Effectiveness of Short-Term Interdisciplinary Intervention on Postacute Patients in Taiwan
Article Outline
Objective
To evaluate the effectiveness of community hospital–based postacute care (PAC) for frail older patients and to provide a baseline profile of functional gain during PAC for use in further long-term outcome studies.
Design
Prospective cohort study.
Setting
A community hospital in Taiwan.
Participants
Elderly patients admitted to a community hospital with acute or postacute conditions.
Measurements
Barthel Index, Instrumental Activities of Daily Living, Mini-Mental State Examination, and Geriatric Depression Scale.
Intervention
A comprehensive geriatric assessment–based functional re-ablement program.
Results
Data were collected for 251 patients recruited between July 2006 and June 2008 from Taipei Veterans General Hospital and the acute wards of Yuanshan Veterans Hospital. Overall, clinical improvement was significant in various dimensions, including cognition (Mini-Mental State Examination from 11.9 ± 8.1 to 15.1 ± 8.3, P < .001), physical function (Barthel Index from 42.2 ± 34.1 to 64.9 ± 33.7, P < .001; Lawton-Brody Instrumental Activities of Daily Living from 1.8 ± 2.4 to 3.0 ± 2.8, P < .001), depression (Geriatric Depression Scale from 0.9 ± 1.9 to 0.6 ± 1.3, P < .001), ambulation (timed up-and-go test from 16.4 ± 19.6 to 10.1 ± 19.0, P < .001), and nutrition (Mini Nutritional Assessment from 15.0 ± 4.2 to 17.4 ± 3.7, P < .001).
Conclusion
A short-term inpatient physical re-ablement program conducted by an interdisciplinary geriatric team in a community hospital can successfully improve the physical and mental function, mood, ambulation, and nutritional conditions of postacute patients. Further study is needed to evaluate long-term clinical outcomes of patients with different rates of functional recovery during treatment in a PAC unit.
Keywords: Comprehensive geriatric assessment, elderly, geriatrics, postacute care
The health care system faces major challenges as the elderly constitute a growing proportion of the population.1 Fit older people generally recover quickly from acute illness, and may return home from the acute ward directly. However, frail older people often have multiple morbidities, as well as functional restrictions. They usually need a longer hospital stay because of poor social networks, ie, a lack of family or friends to care for them in their own home. These older people of “unstable disability” need more time to recover from functional impairment.2, 3, 4 In view of the shortage of acute-ward beds, providing a connection between acute and long-term care is becoming more and more important. Intermediate care, similar to postacute care (PAC), was first introduced in England to support timely discharge.5 PAC can be provided in a variety of settings, including community hospitals, residential care, and nursing homes, among others. The community hospital, in particular, has been considered an important model for providing cost-effective PAC services and, potentially, should have a role in providing PAC services for older people.6 A community hospital is valued for its location, homelike setting, quiet and calm atmosphere, comfortable accommodation, encouragement of social interaction, and the attitude of its staff.7, 8 Green and colleagues9 reported that the provision of PAC services to older people in a locality-based community hospital, compared with a district general hospital, was associated with greater functional independence. Community hospital–based PAC significantly reduced acute hospital readmissions and promoted functional independence with no increase in mortality or number of days in institutions.3 In other words, it can successfully reduce health care expenditure.10
Currently, the Bureau of National Health Insurance (NHI) in Taiwan is planning to move ahead with a change in payment policies from a fee-for-service model to a Diagnostic Related Groups payment system. With this modification, patients not meeting acute illness criteria will be discharged to decrease the length of hospital stays.11 However, the gap between “cure” and total health recovery will enlarge if PAC services are not properly developed. In response to this, the Veterans Affairs Commission of Taiwan has piloted the first PAC model to cope with the challenges that may result from the introduction of the new payment system. This pilot PAC model recruited frail older patients discharged from Taipei Veterans General Hospital (a tertiary medical center) and provided an active rehabilitation program in 2 community veterans hospitals. Although PAC has been shown to improve the functional independence of frail older patients, quantitative data of the functional gains conferred by PAC in all dimensions are lacking. The main purpose of this study, therefore, was to quantitatively evaluate functional gain among elderly patients receiving community hospital–based PAC services in Taiwan so as to provide a baseline profile to support subsequent research in evaluating the impact of short-term functional gain on long-term clinical outcomes.
Methods
This prospective, intervention cohort study was conducted in Yi-Lan County, Taiwan, where a 30-bed PAC unit was established in 2007. With a homelike environment, this PAC unit was staffed as a hospital. All patients, inclusive of those referred from a tertiary medical center and a community hospital acute ward, were evaluated by the geriatric team12 and transferred to the PAC unit when appropriate. The inclusion criteria were (1) age older than 65; (2) medically stable, requiring no intensive medical, laboratory, or oxygen support; and (3) presence of acute functional decline during hospitalizations. Exclusion criteria included (1) admission for elective procedures, (2) acute conditions related to terminal illness, (3) malignancy, and (4) patients who were considered to have a low potential for functional recovery.
Once patients were admitted to the PAC unit, the case manager, a senior nurse, completed a comprehensive geriatric assessment (CGA) within 72 hours, and the interdisciplinary team took charge of further treatment. Usually, treatment was completed within 4 weeks, and functional assessments were performed at weeks 2 and 4; however, the treatment course could be extended, with the agreement of the interdisciplinary team, up to a maximum of 12 weeks. Patients needing more than 12 weeks of treatment would be transferred to long-term care facilities for continuing care.
The main focus was to improve patients' daily activities, inclusive of physical function, psychological status, nutrition, and ambulation, so that they could resume normal daily life. Activities of daily living were assessed by the Barthel Index and the Lawton-Brody instrumental activities of daily living scale (IADL). The Mini-Mental State Examination (MMSE) was conducted to evaluate cognitive function.13 The Geriatric Depression Scale short form (GDS) was used to screen for depression.14 Nutritional status was determined by the Mini Nutritional Assessment (MNA). The timed up-and-go test (TUG) was performed to measure ambulation. Pain was measured by the numerical pain rating scale (NRS).
Continuous variables are expressed as mean ± standard deviation and categorical data are expressed as percentages. Comparisons between continuous variables were done using the Student t or Mann-Whiney test, and comparisons between categorical data were done using the chi-square or Fisher's exact test where appropriate. Comparisons of functional status among patients before and after receiving PAC services were done using the paired t test. All statistical analyses were performed using commercial software (SPSS 17.0 for Mac, SPSS Inc, Chicago, IL). A P value (2-tailed) less than .05 was considered statistically significant.
Results
From July 2006 to June 2008, 301 patients were recruited from the Taipei Veterans General Hospital and the acute wards of Yuanshan Veterans Hospital. All patients were male except for one elderly woman. Among them, 56 patients who had unplanned immediate readmissions or incomplete data were excluded from the analysis. The mean age of all study subjects was 82.7 ± 5.5 years, and the mean length of stay in the PAC unit was 32.3 ± 14.3 days.
Overall, clinical improvement was significant in various dimensions, including cognition (MMSE from 13.4 ± 8.1 to 15.9 ± 8.2, P < .001), physical function (Barthel Index from 47.1 ± 33.6 to 66.2 ± 32.9, P < .001; Lawton-Brody IADL from 2.1 ± 2.4 to 3.1 ± 2.7, P < .001), depression (GDS short form from 1.2 ± 2.1 to 0.8 ± 1.3, P < .001), ambulation (TUG from 19.9 ± 22.5 to 12.9 ± 21.1, P < .001), nutrition (MNA from 16.0 ± 3.9 to 17.8 ± 3.5, P < .001), and pain (NRS from 2.4 ± 3.1 to 1.5 ± 2.0, P < .001) (Table 1).
Table 1. Short-Term Functional Improvement of Frail Older Patients Receiving Community Hospital–based PAC
| Before Services (n = 245) | 4 Weeks after Services (n = 245) | P Value | |
|---|---|---|---|
| BI | 47.1 ± 33.6 | 66.2 ± 32.9 | <.001 |
| IADL | 2.1 ± 2.4 | 3.1 ± 2.7 | <.001 |
| MMSE | 13.4 ± 8.1 | 15.9 ± 8.2 | <.001 |
| GDS | 1.2 ± 2.1 | 0.8 ± 1.3 | <.001 |
| MNA | 16.0 ± 3.9 | 17.8 ± 3.5 | <.001 |
| TUG (sec) | 19.9 ± 22.5 | 12.9 ± 21.1 | <.001 |
| NRS | 2.4 ± 3.1 | 1.5 ± 2.0 | <.001 |
The mean MMSE change was associated with the mean Barthel Index change (P = .003) and the mean IADL change (P = .004). The mean Barthel Index change was associated with the mean MMSE change (P = .003), the mean GDS change (P = .002), the mean IADL change (P < .001), and the mean TUG change (P < .001). Barthel Index at admission was associated with the mean Barthel Index change (P < .001), mean IADL change (P < .001), mean MMSE change (P = .012), and mean TUG change (P = .025). The mean MNA change was not associated with the other variables, with the exception of initial MNA (P = .001) (Table 2).
Table 2. Association of the Barthel Index at Admission with the Functional Improvement in All Dimensions of Frail Older Patients Receiving Community Hospital–based PAC
| Admission BI | ΔBI | ΔMMSE | ΔIADL | ΔTUG | ΔMNA | ΔNRS | |
|---|---|---|---|---|---|---|---|
| Admission BI | — | ||||||
| ΔBI | r=–0.249 P<.001 | — | |||||
| ΔMMSE | r=0.156 P=.026 | r=0.208 P=.003 | — | ||||
| ΔIADL | r=0.316 P<.001 | r=0.426 P<.001 | r=0.225 P=.001 | — | |||
| ΔTUG | r=0.224 P<.001 | r=0.237 P=.001 | r=0.017 P=.807 | r=0.221 P=.002 | — | ||
| ΔMNA | r=0.212 P=.208 | r=0.285 P=.087 | r=0.233 P=.164 | r=0.241 P=.151 | r=0.129 P=.448 | — | |
| ΔNRS | r=0.223 P<.001 | r=0.047 P=.505 | r=-0.055 P=.435 | r=0.148 P=.035 | r=0.192 P=.006 | r=0.070 P=.682 | — |
Discussion
In this study, significant functional improvement in various dimensions including cognition, physical function, depression, ambulation, and nutrition was demonstrated during a mean length of stay of 32 days in the PAC unit. The purpose of this study was to provide precise measurements of functional gain in the previously mentioned dimensions during the 4-week program. Previous reports have supported the effectiveness of PAC by demonstrating a higher 6-month physical independence rate and a lower readmission rate; however, evaluating the long-term effectiveness of PAC without measuring the short-term functional gain during PAC treatment as a baseline may be problematic. To the best of our knowledge, this is the first study providing precise measurements of functional improvement in different dimensions during the PAC service. This quantitative measurement of functional improvement during PAC should be considered when evaluating the long-term effectiveness of PAC services.
Barthel Index at admission and malnutrition have been shown to be strong predictors of clinical outcome and mortality after discharge from acute geriatric wards and at 6-month follow-up.15 In our study, the Barthel Index at admission was strongly associated with improvement in daily activities (Barthel Index and IADL), cognitive function (MMSE), and ambulation ability (TUG). An improvement in nutrition was not associated with the other variables, except for nutritional status at admission. In addition, cognitive function was strongly associated with mortality after discharge from the acute ward.16 Admission MMSE was strongly associated with the other variables at admission (Barthel Index, IADL, TUG, MNA, P < .001; GDS, P = .004), and was also strongly associated with the mean GDS change (P = .028), mean IADL change (P < .001), and mean TUG change (P < .001). Therefore, Barthel Index and MMSE score at admission to the PAC unit may be used as a surrogate for the global improvement in functional status, and these 2 parameters should be measured periodically in postacute patients to predict the effectiveness of PAC services.
It has been shown that community hospitals play an important role in intermediate care, ie, PAC, in England.2 PAC in community hospitals was shown to be an equivalent alternative to ordinary prolonged care in a district general hospital.17 When possible, prompt transfer to a community hospital resulted in enhanced independence after 6 months among older people requiring postacute rehabilitative care.18 The introduction of intermediate care in England has been criticized as “policy before evidence” because of the insufficiency of underpinning evidence, the lack of universal inclusion/exclusion criteria, and a clearly defined intervention program. In this study, we have implemented clear inclusion/exclusion criteria for services and standardized the intervention programs based on the results of functional assessments to overcome these criticisms. Notably, we systematically measured functional improvement in all dimensions. As such, we believe our results provide evidence supporting community hospital–based PAC. Several types of PAC services have been established internationally, but the best location for PAC services remains to be determined. For older patients with a fractured hip, a home-based rehabilitation program yielded better results than institution-based rehabilitation.19 For stroke patients, supported early discharge with a home-based rehabilitation program promoted better functional outcomes.20 More importantly, the REACH-OUT trial showed the effectiveness of home-based rehabilitation for frail older patients after acute hospitalization.21 However, at this time, PAC services have only recently been implemented in Taiwan, so there are no data available on which to base a decision about the best PAC setting. Because it is well known that older people may benefit from a comprehensive, interdisciplinary assessment and a holistic and rehabilitative approach to health care delivery,19, 20 the development of home-based PAC services should be a high priority in Taiwan.
There are some limitations to this study. First, the study cohort was homogeneous in its demographic profile in that the patients were male, veterans, and had a lack of care resources in the community. However, we are convinced that the results of this study may still be applicable to other frail older patients. Second, an estimation of cost was not included in this study, which may limit the ability to systematically implement PAC nationwide. Third, this study measured short-term functional outcomes only. Further investigation is needed to evaluate the longer-term effectiveness of a community hospital–based PAC program.
In conclusion, a short-term, inpatient physical re-ablement program conducted by an interdisciplinary geriatric team in a community hospital can successfully improve the physical function and cognitive, psychological, ambulatory, and nutritional conditions of postacute elderly patients.
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The authors have no conflicts of interest.
PII: S1525-8610(10)00003-4
doi:10.1016/j.jamda.2010.01.002
© 2011 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.
