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Patient Functional Outcomes in Skilled Nursing Facilities: The Mediating Role of Declining Therapy
Rachel A Prusynski1, Andrew Humbert2, Harsha Amaravadi3
1Department of Rehabilitation Medicine, University of Washington, Seattle, WA; Department of Health Systems and Population Health, University of Washington, Seattle, WA.
Objective:
To estimate changes in functional outcomes in Medicare fee-for-service skilled nursing facility (SNF) patients after declines in therapy minutes that occurred after Patient-Driven Payment Model (PDPM) implementation and during the COVID-19 pandemic. We also tested the hypothesis that declines in therapy minutes mediated changes in patient functional outcomes.
Design:
Retrospective cohort study using mediation analysis. Exposures were PDPM implementation (October 2019) and COVID-19 pandemic onset (March 2020). The mediator was average minutes of therapy per day (MTD) including all physical, occupational, and speech therapy minutes during the SNF stay.
Setting:
All US SNFs.
Participants:
Patients (N=3,534,928) at post-acute SNF stays from January 2018 through September 2021.
Interventions:
Not applicable.
Main Outcome Measures:
Functional outcomes based on changes in activities of daily living (ADL) scores between SNF admission and discharge, measured by a validated 28-point scale: (1) ADL decline and (2) high ADL improvement (≥4 points improvement). Mediation analysis quantified effects of declining MTD on functional outcomes, adjusting for patient, facility, and community-level confounders.
Results:
Average MTD declined from 122.2 pre-PDPM to 96.5 post-PDPM and further to 87.7 during COVID-19. After PDPM implementation, the adjusted probability of ADL decline increased by 1.7 percentage points (pp) (95% CI: 1.6-1.7); during COVID-19, ADL decline increased by 3.7 pp (95% CI: 3.6-3.7). Declining MTD mediated 47.9% of the increase in ADL decline post-PDPM and 26.5% during COVID-19. The adjusted probability of high ADL improvement increased by 1.3 pp (95% CI: 1.1-1.3) post-PDPM and 1.0 pp (95% CI: 0.8-1.0) during COVID-19. Declining MTD negatively mediated this increase in high ADL improvement by -2.9 pp post-PDPM (95% CI: -2.9 to -2.9) and by -3.5 pp during COVID-19 (95% CI: -3.6 to -3.5).
Conclusions:
Declines in SNF therapy after PDPM implementation and during COVID-19 mediated substantial worsening in patient functional outcomes. Ensuring adequate therapy provision may improve functional recovery in SNF patients.
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