Tamra Keeney

Importance: Advanced heart failure (HF) is a life-limiting condition that frequently necessitates hospitalization and subsequent post-acute rehabilitation for older adults. Despite high rates of post-acute care utilization, a notable gap exists in understanding the rehabilitation experiences of both patients and their care partners. Objective: The objective was to conduct semi-structured interviews with older adults hospitalized with advanced HF and their care partners to explore their prior experiences with HF rehabilitation, including perceived benefits, unmet needs, and opportunities for improvement. Design: Between 2021 and 2023, a qualitative descriptive approach was used to conduct semi-structured interviews with patients hospitalized at an urban academic medical center with advanced HF (n = 12) and care partners (n = 11). Human-centered design principles and the Framework Method were used to guide study design and analyze semi-structured interviews. Setting: Qualitative interviews were conducted at bedside, in a quiet area in the hospital, or via Zoom after discharge. Interview location was guided by participant preferences and whether the patient had previously participated in HF rehabilitation prior to their current admission or was initiating rehabilitation for the first time following their hospitalization. Participants: Patients were eligible to participate if they were community-dwelling (non-institutionalized), aged 65 years and older, had New York Heart Association Class III to IV symptoms, able to speak and read English, and had a history of receiving rehabilitation for their HF in the past (in any setting) or would be initiating it upon discharge. Patients were excluded if they were undergoing advanced therapy (organ transplant or left ventricular assist device placement), had severe cognitive impairment (diagnosis of Alzheimer disease or related dementia, delirium, or altered mental status), or were enrolled in hospice during hospitalization or at hospital discharge. Results: Three deductive domains were characterized: (1) patient and care partner rehabilitation experiences, (2) facilitators and barriers to participating in rehabilitation, and (3) recommendations for optimizing rehabilitation. In the recommendations domain, several inductive themes emerged, including: (1) enhance rehabilitation structure, (2) optimize communication between patients and therapists, (3) incorporate symptom management, and (4) provide structured activity recommendations and goals. Relevance: Older adults with advanced HF are frequently hospitalized and require post-acute rehabilitation to address impairments in physical function. Our findings characterize patient and care partner experiences with post-acute rehabilitation and identify areas for improvement that may support the development of more effective post-acute rehabilitation interventions in advanced HF.

Palliative care (PC) clinicians are well poised to help people with disabilities (PWD) live well in the context of serious illness. PC prioritizes person-centered care with a focus on function, autonomy, and quality of life. This approach aligns with principles of high-quality care for PWD. An understanding of the unique experiences and needs of PWD can advance the delivery of comprehensive, equitable PC for this population. In this article, we provide 10 tips to help PC clinicians develop an informed disability lens in their approach to care.

Background: Many older adults with advanced heart failure receive home health rehabilitation after hospitalization. Yet, integration of palliative care skills into rehabilitation is limited. Objective: Describe using the Multiphase Optimization Strategy (MOST) framework with human-centered design principles to engage clinical partners in the Preparation phase of palliative physical therapy intervention development. Design: We convened a home-based physical therapy advisory team (four clinicians, three clinical leaders) to identify physical therapist needs and preferences for incorporating palliative care skills in rehabilitation and design an intervention prototype. Results: Between 2022 and 2023, we held five advisory team meetings. Initial feedback on palliative care skill preferences and training needs directly informed refinement of our conceptual model and skills in the intervention prototype. Later feedback focused on reviewing and revising intervention content, delivery strategy, and training considerations. Conclusion: Incorporating human-centered design principles within the MOST provided a useful framework to partner with clinical colleagues in intervention design.

Orthopaedic and related care has the potential to present unique obstacles for patients with a range of autism manifestations. In this review, we aim to describe and analyze the literature on autistic patients’ experience within orthopaedics and closely related fields. This literature search utilized the PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature databases. Three major concepts were built into the search terms: (1) patients on the autism spectrum; (2) patient experience; and (3) movement sciences, including orthopaedics, physical medicine and rehabilitation (PM&R), occupational therapy (OT), and physical therapy (PT). Our search yielded 35 topical publications, with the major topic areas addressed as follows: (1) clinical and perioperative management, (2) therapy interventions, (3) participation in exercise and social play, (4) sensory management and accommodations, (5) caregiver/parent training and involvement in care, (6) healthcare needs and barriers to care, and (7) utilization of technology. In the current literature, there are no studies that attempt to directly assess autistic patient experience with care practices and clinical environments in orthopaedics. Rigorous, direct examination of the experience of autistic patients within clinical orthopaedic settings is urgently needed to address this gap.

Frailty is associated with mortality in older adults hospitalized with COVID-19, yet few studies have quantified healthcare utilization and spending following COVID-19 hospitalization. To evaluate whether survival and follow-up healthcare utilization and expenditures varied as a function of claims-based frailty status for older adults hospitalized with COVID-19. Retrospective cohort study. 136 patients aged 65 and older enrolled in an Accountable Care Organization (ACO) risk contract at an academic medical center and hospitalized for COVID-19 between March 11, 2020 - June 3, 2020. We linked a COVID-19 Registry with administrative claims data to quantify a frailty index and its relationship to mortality, healthcare utilization, and expenditures over 6 months following hospital discharge. Kaplan Meier curves and Cox Proportional Hazards models were used to evaluate survival by frailty. Kruskal-Wallis tests were used to compare utilization. A generalized linear model with a gamma distribution was used to evaluate differences in monthly Medicare expenditures. Much of the cohort was classified as moderate to severely frail (65.4%), 24.3% mildly frail, and 10.3% robust or pre-frail. Overall, 27.2% (n=37) of the cohort died (n=26 during hospitalization, n=11 after discharge) and survival did not significantly differ by frailty. Among survivors, inpatient hospitalizations during the 6-month follow-up period varied significantly by frailty (p=0.02). Mean cost over follow-up was $856.37 for the mild and $4914.16 for the moderate to severe frailty group, and monthly expenditures increased with higher frailty classification (p <.001). In this cohort, claims-based frailty was not significantly associated with survival but was associated with follow-up hospitalizations and Medicare expenditures.

The aims of this study were to identify disability subgroups among patients hospitalized for ischemic stroke and to determine the predictors and distal outcomes for the disability subgroups. A retrospective, cross-sectional study design was used. Data on patients after ischemic stroke were collected from the electronic health records at 5 hospitals within a single health system. Covariates included social and demographic factors. Disability was characterized according to the Activity Measure for Post-Acute Care assessment. Distal outcomes were physical therapist treatment use, occupational therapist treatment use, and discharge disposition. Latent class analysis was used to identify disability subgroups of patients hospitalized for ischemic stroke. A total of 1549 patients were included in the analyses. Five disability subgroups were identified and labeled as follows: globally impaired (subgroup 1), impaired dynamic balance (subgroup 2), impaired self-care (subgroup 3), impaired mobility (subgroup 4), and independent (subgroup 5). Physical therapist treatment use (χ²₄ = 113.21 [P < .001]) and occupational therapist treatment use (χ²₄ = 122.97 [P < .001]) varied significantly across the disability subgroups. The globally impaired group had the highest probability of physical and occupational therapist treatment use. Similarly, discharge disposition varied across the subgroups (for home without services, χ²₄ = 246.61 [P < .001]; for home with home health care, χ²₄ = 35.49 [P < .001]; for institutional discharge, χ²₄ = 237.18 [P < .001]). The independent subgroup had the highest probability of discharge to home without services. Five disability subgroups were identified for patients after ischemic stroke. The disability subgroups provide a common language for clinicians to organize the heterogeneity of disability after stroke. Using the disability subgroups, the multidisciplinary team might be able to improve the accuracy and efficiency of care decisions. The number of current rehabilitation interventions is indeterminable, these subgroups may help to guide clinicians in selecting the most beneficial interventions for patients based on subgroup membership.

Background: Heart failure (HF) is the leading cause of hospitalization among older adults in the United States and results in high rates of post‐acute care (PAC) utilization. Federal policies have focused on shifting PAC to less intensive settings and reducing length of stay to lower spending. This study evaluates the impact of policy changes on PAC use among Medicare beneficiaries hospitalized with HF between 2008 and 2015 by (1) characterizing trends in PAC use and cost and (2) evaluating changes in readmission, mortality, and days in the community, overall and by frailty. Methods: Annual cross‐section prospective cohorts of all HF admissions between 1/1/2008 and 9/30/2015 among a 20% random sample of all Medicare Fee‐for‐Service beneficiaries ( n = 718,737). The Claims‐based Frailty Index (CFI) was used to classify frailty status. Multivariable regression models were used to evaluate trends in first discharge location, readmissions, mortality, days alive in the community, and costs; overall and by frailty status. Results: Frailty was prevalent among HF patients: 54.1% were prefrail, 37.0% mildly frail, and 6.9% moderate to severely frail. Between 2008 and 2015, almost 4% more HF beneficiaries received PAC, with most of the increase concentrated in skilled nursing facilities (SNF) (+2.3%) and home health agencies (HHA) (+1.1%), and PAC cost increased by $123 (3.5%). Over the 180‐days follow‐up after hospitalization, hospital readmissions decreased significantly (−3.4% at 30‐day; −6.3% at 180‐day), days alive in the community increased (+1.5), and 180‐day Medicare costs declined $2948 (−18.7%) without negative impact in mortality (except a minor increase in the pre‐frail group). Gains were greatest among the frailest patients. Conclusions: Medicare beneficiaries hospitalized with HF spent more time in the community and experienced lower rehospitalization rates at lower cost without significant increases in mortality. However, important opportunities remain to optimize care for frail older adults hospitalized with HF.