Improving Physical Function in Skilled Nursing Facility Residents
| Status: | Recruiting |
|---|---|
| Conditions: | Neurology |
| Therapuetic Areas: | Neurology |
| Healthy: | No |
| Age Range: | 55 - Any |
| Updated: | 4/21/2016 |
| Start Date: | April 2015 |
| End Date: | September 2017 |
| Contact: | Jennifer Stevens-Lapsley, PT, PhD |
| Email: | Jennifer.Stevens-Lapsley@ucdenver.edu |
| Phone: | 303-724-9170 |
Each year Medicare spends approximately $31.3 billion on 2.4 million skilled nursing
facility (SNF) episodes of care. SNFs rely on interdisciplinary approaches to patient care
to maximize rehabilitation potential for return to prior level of function and reduce the
risk of adverse events in older adults. However despite a substantial increase in spending
on SNF services and minimal change in complexity of the caseload, 68% of patients are below
their pre-hospitalization level of function at discharge, 25% return to the community, and
18% are hospitalized. This may be partially explained by current SNF approaches to patient
care which foster inactivity and participation in low intensity rehabilitation interventions
(preliminary data). Both inactivity and low-intensity interventions may perpetuate further
functional decline or impede maximal recovery. The serious implication of risk with
functional decline is exemplified by studies which have shown declines in physical function
can increase the risk of being re-hospitalized six-fold and may infer other long term
effects such as increased risk for mortality, morbidity, and institutionalization. Muscle
weakness, reduced cardiorespiratory reserve, and neuromuscular deficits have been attributed
to this acute decline in function. However current rehabilitation strategies in SNFs do not
promote adequate dose and mode of interventions to induce beneficial systemic adaptations,
perhaps due to the lack of evidence on effective rehabilitation protocols for this
medically-complex population. Therefore, the investigators have designed an
interdisciplinary "IntenSive Therapeutic Rehabilitation for Older Skilled NursinG HomE
Residents" (I-STRONGER) program, which uniquely integrates principles of physiologic tissue
overload with strengthening and functional interventions for greater gains in physical
function. Data will be collected on the first cohort of patients who cycle through a SNF
during Stage 1, in which usual care occurs (5 months). Then, staff training on I-STRONGER
will occur over 2 months. Finally, data will be collected on a second cohort of patients who
cycle through a SNF during Stage 2, in which I-STRONGER implemented by SNF staff (5 months).
Given the high turnover of patients in SNFs (average length of stay ~21 days), 2 different
cohorts of patients will be studied and the analysis will consist of independent 2-sample
t-tests. During Stage 1 and 2, measures of physical function will be assessed on all
eligible patients at admission and discharge from SNF. Therapists will be assessed on
adherence to I-STRONGER protocols through documentation audits and use of on-site
observational checklist. Acceptability of I-STRONGER by the patients will be assessed by a
patient satisfaction survey. Any adverse events will be obtained from the medical record and
documented. The discharge location of all patients will be documented.
facility (SNF) episodes of care. SNFs rely on interdisciplinary approaches to patient care
to maximize rehabilitation potential for return to prior level of function and reduce the
risk of adverse events in older adults. However despite a substantial increase in spending
on SNF services and minimal change in complexity of the caseload, 68% of patients are below
their pre-hospitalization level of function at discharge, 25% return to the community, and
18% are hospitalized. This may be partially explained by current SNF approaches to patient
care which foster inactivity and participation in low intensity rehabilitation interventions
(preliminary data). Both inactivity and low-intensity interventions may perpetuate further
functional decline or impede maximal recovery. The serious implication of risk with
functional decline is exemplified by studies which have shown declines in physical function
can increase the risk of being re-hospitalized six-fold and may infer other long term
effects such as increased risk for mortality, morbidity, and institutionalization. Muscle
weakness, reduced cardiorespiratory reserve, and neuromuscular deficits have been attributed
to this acute decline in function. However current rehabilitation strategies in SNFs do not
promote adequate dose and mode of interventions to induce beneficial systemic adaptations,
perhaps due to the lack of evidence on effective rehabilitation protocols for this
medically-complex population. Therefore, the investigators have designed an
interdisciplinary "IntenSive Therapeutic Rehabilitation for Older Skilled NursinG HomE
Residents" (I-STRONGER) program, which uniquely integrates principles of physiologic tissue
overload with strengthening and functional interventions for greater gains in physical
function. Data will be collected on the first cohort of patients who cycle through a SNF
during Stage 1, in which usual care occurs (5 months). Then, staff training on I-STRONGER
will occur over 2 months. Finally, data will be collected on a second cohort of patients who
cycle through a SNF during Stage 2, in which I-STRONGER implemented by SNF staff (5 months).
Given the high turnover of patients in SNFs (average length of stay ~21 days), 2 different
cohorts of patients will be studied and the analysis will consist of independent 2-sample
t-tests. During Stage 1 and 2, measures of physical function will be assessed on all
eligible patients at admission and discharge from SNF. Therapists will be assessed on
adherence to I-STRONGER protocols through documentation audits and use of on-site
observational checklist. Acceptability of I-STRONGER by the patients will be assessed by a
patient satisfaction survey. Any adverse events will be obtained from the medical record and
documented. The discharge location of all patients will be documented.
Inclusion Criteria:
1. Adults older ≥55 years of age who are admitted to a skilled nursing facility
following hospitalization
2. Qualify to receive at least physical therapy services.
Exclusion Criteria:
1. Patients with primary diagnoses related to neurological disorders will be excluded as
patient needs require more of a motor-control approach versus the proposed
high-intensity approach. Such patient populations include:
1. Parkinson's Disease
2. Traumatic Brain Injury
3. Recent Cerebral Vascular Accident
4. Alzheimer's
2. Patients on hospice care will be excluded as the approach is based on palliative
principles. Other patients to be excluded will include those with conditions where
strength training is contraindicated (as indicated by the American College of Sports
Medicine Guidelines for Exercise Testing and Prescription):
1. Recent unstable fractures
2. Advanced congestive heart failure (ejection fracture <30%)
3. Bone metastasis sites
4. Tumors in strengthening target areas
5. Acute illness
6. Recent myocardial infarction (within 3-6 weeks)
7. Weight bearing restrictions on graft or fracture sites
8. Exposed tendon or muscle
9. Absence of pedal pulses
10. Presence of a fistula
11. Platelet levels <50,000/µL.
3. Additional exclusions assessed prior to randomization include a score of less than 21
on the Mini-Mental Status Exam.
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