Mobility Programs in the Sub-Acute Setting – Are they Really Helping?

Early Mobility

Early mobility is the application of physical activity after the onset of a critical illness or injury to improve patient outcomes. Physical impairments affect approximately 50% of ICU patients, burdening families and the health care system with high rates of hospital readmissions and increased healthcare utilization.^1,2 There is substantial evidence that early mobility in the ICU setting is safe, reduces ventilator days, hospital length of stay, and mortality, while also allowing the patient to return to their independent functional status post-discharge. Continuing a robust mobility program in the post-acute setting is the next logical step in the transition of care.

Where Do Patients Discharge To?

With the payment models for physician, hospital, and system shifting from volume to value-based, acute care staff must be aware of all Post-Acute Care (PAC) options that can manage high-acuity patients. Centers of Medicare and Medicaid Services (CMS) list four PAC options: Long Term Care Hospitals (LTCH), Inpatient Rehabilitation Facilities (IRF), Skilled Nursing Facilities (SNF), and Home Health Care (HHC). According to the MedPAC’s 2019 Report to Congress, Medicare spent $28.4 billion on SNFs, which was 50% of PAC spending, double that of home health. Only 13% of spending went to Inpatient Rehabilitation Facilities.

Effective October 1, 2019, CMS implemented an SNF Patient Driven Payment Model (PDPM) to improve payment appropriateness by focusing on the patient’s individualized needs, characteristics, and goals, encouraging a more patient-driven care model. There are five case-mix adjusted components: physical therapy, occupational therapy, nursing, speech therapy, and non-therapy ancillary services. SNFs receive higher reimbursement for accepting higher acuity patients, such as ventilator-dependent or tracheostomy patients. This payment model incentivizes facilities to take in these patients and employ staff that are qualified to manage them, such as respiratory therapists.

Subacute Care Mobilization

Subacute care is a comprehensive program for patients needing intensive medical supervision and therapy through an outcome-focused, interdisciplinary approach by healthcare professionals. It requires recurrent patient assessments and rehabilitation until the condition is stabilized. Potential subacute care patients include patients that are ventilator dependent, have brain or head injury, are post-surgical or require orthopedic or cardiac rehabilitation. Services include ventilator support/weaning, wound care, and hemodialysis. An interdisciplinary team collaborates to optimize the patient’s care plan and outcomes. These services are provided in many settings, including hospitals, Skilled Nursing Facilities, recovery units of a surgical center, and at home with or without home care.³

Regardless of the setting, subacute care aims to progress the patient’s mobility to allow the patient to return home safely.

RT’s Role in Mobility Programs

Traditionally, nursing, physician and occupational therapy have been responsible for the mobility of patients, so protocols have not been respiratory-driven. With a multidisciplinary approach, respiratory therapists can play a larger role in mobilizing patients on and off mechanical ventilation in the subacute setting by focusing on pulmonary rehabilitation, education, and disease management. Unfortunately, there is not a consensus by experts on how early, how often, or how long a mobility program should be. Research has focused on early mobility strategies in the ICU, with little evidence in the subacute arena.

A meta-analyses of 13 randomized trials showed a clinically significant reduction of mortality and number of readmissions after early initiation of pulmonary rehabilitation in patients hospitalized with COPD exacerbation.⁴ When a program is initiated within the first 4 weeks of hospital discharge, exercise capacity and health-related-quality of life (HRQoL) indicators were maintained at least 12 months.

A recent study compared starting pulmonary rehabilitation during hospitalization or within the first month after discharge for patients admitted for a severe COPD exacerbation.⁵ In both groups, there was improvement in dyspnea with activities of daily living, exercise capacity and HRQoL indicators. The outcomes were overall better in the discharge group where patients were more stable and stronger than in the hospital.

Without a respiratory expert to manage a pulmonary rehab program, respiratory equipment and tracheostomies, skilled nursing facilities choose not to accept these high acuity patients. An RT onsite can conduct bedside assessments, build a care plan in collaboration with the nursing and therapy teams, conduct pulmonary rehab and measure treatment outcomes. Ventilator and tracheostomy care automatically put a resident in the highest reimbursement case-mix group of PDPM and captures a complex patient with an increased length of stay. Employing a respiratory therapist will allow a facility to capitalize on Medicare reimbursement, set them apart from the competition, and be deemed a Centers of Excellence for respiratory patients.

Mobility Strategies by Respiratory Therapists during COVID-19

In the coming months, hospitals may be overwhelmed with COVID-19 patients, increasing the surge of patients in need of post-acute rehabilitation. Data from Medicare shows that more than 30% of patients hospitalized with sepsis, a condition associated with COVID-19, need facility-based care, and 20% need home health.⁶

Pulmonary rehabilitation in COVID-19 patients shows improvement in dyspnea and anxiety symptoms, a reduction in complications, minimized disability, and improved quality of life.⁷ In an outpatient or home setting, telemedicine is considered for education, physical exercise, breathing exercise, activity guidance, and anxiety management.⁸ In a facility setting for moderate to severe disease, data suggests that patients who are non-ambulatory should receive bed mobility exercises, breathing exercises such as diaphragmatic breathing, and inspiratory muscle training. If ambulatory, the progression of exercise with a pursed lip breathing technique to improve oxygenation above 90% is suggested. Airway clearance techniques would include lung volume recruitment, positioning, forced expiratory maneuvers, and vibration.⁹

Respiratory therapists can unload the burden placed on physical therapists, occupational therapists, and nurses by utilizing their expertise in oxygenation, ventilation, airway clearance techniques, breathing exercises, manual and physical activity. They can play a key role in managing these patients physically or virtually to reduce hospital readmission rates and better quality of life.

Barriers to Subacute Mobility Programs

Common barriers to implementing an evidence-based intervention include awareness, agreement, and access by the clinicians. Caregivers must receive education on the intervention, agree that the outcomes are best for their patients, and have access to equipment and supplies needed.¹

Strong leadership is required to facilitate a multidisciplinary team, including physicians, nurses, physical therapists, and respiratory therapists. The support of institutional level leadership is key to ensure there is buy-in from staff. Clinical training and education across disciplines are needed for safety and consistency for patients and staff. These barriers can be overcome by thorough education, staff engagement, a collaboration of clinical teams, and a culture change of mobility.

There is a lack of resources, including staff and equipment, to support system wide programs. The subacute sector faces challenges in identifying high-quality staff to work at these facilities.⁹ This issue is amplified with COVID-19 as there is a lack of personal protective equipment (PPE) to treat these patients safely and issues being able to socially distance.⁶ A pivot to hospital-at-home models may be needed to manage the influx of patients needing subacute care.

Respiratory Legislation

Currently, home visits and tele-visits by respiratory therapists are not reimbursed by Medicare. By passing legislative initiatives such as CONNECT for Health Act 2019 to increase access to respiratory therapists as telehealth practitioners and SOS Act to protect payment for cardiac and pulmonary rehab, opportunities to promote higher quality care can be created for respiratory therapists to manage patients at home or in a subacute setting.

References

1. Early Mobility Guide for Reducing Ventilator-Associated Events in Mechanically Ventilated Patients. AHRQ Publication. No 16(17)-0018-4-EF. January 2017.
2. Cheung AM, Tansey CM, Tomlinson G, Diaz-Granados N, Matte A, Barr A, et al. Two-year outcomes, health care use, and costs of survivors of acute respiratory distress syndrome. Am J Respir Crit Care Med 2006;174:538–544.
3. Subacute Care: Review of the Literature. Office of the Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services. Lewin -VHI, Inc. December 1994.
4. Ryrsø CK, Godtfredsen NS, Kofod LM, Lavesen M, Mogensen L, Tobberup R, Farver-Vestergaard I, et al. Lower mortality after early supervised pulmonary rehabilitation following COPD-exacerbations: a systematic review and meta-analysis. BMC Pulm Med. 2018 Sep 15;18(1):154.
5. Grabowski DC, Joynt Maddox KE. Postacute Care Preparedness for COVID-19: Thinking Ahead. JAMA. 2020;323(20):2007–2008.
6. Güell-Rous MR, Morante-Vélez F, Flotats-Farré G, Paz-Del Río LD, Closa-Rusinés C, Ouchi-Vernet D, Segura-Medina M, Bolíbar-Ribas I. Timing of Pulmonary Rehabilitation in Readmitted Patients with Severe Chronic Obstructive Pulmonary Disease: A Randomized Clinical Trial. COPD. 2020 Dec 7:1-13. Wang, TJ., Chau, B, Lui, M, Lam, GT, Lin, N, Humbert, S. Physical Medicine and Rehabilitation and Pulmonary Rehabilitation for COVID-19, American Journal of Physical Medicine & Rehabilitation: September 2020 – Volume 99 – Issue 9 – p 769-774.
7. Chinese Association of Rehabilitation Medicine; Respiratory rehabilitation committee of Chinese Association of Rehabilitation Medicine; Cardiopulmonary rehabilitation Group of Chinese Society of Physical Medicine and Rehabilitation: Recommendations for respiratory rehabilitation of coronavirus disease 2019 in adult. Zhonghua Jie He He Hu Xi Za Zhi 2020;43:308–14.
8. Jones SE, Barker RE, Nolan CM, Patel S, Maddocks M, Man WDC. Pulmonary rehabilitation in patients with an acute exacerbation of chronic obstructive pulmonary disease. J Thorac Dis. 2018 May;10(Suppl 12):S1390-S1399.
9. Geng F, Stevenson DG, Grabowski DC. Daily Nursing Home Staffing Levels Highly Variable, Often Below CMS Expectations. Health Aff (Millwood). 2019 Jul;38(7):1095-1100.

Email newsroom@aarc.org with questions or comments, we’d love to hear from you.

Vrati Doshi is the Respiratory Programs Director at Integrated Respiratory Solutions. She graduated with her Master of Science in Respiratory Care from Rush University Chicago. She currently builds and executes chronic disease management programs for the post-acute population with the goal to reduce hospital readmission rate while managing a team of respiratory therapists.