Janet Kues Freburger

Introduction: Stakeholder engagement is a core element of a learning health system (LHS). Meaningful engagement of stakeholders can improve learning within a health system by informing program development and service delivery and by increasing buy‐in and sustainability of evidence‐based practices. While health systems recognize the value of stakeholder engagement, conducting stakeholder engagement activities requires time, resources, and the support of health system leadership. The objective of this pilot study was to obtain preliminary data on the value of stakeholder engagement from the perspective of rehabilitation directors. Methods: We conducted a general qualitative study utilizing 90‐min focus groups. The main outcomes were domains identified from analysis of the focus group transcripts. Results: Six individuals from 4 health systems participated in one of two focus groups. Seven domains were identified: (1) how stakeholder engagement supports organizational mission and priorities; (2) types of stakeholders working with health systems; (3) past stakeholder engagement experiences; (4) engagement with stakeholders with lived experiences; (5) sustaining stakeholder relationships; (6) challenges with stakeholder engagement; and (7) future stakeholder engagement goals. Conclusions: This qualitative pilot study of the perspectives of rehabilitation LHS leaders on stakeholder engagement provides preliminary data that can be used to inform future research. While we found consistent themes recognizing the value of stakeholder engagement and participation in stakeholder engagement, respondents noted challenges in engaging stakeholders and using the information gained to effect change.

Background: Community‐based physical and occupational therapy (PT/OT) are critical for stroke recovery but are underused. We conducted a secondary analysis of the COMPASS (Comprehensive Post‐Acute Stroke Services) study, a pragmatic trial of comprehensive postacute transitional care (TC) to investigate whether TC programs increase PT/OT use. Methods: Forty hospitals were randomized to implement COMPASS‐TC or maintain usual care for patients with stroke/transient ischemic attack. In a crossover phase, usual care hospitals implemented COMPASS‐TC. We linked participants to administrative claims to assess PT/OT use after stroke. Adjusted generalized estimating equations compared COMPASS‐TC to usual care within the trial and crossover cohorts on 30‐/90‐day PT/OT use, time to first visit, number of visits, and receipt of PT and OT versus single therapy. Per protocol analysis estimated complier average causal effects. Results: COMPASS enrolled 8377 patients from July 2016 to March 2019; 5261 were linked to administrative claims. Thirty‐day PT/OT ranged from 22.6% in usual care to 37.5% in COMPASS‐TC. Therapy use was similar between groups in the trial cohort, and COMPASS‐TC was associated with increased use in crossover analysis (9.4% [95% CI, 5.6–13.3%] at 30 days). COMPASS‐TC was consistently associated with a shorter time to therapy (mean difference, −0.16 [95% CI, −0.03 to −0.29]). Per protocol results were larger for most outcomes. Conclusions: COMPASS‐TC was associated with shorter time to PT/OT and with greater therapy receipt in the crossover, but not the trial, analysis. Inconsistencies may reflect confounding or differences in hospitals that chose to adopt the intervention in Phase 2. Implementation studies to improve care transitions after stroke are needed to enhance use of postacute rehabilitation.

Introduction: Significant declines in therapy provision in skilled nursing facilities (SNFs) followed the 2019 implementation of Medicare's Patient-Driven Payment Model (PDPM) and the onset of the COVID-19 pandemic, raising concerns about effects on patient outcomes. Methods: Using Medicare fee-for-service claims and SNF assessment data from January 2018 through September 2021, we analyzed 3.5 million post-hospital SNF stays to assess whether changes in therapy volumes mediated changes in successful community discharge and 30-day hospital readmissions. Results: Average total physical, occupational, and speech therapy minutes per day declined from 122.2 before PDPM to 96.5 immediately after implementation and to 87.7 during the pandemic. Adjusted probabilities of successful community discharge rose modestly after PDPM but fell during COVID-19, while readmissions declined initially and then increased. Mediation analyses showed that reductions in therapy volumes were strongly associated with the declines in community discharge and increases in readmissions. These findings persisted for patients with dementia and moderate levels of functional impairment at admission; declining therapy volumes were associated with the observed worsening of discharge outcomes after PDPM implementation and during the pandemic. Conclusions: Results highlight therapy provision as a key modifiable policy target for improving post-acute outcomes and reducing rehospitalizations among older adults in SNFs.

Background: Our objective was to assess the extent of sociodemographic and geographic disparities in the use of community‐based rehabilitation following stroke, an area that has been understudied. Methods: We conducted an observational, secondary analysis of data from the COMPASS (Comprehensive Post‐Acute Stroke Services) trial, linking data of 6754 survivors of stroke to insurance claims. Our primary outcome was receipt of physical or occupational therapy in the home or outpatient setting within 30 days of hospital discharge. Secondary outcomes included therapy receipt within 90 days, time to first visit, number of visits, care in the home versus outpatient setting, and therapy type (physical therapy and occupational therapy versus 1 type). Our exposures were sex, race, rurality of patient residence, and socioeconomic status (Medicaid insurance). We used generalized estimating equations to examine associations between exposures and outcomes, controlling for therapy need. Results: We found evidence of disparities in therapy receipt, setting, and type. Individuals on Medicaid (versus no Medicaid) were 8% (−0.08 [95% CI, −0.10 to −0.05]) less likely to receive therapy within 30 days, with the effect being slightly smaller for White patients (−0.05 [95% CI, −0.09 to −0.01]). Individuals living in rural versus metropolitan areas were 5% less likely (−0.05 [95% CI, −0.08 to −0.02]) to receive care within 30 days and 12% (−0.12 [95% CI, −0.22 to −0.03]) less likely to receive physical therapy and occupational therapy. Overall, we found minimal evidence of racial disparities. Conclusions: Our findings add to the limited evidence on disparities in community‐based rehabilitation after stroke.

Health insurance claims are a rich source of information for health services researchers and can provide evidence to understand issues related to access, efficiency, and effectiveness of care. While numerous studies have examined rehabilitation utilization using Medicare, Medicaid, and/or private insurance claims data, these studies typically lack detail on approaches used to identify rehabilitation services. The primary objectives of this perspective are: (1) to raise awareness of the need for and importance of methodological transparency and openness in rehabilitation-related health services research using claims data and (2) to provide a case example by sharing the details of a method for identifying community-based physical therapy and occupational therapy in Medicare claims. General decisions made in claims-based analyses are discussed and then illustrated with the approach used for identifying community-based therapy claims within the context of a secondary analysis of data from a large, multicenter pragmatic clinical trial. Specific decisions made and challenges encountered are discussed, and recommendations are made for future work in this area. Sharing methodological details, data when possible, and metadata on approaches for conducting rehabilitation-related health services research can enhance its validity, rigor, and—ultimately—overall value. Rehabilitation health services researchers are encouraged to make greater efforts to share information on their methodological approaches using claims data and other data relevant to health services research.

BACKGROUND: Stroke survivors with limitations in activities of daily living (ADL) have a greater risk of experiencing falls, hospitalizations, or physical function decline. We examined how informal caregiving received in hours per week by stroke survivors moderated the relationship between ADL limitations and adverse outcomes. METHODS: In this retrospective cohort, community-dwelling participants were extracted from the National Health and Aging Trends Study (2011–2020; n=277) and included if they had at least 1 formal or informal caregiver and reported an incident stroke in the prior year. Participants reported the amount of informal caregiving received in the month prior (low [P =0.041) than those who received the highest amounts. CONCLUSIONS: Informal caregiving hours moderated the relationship between ADL limitations and adverse outcomes in this sample of community-based stroke survivors. Higher amounts relative to lower amounts of informal caregiving hours per week may be protective by decreasing the rate of adverse outcomes per ADL limitation.

BACKGROUND: Few studies on care transitions following acute stroke have evaluated whether referral to community-based rehabilitation occurred as part of discharge planning. Our objectives were to describe the extent to which patients discharged home were referred to community-based rehabilitation and identify the patient, hospital, and community-level predictors of referral. METHODS: We examined data from 40 North Carolina hospitals that participated in the COMPASS (Comprehensive Post-Acute Stroke Services) cluster-randomized trial. Participants included adults discharged home following stroke or transient ischemic attack (N=10 702). In this observational analysis, COMPASS data were supplemented with hospital-level and county-level data from various sources. The primary outcome was referral to community-based rehabilitation (physical, occupational, or speech therapy) at discharge. Predictor variables included patient (demographic, stroke-related, medical history), hospital (structure, process), and community (therapist supply) measures. We used generalized linear mixed models with a hospital random effect and hierarchical backward model selection procedures to identify predictors of therapy referral. RESULTS: Approximately, one-third (36%) of stroke survivors (mean age, 66.8 [SD, 14.0] years; 49% female, 72% White race) were referred to community-based rehabilitation. Rates of referral to physical, occupational, and speech therapists were 31%, 18%, and 10%, respectively. Referral rates by hospital ranged from 3% to 78% with a median of 35%. Patient-level predictors included higher stroke severity, presence of medical comorbidities, and older age. Female sex (odds ratio, 1.24 [95% CI, 1.12–1.38]), non-White race (2.20 [2.01–2.44]), and having Medicare insurance (1.12 [1.02–1.23]) were also predictors of referral. Referral was higher for patients living in counties with greater physical therapist supply. Much of the variation in referral across hospitals remained unexplained. CONCLUSIONS: One-third of stroke survivors were referred to community-based rehabilitation. Patient-level factors predominated as predictors. Variation across hospitals was notable and presents an opportunity for further evaluation and possible targets for improved poststroke rehabilitative care. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02588664.