at first glance: measuring rehabilitation intensity in ontario€¦ · canadian institute for...

Canadian Institute for Health Information

cihi.ca @cihi_icis

Measuring Rehabilitation Intensity in Ontario

May 9, 2017 Presentation to Central South Rehabilitation Intensity Forum

Beth Linkewich ([email protected]) Toronto Stroke Networks, Sunnybrook Health Sciences Centre Ruth Hall ([email protected])

Ontario Stroke Network, Institute for Clinical Evaluative Sciences Ryan Metcalfe ([email protected])

2

Rehab Intensity (RI) Following Stroke • Increased activity and environmental stimulation is important to neurological

recovery after stroke.

• Stroke best practices recommend a minimum of 3 hours of therapy per-patient-day in inpatient rehabilitation [1].

• The Ontario Stroke Network (OSN) partnered with the Canadian Institute for Health Information (CIHI) and Ontario’s MOHLTC to include mandatory collection of RI data as part of the National Rehabilitation Reporting System (NRS) from April 2015 onward.

• The OSN and regional stroke networks have worked with rehabilitation programs to support implementation and quality assurance.

[1] Lindsay, M.P., Gubitz, G., Bayley, M. et al. (2010). Canadian Best Practice Recommendations for Stroke Care (Update 2010). On behalf of the Canadian Stroke Strategy Best Practices and Standards Writing Group. Ottawa, ON, Canadian Stroke Network. Retrieved from: www.strokebestpractices.ca

Definition of Rehabilitation Intensity • Rehabilitation Intensity is defined as:

• The amount of time that a patient is engaged in active, goal-directed, face to face rehabilitation therapy, monitored or guided by a therapist, over a seven day/week period.

• Physical, functional, cognitive, perceptual and social goals to maximize the patient’s recovery *

* Ontario Stroke Network, 2012.

Measuring Rehabilitation Time in the National Rehabilitation Reporting System (NRS): # minutes of rehabilitation intensity (defined above) for OT, PT, S-LP, OTA, PTA, CDA

Rehabilitation Intensity Requires a Cultural Shift • Shift in thinking from therapist time spent providing the therapy to the patient time spent actively engaged in and receiving therapy. • “Bigger picture” experience

• Setting up the environment for success

Volunteers

Groups

I am very busy all day long, but what are the stroke patients doing all day? How can we provide the most minutes of therapy AND maintain a complex stimulating environment?

5

Rehabilitation Intensity Calculations

Rehab Time with an OT Rehab Time with a PT Rehab Time with an SLP Rehab Time with an OTA Rehab Time with a PTA + Rehab Time with a CDA _____________________ = Total Rehab Time

Rehabilitation Intensity = Total Rehab Time (minutes) Active Rehab LOS (days)

At a facility or geographic level:

Average Rehab Intensity = Sum [Rehab Intensity per client] Number of clients

(# Days from Admit to Date Ready for Discharge) – (Service Interruption Days) ______________________________________ = Active Rehab LOS

6

Methodology & Data Quality

5,102 stroke discharges from Ontario facilities in 2015-2016

~ 95% had valid, non-zero values coded in one or more of the rehab time fields – i.e., full or partial rehab time captured

Top and bottom 1% (according to total number of minutes per day) were

discarded from analysis

4,763 stroke rehab episodes

7

Data Availability/Quality Issues

  4.7% of records had only ‘0’, ‘999’, ‘9999’, or ‘99999’ coded and were excluded from analysis

  Large regional variation   (0 - 25.5%)

  Q1 (12.6%) much worse than subsequent quarters (3.5% or less) 0

5

10

15

20

25

30

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Rec

ords

Exc

lude

d fr

om A

naly

sis (

%)

LHIN (Rank Ordered)

Proportion of Stroke Records Excluded

Source: National Rehabilitation Reporting System, 2015–2016, Canadian Institute for Health Information.

8

  What does the data tell us?

9

Who is Providing Therapy?

PT and OT most common

CDA least common

12.4% of clients served by all provider types

97% 95%

81% 78% 75%

18%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PT OT PTA OTA SLP CDA

Prop

ortio

n of

Clie

nts

Trea

ted

(Nto

tal =

4,7

63)

Therapy/Provider Type

Prevalence of Each Therapy Type, 2015-2016


10

How Much 1:1 Therapy Do Clients Receive?

• Amount increased over quarters: 63.1 (Q1) – 66.5 (Q4) min/day

• Therapy assistants account for 25% of therapy

• Less than 1% of clients meeting the therapy-per-day target

20.2

18.9

9.9

7.7

7.2 1.7 PT

OT

SLP

OTA

PTA

CDA

Total = 65.5 min/day (Target = 180 min/day)

Average Minutes/Day by Therapy Type


11

How Much 1:1 Therapy Do Clients Receive?

• 61.5 min/day of 1:1 therapy during the period of “active rehabilitation”

• Amount increased over quarters: 57.4 (Q1) – 63.6 (Q4) min/day

• 180 min/day target is being met by approx. 1% of clients

19.1

17.5

5.0

5.7

5.4

Median Therapy Minutes per Day by Therapy Type

PT

OT

SLP

OTA

PTA

CDA

Total = 61.5

12

How Much 1:1 Therapy Do Clients Receive?   Average amount of

therapy is greater when you only look at those clients receiving that type of therapy

  e.g., People that received therapy from CDA received 9.7 min/day; all clients together received 1.7 min/day

20.2 18.9

9.9

7.7 7.2

1.7

20.9 19.8

13.1

9.9 8.8

9.7

0

5

10

15

20

25

PT(n=4608)

OT(n=4542)

SLP(n=3593)

OTA(n=3718)

PTA(n=3870)

CDA(n=847)

Min

utes

per

day

(mea

n)

Therapy Type (n=Number of clients receiving that therapy type)

Average Rehab per Day by Therapy Type

Averagecalculated fromall clients

Averagecalculated fromonly thoseclients receivingthat particulartherapy type


13

Regional Variation in Rehab Intensity?

  Much variability between regions (37.3 – 89.1 min/day)

0

10

20

30

40

50

60

70

80

90

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Min

utes

per

day

(Mea

n)

LHIN

Average Minutes/Day by LHIN

Provincial mean = 65.5 min/day


14

Rehab Intensity by Resource Utilization Group (loosely… “severity”)

  Most therapy per day provided to “most severe” RPG; Least therapy per day provided to “least severe” RPG

14%

27%

24%

14%

8%

9% 4%

Discharges by Rehab Patient Group (RPG)

1100

1110

1120

1130

1140

1150

1160

71.9

61.9 68.7 68.4

63.6 59.9

53.9

0

10

20

30

40

50

60

70

80

1100 1110 1120 1130 1140 1150 1160

Reha

b Ti

me

per D

ay (m

inut

es)

Rehab Patient Group (RPG)

Rehab Intensity by RPG

Mean

Median

Decreasing Resource Utilization (“Severity”)


15

Next… We grouped clients based on Rehab Intensity (minutes of 1:1 therapy per day) into 4 groups (quartiles) and compared groups

16

This is what the groups (RI Quartiles) look like

  Group 4 receives more than twice the amount of therapy of Group 2, and approx. four times what Group 1 receives 28.2

51.9

72.5

103.2

27.2

51.7

72.9

110.1

0

20

40

60

80

100

120

1 2 3 4

Ther

apy

Min

utes

Per

Day

Group (RI Quartile)

RI min per day

Median

Mean


17

Age

  Clients receiving more therapy per day are younger

77

74 73

71

74.6

72.2 71.3

69.4

64

66

68

70

72

74

76

78

27 min/day 52 min/day 73 min/day 110 min/day

Age

(yea

rs)

Group (RI Quartile)

Age by RI Quartile

Median

Mean


18

Total Function Change

  Clients that receive the most therapy per day have the most function change over the course of their stay

19.1

23.0 25.9

28.6

0

5

10

15

20

25

30

35


Tota

l Fun

ctio

n Sc

ore

Chan

ge (m

ean)

Group (RI Quartile)

Average Total Function Change by RI Quartile


19

  So… more therapy per day results in more function change… right?

20

Active Rehab LOS Efficiency

  Clients receiving the most therapy per day are achieving a greater overall FIM/LOS efficiency than those receiving the least therapy per day, despite having longer rehab stays

0.83

0.94 1.00 1.03

1.01 1.10 1.16 1.19

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40


Activ

e Re

hab

LOS

Effic

ienc

y

Group (RI Quartile)

Active LOS Efficiency by RI Quartile

Median

Mean


21

Active Rehab LOS   Clients receiving

most therapy per day are staying ~5 days longer than those receiving least therapy per day, on average

  So… these clients are receiving more therapy per day over more days

  i.e. (Rehab Intensity) x (Active LOS)

21

24 26 26 24.7

26.2 28.2 29.4

0

5

10

15

20

25

30

35


Activ

e LO

S (d

ays)

Group (RI Quartile)

Active LOS by RI Quartile

Median

Mean

22

Conclusions (data capture & therapy provided)

• Mandating data collection with regional implementation collaboration has resulted in strong uptake for RI data collection for stroke inpatient rehabilitation.

• Coding of unknown values decreased over time and is anticipated to continue decreasing. (Care should be taken to ensure that zeros are used when associated service is not provided, regardless of the need or reason.)

• Currently, persons with stroke in Ontario are receiving one-third the recommended therapy-per-day in inpatient rehab.

• Strategies to increase rehabilitation intensity are needed.

23

Conclusions (quartile analysis)

• Younger patients and patients with severe stroke receiving more therapy.

• Patients receiving greater RI have more functional gains and LOS efficiencies, despite a longer active LOS.

24

What’s next?

• Focus on clinical implementation of rehabilitation intensity

• Take advantage of the resources available to you

‒ Whiteboard

‒ Portal

‒ Pocket card to guide inclusion

• Education resources under development to support a sustainability

Common Opportunities Identified by Rehab Teams

[email protected] [email protected]

at first glance: measuring rehabilitation intensity in ontario€¦ · canadian institute for...

Documents