be left up to an individual clinician's knowledge and past experience as well as what insurance will pay for, Ms. Pena said.

Dr. Falvey reported royalties related to an online continuing education course on hospital readmissions. No other disclosures were reported.

SOURCE: Falvey J et al. Crit Care Med. 2020 Jan;48(1):28.

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