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Objective: To compare use of rehabilitation and other health services among patients with knee and hip replacement after discharge from a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IRF)., Design: Follow-up interview study at 7.5 months after discharge., Setting: Five freestanding SNFs, 1 hospital-based SNF, and 6 IRFs from across the United States., Participants: Patients (N=856): patients with knee replacement (n=561) and patients with hip replacement (n=295)., Interventions: No interventions., Main Outcome Measures: Number of home and outpatient therapy visits, physician visits, emergency room visits, rehospitalizations, and medical complications., Results: After discharge from postacute care, the vast majority of patients received home rehabilitation, outpatient rehabilitation, or both. Patients with knee replacement received an average of 19 home and/or outpatient rehabilitation visits; patients with hip replacement received almost 15 visits. There were no statistically significant differences in rates of emergency room use and rehospitalization except that patients with hip replacement discharged from IRFs had higher rates of rehospitalization than those discharged from freestanding SNFs (15.8% vs 3.1%). Multivariate analyses did not find any SNF/IRF effects., Conclusions: Patients with joint replacement from both SNFs and IRFs receive considerable amounts of follow-up rehabilitation care. Study uncovered no setting effects related to rehospitalization or medical complications. Looking only at care rendered in the initial postacute setting provides an incomplete picture of all care received and how it may affect follow-up outcomes.

Objective: To examine functional and health status outcomes of patients with joint replacement discharged from a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IRF)., Design: Postdischarge follow-up interview study at 7.5 months after admission., Setting: Five freestanding SNFs, 1 hospital-based SNF, and 6 IRFs., Participants: Patients (N=856): 561 with knee replacement and 295 with hip replacement., Interventions: None., Main Outcome Measures: FIM and Short-Form 12-Item Health Survey (SF-12)., Results: Among patients with knee and hip replacement, IRF patients made larger motor FIM gains from admission and discharge to follow-up. IRF patients, however, were admitted with lower FIM scores and also had more to gain (especially given the ceiling effects within the FIM at follow-up). When adjusted for case mix, IRF patients made larger motor FIM gains and had higher SF-12-related scores among patients with hip replacement but not among patients with knee replacement. Multivariate regressions found modest setting effects that favored IRFs, and the setting effects explained only a modest portion of the variance in motor FIM outcomes., Conclusions: At follow-up, patients with joint replacement discharged from IRFs had better motor FIM outcomes than those discharged from freestanding SNFs and the hospital-based SNF. Settings did not differ materially in terms of SF-12 outcomes. Findings do not favor one setting decisively over another. A sole focus on initial postacute placement overlooks the larger trajectory of postacute care that needs to be managed to achieve superior outcomes.

Objective: To compare functional outcomes at discharge across postacute settings., Design: Prospective observational cohort study., Setting: Eleven inpatient rehabilitation facilities (IRFs), 8 freestanding skilled nursing facilities (SNFs), and 1 hospital-based SNF from across the United States., Participants: Consecutively enrolled patients (N=2152): patients with knee replacement (n=1401) and patients with hip replacement (n=751)., Interventions: None; examination of existing practice patterns., Main Outcome Measure: FIM discharge motor score., Results: Freestanding SNF patients entered with higher motor FIM scores and left with higher scores than did IRF patients. IRF patients, however, achieved larger motor FIM gains and achieved them in a shorter time. In multivariate models controlling for patient differences and onset days, IRFs were associated with better discharge motor outcomes, but the overall setting effect was not large. The largest motor FIM differences were between medium-volume IRFs and low-volume freestanding SNFs: 4.6 motor FIM points for patients with knee replacement and 7.3 motor FIM points for patients with hip replacement. Other differences between settings were much smaller. Multivariate models explained between a third and a half of the variance in outcome., Conclusions: As a group, IRFs had better motor FIM outcomes than did SNFs, but the size of the IRF advantage was not large. Other important facility and practice characteristics also were associated with discharge outcomes after joint replacement rehabilitation. Earlier and more intensive rehabilitation was associated with better outcomes. The volume of joint replacement patients seen by a facility also plays a part: medium-volume facilities among both SNFs and IRFs had better outcomes.

Objective: To characterize rehabilitation services for patients with knee and hip replacement in 3 types of postacute facilities in the U.S., Design: Multi-site prospective observational cohort study., Setting: Eight freestanding skilled nursing facilities (SNFs), 1 hospital-based SNF, and 11 inpatient rehabilitation facilities (IRFs)., Participants: Patients (N=2158) with knee or hip replacement., Interventions: No new interventions., Main Outcome Measures: Length of stay (LOS), amount and intensity of physical therapy (PT) and occupational therapy (OT), types of therapy activities., Results: Average LOS was about 15 days for freestanding SNF patients, and 9 to 10 days for hospital-based SNF and IRF patients. Freestanding SNFs and IRFs provide about the same number of hours of PT and OT; the hospital-based SNF provided 27% fewer hours. Freestanding SNFs and the hospital-based SNF provided fewer hours a day than did IRFs. Joint replacement patients across all 3 types of facilities spent, on average, 70% to 75% of their PT time in just 2 activities--exercise and gait and spent 56% to 66% of their OT time in 3 activities--exercise, functional mobility, and dressing lower body., Conclusions: Both freestanding SNFs and IRFs provided similar amounts of PT with a similar emphasis on exercise and gait activities. IRFs, however, provided more OT than freestanding SNFs. IRFs had shorter LOSs and more intensive therapy services than freestanding SNFs. Study freestanding SNFs exhibited greater variation in LOS and intensity of therapy than IRFs.

Objective: To prospectively monitor occupational therapy activities and intervention techniques used during inpatient stroke rehabilitation in order to provide a description of current clinical practice., Methods: Data were collected prospectively from 954 clients with stroke receiving occupational therapy from six U.S. rehabilitation hospitals. Descriptive statistics summarized frequency, intensity, and duration of occupational therapy sessions; proportion of time spent in 16 therapeutic activities; and proportion of those activities that included any of 31 interventions., Results: Clients received on average 11.8 days (SD = 7.2) of occupational therapy, with each session lasting on average 39.4 min (SD = 16.9). Upper-extremity control (22.9% of treatment time) and dressing (14.2% of treatment time) were the most frequently provided activities. Interventions provided most frequently during upper-extremity control activities were strengthening, motor learning, and postural awareness., Conclusion: Occupational therapy provided reflected an integration of treatment approaches. Upper-extremity control and basic activities of daily living were the most frequent activities. A small proportion of sessions addressed community integration.

Unlabelled: Horn SD, DeJong G, Smout RJ, Gassaway J, James R, Conroy B. Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better?, Objective: To examine associations of patient characteristics, rehabilitation therapies, neurotropic medications, nutritional support, and timing of initiation of rehabilitation with functional outcomes and discharge destination for inpatient stroke rehabilitation patients., Design: Prospective observational cohort study., Setting: Five U.S. inpatient rehabilitation facilities., Participants: Post-stroke rehabilitation patients (N=830; age, >18 y) with moderate or severe strokes, from the Post-Stroke Rehabilitation Outcomes Project database., Interventions: Not applicable., Main Outcome Measures: Discharge total, motor, and cognitive FIM scores and discharge destination., Results: Controlling for patient differences, various activities and interventions were associated with better outcomes including earlier initiation of rehabilitation, more time spent per day in higher-level rehabilitation activities such as gait, upper-extremity control, and problem solving, use of newer psychiatric medications, and enteral feeding. Several findings part with conventional practice, such as starting gait training in the first 3 hours of physical therapy, even for low-level patients, was associated with better outcomes., Conclusions: Specific therapy activities and interventions are associated with better outcomes. Earlier rehabilitation admission, higher-level activities early in the rehabilitation process, tube feeding, and newer medications are associated with better stroke rehabilitation outcomes.

Background and Purpose: The purpose of this study was to describe physical therapy provided to patients with stroke in inpatient rehabilitation facilities., Subjects and Methods: Data were collected from 972 patients with stroke receiving physical therapy services at 6 rehabilitation facilities in the United States. Descriptive statistics were derived to describe physical therapy sessions, including proportion of therapy time spent in specific functional activities and proportion of those activities that included any of 59 interventions., Results: Mean length of stay was 18.7 days (SD=10.3), and patients received physical therapy, on average, 13.6 days (SD=7.8). Patients attended, on average, 1.5 (SD=0.3) physical therapy sessions per day, with each session lasting 38.1 minutes (SD=17.1). Gait and prefunctional activities were performed most frequently (31.3% and 19.7% of total treatment time, respectively). For gait activity, physical therapists used balance and postural awareness training in more than 50% of sessions and used strength training for more than 50% of sessions of prefunctional activities. Eighty-six percent of the patients received evaluation, and 84% of the patients and families received education., Discussion and Conclusion: Therapists selected an eclectic approach to intervention rather than specific intervention techniques. The approach to patients' care included interventions to remediate impairments and to compensate for functional limitations. Therapists also reported frequently using motor control and motor learning approaches to facilitate all activities. This approach to care is largely consistent with existing stroke care guidelines and advances in the scientific theories of motor control and motor learning.