Functional Status Preservation and Rehabilitation

Importance

Mortality
Noninstitutionalized adults needing help of another person with activities of daily living (ADLs) xxvii(2007)	4.4 million57
Noninstitutionalized adults age 75 and over needing help of another person with ADLs (2007)	11%57
Noninstitutionalized adults needing help with instrumental activities of daily living (IADLs)xxviii (2007)	8.6 million57
Noninstitutionalized adults age 75 and over needing help with IADLs (2007)	20%57
Nursing home residents needing help with ADLs (2004)	1.5 million58
Cost
Medicare payments for outpatient physical therapy (2006 est.)	$3.1 billion59
Medicare payments for outpatient occupational therapy (2006 est.)	$747 million59
Medicare payments for outpatient speech-language pathology services (2006 est.)	$270 million59

Measures

A person's ability to function can decline with disease or age, but it is not always an inevitable consequence. Threats to function span a wide variety of medical conditions. Services to maximize function are delivered in a variety of settings, including providers' offices, patients' homes, long-term care facilities, and hospitals. Some health care interventions can help prevent diseases that commonly cause declines in functional status. Other interventions, such as physical therapy, occupational therapy, and speech-language pathology services, can help patients regain function that has been lost or minimize the rate of decline in functioning.

The NHQR tracks several measures related to functional status preservation and rehabilitation. Three core report measures are highlighted in this section:

• Osteoporosis screening among older women.
• Improvement in ambulation in home health care patients.
• Nursing home residents needing more help with daily activities.

Findings

Prevention: Osteoporosis Screening Among Older Women

Osteoporosis is a disease characterized by loss of bone tissue. About 10 million people in the United States have osteoporosis, and another 34 million with low bone mass are at risk for developing the disease. Women represent more than two-thirds of Americans at risk for or diagnosed with osteoporosis.⁶⁰

Osteoporosis increases the risk of fractures of the hip, spine, and wrist, and about half of all postmenopausal women will experience an osteoporotic fracture. Osteoporotic fractures cost the U.S. health care system $17 billion each year and cause considerable morbidity and mortality. For example, of patients with hip fractures, one-fifth will die during the first year, one-third will require nursing home care, and only one-third will return to the functional status they had before the fracture.⁶⁰

Because older women are at highest risk for osteoporosis, the U.S. Preventive Services Task Force recommends routine osteoporosis screening of women age 65 and over. Women with low bone density can reduce their risk of fracture and subsequent functional impairment by taking appropriate medications.⁶¹

Figure 2.38. Older female Medicare beneficiaries who reported ever being screened for osteoporosis with a bone mass or bone density measurement, by insurance status, 2001, 2003, and 2006

Key: HMO = health maintenance organization.

Source: Medicare Current Beneficiary Survey, 2001, 2003, and 2006.

Denominator: Female Medicare beneficiaries age 65 and over living in the community.

• From 2001 to 2006, the percentage of older female Medicare beneficiaries who reported ever being screened for osteoporosis with a bone mass or bone density measurement increased overall and among all insurance groups (Figure 2.38).
• In all years, the percentage of older female Medicare beneficiaries who reported ever being screened for osteoporosis was lower among those with Medicare and health maintenance organization, Medicare and Medicaid, or Medicare only compared with those with Medicare and private insurance.

Outcome: Improvement in Ambulation in Home Health Care Patients

After an illness or injury, many patients receiving home health care may need temporary help to walk safely. This assistance can come from another person or from equipment, such as a cane. Patients who use a wheelchair may have difficulty moving around safely, but if they can perform this activity with little assistance, they are more independent, self-confident, and active.

As patients recover from illness or injury, many experience improvements in walking and moving with a wheelchair, which can be facilitated by physical therapy. However, in cases of patients with some neurologic conditions, such as progressive multiple sclerosis or Parkinson's disease, ambulation may not improve even when the home health agency provides good care. In addition, the characteristics of patients referred to home health agencies vary across States.

Figure 2.39. Adult home health care patients whose ability to walk or move around improved between the start and end of a home health care episode, by age, 2002-2007

Source: Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set (OASIS), 2002-2007.

Denominator: Adult nonmaternity patients completing an episode of skilled home health care and not already performing at the highest level according to the OASIS question on ambulation at the start of the episode.

• In 2007, 43.3% of adult home health care patients showed improvement in walking or moving around (Figure 2.39).
• From 2002 to 2007, the percentage of adult home health care patients whose ability to walk or move around improved increased overall and for every age group.
• In all years, home health patients ages 18-64, 75-84, and 85 and over were less likely to show improvement compared with patients ages 65-74. These patients may have higher levels of disability or infirmity than patients ages 65-74 that make improvements in mobility harder to achieve.

Figure 2.40. State variation: Adult home health care patients whose ability to walk or move around improved, 2008

Key: Best quartile indicates States with highest rates of improvement in ability to walk or move around; worst quartile indicates States with lowest rates.

Source: Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set, 2008.

• The 13 States^xxix in the best quartile (highest rates of improvement in ability to walk or move around) for home health patients had a combined average rate of 45.6% in 2008 (Figure 2.40). These States are primarily located in the South.
• Nine States^xxx and the District of Columbia are in the worst quartile (lowest rates) in 2008, with a combined average rate of 38.7%.

Outcome: Nursing Home Residents Needing More Help With Daily Activities

Patients go to live in nursing homes when they are too frail or sick to be cared for at home. While almost all long-stay nursing home residents have limitations in their activities of daily living, nursing home staff help residents stay as independent as possible. Most residents want to care for themselves, and the ability to perform daily activities is important to their quality of life. Some functional decline among residents cannot be avoided, but optimal nursing home care seeks to minimize the rate of decline.

Figure 2.41. Long-stay nursing home residents whose need for help with daily activities increased, by age, 2000-2007

Source: Centers for Medicare & Medicaid Services, Minimum Data Set, 2000-2007. Data are from the third quarter of each calendar year.

Denominator: All long-stay residents in Medicare or Medicaid certified nursing home facilities.

• The overall percentage of long-stay nursing home residents whose need for help with daily activities increased did not change between 2000 and 2007 (Figure 2.41). The percentage increased among residents ages 0-64 and ages 65-74.
• In all years, residents ages 0-64 were less likely to need increasing help with daily activities compared with residents ages 65-74. In all years except 2007, residents ages 75-84 and age 85 and over were significantly more likely to need increasing help with daily activities compared with residents ages 65-74.

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Supportive and Palliative Care

Importance

Demographics
Number of nursing home residents ever admitted during the calendar year (2007)	3,196,31062
Number of Medicare fee-for-service (FFS) home health patientsxxxi(2006)	3,031,81463
Number of Medicare FFS beneficiaries using Medicare hospice services (2006)	935,56564
Cost
Total costs of nursing home carexxxii (2007 est.)	$131.3 billion65
Total costs of home health carexxxii (2007 est.)	$59.0 billion65
Medicare FFS payments for hospice services (2008 est.)	11.2 billion66

Measures

Disease cannot always be cured, and disability cannot always be reversed. For patients with long-term health conditions, managing symptoms and preventing complications are important goals. Supportive care focuses on enhancing patient comfort and quality of life and preventing and relieving symptoms and complications. Toward the end of life, palliative care also provides patients and families with emotional and spiritual support to help cope with death. Honoring patient values and preferences for care is also critical.⁶⁷

Supportive and palliative care cuts across many medical conditions and is delivered by many health care providers. The NHQR tracks several measures of supportive and palliative care delivered by home health agencies, nursing homes, and hospices. One core report measure on home health care and two core report measures on nursing home care are highlighted in this section:

• Shortness of breath among home health care patients.
• Use of physical restraints on nursing home residents.
• Pressure sores in nursing home residents.

The two noncore measures presented here from the National Hospice and Palliative Care Organization's Family Evaluation of Hospice Care survey are:

• Referral to hospice at the right time.
• Receipt of right amount of pain medicine by hospice patients.

In addition, this NHQR includes a section focusing on pain management from the National Home and Hospice Care Survey.

Findings

Outcome: Shortness of Breath Among Home Health Care Patients

Shortness of breath is uncomfortable. Many patients with heart or lung problems experience difficulty breathing and may tire easily or be unable to perform daily activities. Doctors and home health staff should monitor shortness of breath and may give advice, therapy, medication, or oxygen to help lessen this symptom.

Figure 2.42. Adult home health care patients who had less shortness of breath between the start and end of a home health care episode, by age, 2002-2007

Source: Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set, 2002-2007.

Denominator: Adult nonmaternity patients completing an episode of skilled home health care.

• Between 2002 and 2007, the percentage of adult home health care patients who had less shortness of breath improved from 53.3% to 61.3% (Figure 2.42). Improvements were observed in all age groups.
• In 2006 and 2007, home health care patients ages 18-64 years were significantly less likely than patients ages 65-74 to have experienced less shortness of breath. Medicare patients under age 65 are usually disabled or have ESRD.

Management: Use of Physical Restraints on Nursing Home Residents

Many medical conditions can cause alterations in mental status. Patients with impaired mental status may fall down, wander, get lost, or become injured. A physical restraint is any device, material, or equipment that keeps a person from moving freely. Some facilities use restraints to prevent some patients from falling or wandering because it is less labor intensive than having staff watch patients closely.

Despite their potential benefits, restraints used daily can lead patients to become weak and develop other medical complications. The use of physical and pharmacologic restraints can result in a variety of emotional, mental, and physical problems. According to regulations for the nursing home industry, restraints should be used only when medically necessary. Bedrails are not included in this measure because they may be appropriate at night for some patients to prevent falls.

Figure 2.43. Long-stay nursing home residents with physical restraints, by age, 2000-2007

Source: Centers for Medicare & Medicaid Services, Minimum Data Set, 2000-2007. Data are from the third quarter of each calendar year.

Denominator: All long-stay residents in Medicare or Medicaid certified nursing home facilities.

Note: Restraint use was determined based on a 7-day assessment period.

• The overall percentage of long-stay nursing home residents who were physically restrained decreased from 10.4% in 2000 to 5.0% in 2007 (Figure 2.43).
• Decreases in the use of physical restraints were observed for all age groups between 2000 and 2007.
• In all years, residents ages 0-64, 75-84, and 85 and over were more likely to be physically restrained compared with residents ages 65-74.

Figure 2.44. State variation: Long-stay nursing home residents with physical restraints, 2008

Key: Best quartile indicates States with lowest rates of physical restraints; worst quartile indicates States with highest rates.

Source: Centers for Medicare & Medicaid Services, Minimum Data Set, Nursing Home Compare, 2008.

• Eleven States^xxxiii and the District of Columbia were in the best quartile (lowest rates of physical restraints) in 2008 and had an average rate of 1.4% (Figure 2.44). These States are primarily located in New England and the Midwest.
• The 13 States^xxxiv in the worst quartile (highest rates) in 2008 had a combined average rate of 5.9%. These States are primarily located in the South and Southwest.

Outcome: Pressure Sores in Nursing Home Residents

Pressure sores are skin breakdowns caused by sustained sitting or lying in one position for an extended period of time. They can be painful, take a long time to heal, and cause other complications, such as skin or bone infections. Nursing home residents who are bed or chair bound, have difficulty turning and repositioning themselves, are incontinent, and may not receive the nutrients they need to maintain good skin health are at high risk of pressure sores. Residents who lack these characteristics would be considered at low risk of developing pressure sores. Pressure sores require attentive skin care, hygiene, and pressure relief to prevent and heal. The estimates below include pressure sores of all stages.

Nursing home residents differ in their personal care needs and health risks. Short-stay residents commonly have a brief stay in a nursing home after a hospitalization, which is usually followed by return to their home. Long-stay residents, in contrast, are expected to stay in the nursing home either permanently or for an extended time.

Figure 2.45. Short-stay and long-stay nursing home residents with pressure sores, by type of resident, 2000-2007

Source: Centers for Medicare & Medicaid Services, Minimum Data Set, 2000-2007.

Denominator: All residents in Medicare or Medicaid certified nursing and long-term care facilities.

• From 2000 to 2007, the rate of short-stay residents with pressure sores fell from 22.6% to 19.5% (Figure 2.45).^xxxv For high-risk long-stay residents, the rate fell from 13.9% to 12.0%, and for low-risk long-stay residents, the rate fell from 2.6% to 2.2%.^xxxvi
• Short-stay residents have the highest rates of pressure sores; some of these patients may be admitted to nursing homes because of sores acquired during an acute care hospitalization. As expected, high-risk long-stay residents have a greater risk of having pressure sores than low-risk long-stay residents.

Management: Referral to Hospice at the Right Time

Hospice care is delivered at the end of life to patients with a terminal illness or condition requiring comprehensive medical care and provides psychosocial and spiritual support for the patient and family. The goal of end-of-life care is to achieve a "good death," defined by the Institute of Medicine as one that is "free from avoidable distress and suffering for patients, families, and caregivers; in general accord with the patients' and families' wishes; and reasonably consistent with clinical, cultural, and ethical standards."⁶⁸

The National Hospice and Palliative Care Organization's Family Evaluation of Hospice Care survey examines the quality of hospice care for dying patients and their family members. Family respondents report how well hospices respect patients' wishes, communicate about illness, control symptoms, support dying on one's own terms, and provide family emotional support.^69,xxxvii

Caregivers' perception of the timing of the referral to hospice is often associated with increased reports of unmet needs and lower satisfaction with hospice care. The perception of referral timing may be an indicator of adequacy of access to hospice care.

Figure 2.46. Hospice patient caregivers who perceived that the patient was NOT referred to hospice at the right time, by age, 2005-2008

Source: National Hospice and Palliative Care Organization, Family Evaluation of Hospice Care, 2005-2008.

Denominator: Adult hospice patients.

Note: Caregivers were family members who interacted with hospice providers.

• The percentage of hospice patient caregivers who perceived that the patient was not referred to hospice at the right time was 11.3% in 2008 (Figure 2.46).
• From 2005 to 2008, caregivers' perception that the patient was referred at the right time improved overall and for patients ages 45-64 and 65 and over.
• In all years, caregivers of patients ages 18-44 and 45-64 were less likely to perceive the patient was referred at the right time compared with caregivers of patients age 65 and over.

Management: Receipt of Right Amount of Pain Medicine by Hospice Patients

Addressing the comfort aspects of care, such as relief from pain, fatigue, and nausea, is an important component of hospice care.^xxxviii

Figure 2.47. Hospice patients who did NOT receive the right amount of medicine for pain, by age, 2006-2008

Source: National Hospice and Palliative Care Organization, Family Evaluation of Hospice Care, 2006-2008.

Denominator: Adult hospice patients.

• The percentage of hospice patients whose families reported that they did not receive the right amount of medicine for pain was 5.5% in 2008 (Figure 2.47).
• From 2006 to 2008, the percentage of hospice patients whose families reported that they did not receive the right amount of medicine for pain decreased overall and for adults age 65 and over. There was no significant change during this time period for adults ages 18-44 and ages 45-64.
• In all years, families of hospice patients ages 18-44 and ages 45-64 were more likely to report that the patient did not receive the right amount of pain medicine compared with families of patients age 65 and over.

Focus on Pain Management From the National Home and Hospice Care Survey

Pain management among home health and hospice patients is complex and is made more difficult by the high prevalence of multiple chronic conditions, dementia, and other impairments. Medication only as needed (pro re nata, or PRN) is a common pain management strategy. Although appropriate in some cases, this strategy generally yields less than optimal pain control, and high use of PRN-only pain medications may indicate suboptimal management of pain. Administration of medication by standing order is often more clinically appropriate for those with higher pain levels.

This report and previous reports have shown the percentage of hospice patients who received the right amount of medicine for pain management based on surveys of families and caregivers. However, information on how pain is managed among home health and hospice patients is generally not available.

The 2007 National Home and Hospice Care Survey (NHHCS) is a nationally representative sample survey of home health and hospice agencies that are either certified by Medicare or Medicaid or licensed by a State to provide home health or hospice services. The total number of agencies that participated in the 2007 NHHCS is 1,036, and data are available on 4,683 current home health patients and 4,733 hospice discharges from these agencies.

The 2007 NHHCS data were collected through in-person interviews with agency directors and their designated staff; no interviews were conducted directly with patients or their families and friends. NHHCS also collected information from patient records on the occurrence, intensity, and management of pain. Separate analyses of pain management of home health patients and hospice care discharges are presented.

Figure 2.48. Current home health patients with any pain at last assessment and, if any pain present, only PRN orders for pain management, by age, 2007

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Home and Hospice Care Survey, 2007.

Denominator: Current home health patients.

• Among current home health patients, 45.3% were assessed to have any pain at the last assessment (Figure 2.48).
• Of current home health patients with any pain, 51.9% were managed with PRN orders only. Differences by age were not statistically significant.

Figure 2.49. Hospice care discharges with any pain at last assessment and, if any pain present, only PRN orders for pain management, by age, 2007

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Home and Hospice Care Survey, 2007.

Denominator: Hospice care discharges with pain assessment.

• Among hospice care discharges in 2007, 30.1% of assessed patients had pain at the last assessment (Figure 2.49).
• Of hospice care discharges in which the patient had any pain, 26.3% were managed with PRN orders only.
• Hospice care discharges of patients under age 65 were more likely to have any pain at last assessment compared with hospice discharges of patients age 65 and over, but management of pain with PRN orders only was similar between the two age groups.

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^xxvii ADLs consist of basic self-care tasks, such as bathing, dressing, eating, transferring, using the toilet, and walking.
^xxviii IADLs consist of tasks needed for a person to live independently, such as shopping, doing housework, preparing meals, taking medications, using the telephone, and managing money.
^xxix The States are Georgia, Kentucky, Maine, Maryland, Mississippi, Nevada, New Jersey, Rhode Island, South Carolina, Tennessee, Utah, Virginia, and West Virginia.
^xxx The States are Alaska, Arizona, Delaware, Iowa, Minnesota, New York, Oregon, Texas, and Wyoming.
^xxxi Medicare FFS patients represent only a portion of all home health patients.
^xxxii Cost estimates for nursing home and home health services include only costs for freestanding skilled nursing facilities, nursing homes, and home health agencies and not those that are hospital based.
^xxxiii The States are Alaska, Delaware, Iowa, Kansas, Maine, Nebraska, New Hampshire, North Dakota, Rhode Island, Virginia, and Wisconsin.
^xxxiv The States are Arkansas, California, Colorado, Florida, Kentucky, Louisiana, Mississippi, New Mexico, Ohio, Oklahoma, South Carolina, Tennessee, and Utah.
^xxxv "Short stay" refers to residents who are admitted to a facility and stay fewer than 30 days; these admissions, also referred to as "postacute," typically follow an acute care hospitalization.
^xxxvi "Long stay" or "chronic care" refers to residents who enter a nursing facility typically because they are no longer able to care for themselves at home; they tend to remain in the facility from several months to several years. High-risk residents are those who are in a coma, do not get the nutrients they need to maintain good skin health, or cannot change position on their own. Low-risk residents are active, can change positions, and are getting the nutrients they need to maintain good skin health.
^xxxvii This survey provides unique insight into end-of-life care and captures information about a large percentage of hospice patients but is limited by nonrandom data collection and a response rate of about 40%. Survey questions were answered by family members, who might not be fully aware of the patients' wishes and concerns. These limitations should be considered when interpreting these findings.
^xxxviii This measure is based on responses from patients' family members, who may or may not be able to determine whether the right amount of medicine for pain was administered.

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