Taking the Pulse of Patient Care

New Research Reveals Need for Standardized Assessments of Older Patients

While returning to normal life after being hospitalized can be hard for any patient, it is particularly challenging for older adults, who may need additional post-acute care (PAC) in either home healthcare (HHC) or skilled nursing facilities (SNF) settings.

According to Zainab Toteh Osakwe, Ph.D., assistant professor in Adelphi’s College of Nursing and Public Health, the use of post-acute care services has increased dramatically over the past two decades for patients recently discharged from a hospital. “As the lengths of hospital stays get shorter, the needs of patients discharged to home healthcare have become increasingly more complex,” she said.

With nearly half of hospitalized Medicare patients requiring post-acute services after discharge, post-acute care is becoming the fastest growing area of Medicare spending, accounting for more than $62 billion in expenditures in 2012 alone.

The 2014 Improving Medicare Post-Acute Care Transformation Act (IMPACT) mandated that post-acute care providers collect and report data in order to standardize payment procedures and quality care measurements. One crucial data element collected in post-acute care settings is information about activities of daily living, or ADLs. “In these settings,” Dr. Osakwe explained, “ADL measures are used to calculate each patient’s reimbursement rate and to evaluate the quality of care.”

For adults age 65 and older, the ability to self-manage illness and recovery at home largely depends on being able to perform basic self-care tasks.

“These activities of daily living include toileting, bathing or showering, dressing, getting in and out of bed or up and down from chairs, and walking. Among older adults, ADL ability contributes to the quality of life and is essential to living independently,” Dr. Osakwe said. “Low ADLs have been strongly associated with poor outcomes such as higher rates of hospitalization, a higher cost of medical care, an increased risk of admission to a nursing home and increased mortality.”

As the lead author of “Assessment of Activity of Daily Living Among Older Adult Patients in Home Healthcare and Skilled Nursing Facilities: An Integrative Review,” published in Home Healthcare Now in May 2017, Dr. Osakwe compares methods currently used to assess ADLs in home healthcare and skilled nursing facilities.

Supported by funding from the National Institutes of Health, National Institute of Nursing Research, the review concluded that there were substantial variations and inconsistencies in ADL assessments of self-care and mobility in both home healthcare and skilled nursing facility settings. Even the terms used to define the basic ADLs in each of the settings vary widely.

“The lack of uniformity in the methods used to assess ADLs in HHC and SNF—the two most common post-acute care settings—warrants closer attention, and aligns with the IMPACT act’s goal to improve data interoperability across the two settings,“ said Dr. Osakwe. “This study highlights the need for more objective performance-based approaches to assessing ADLs to ensure that HHC and SNF clinicians use a consistent approach to assess ADL ability.”

Study findings recommend the adoption of uniform descriptive terminology for ADLs in skilled nursing facilities and home healthcare, which aligns with the goals of IMPACT 2014.

Continuing to build on her research in the field of home-based care, Dr. Osakwe recently led a study identifying patient characteristics associated with ADL improvement and ADL dependency among the homebound elderly, using nationwide 2013 home healthcare data. According to Dr. Osakwe, findings from this study point to possible racial disparities in home healthcare, with black patients less likely to experience ADL improvement than white patients, Dr. Osakwe said.

Dr. Osakwe reported that changes in ADLs, a key measure monitored by the Centers for Medicare and Medicaid, have long provided information on patient improvement. Her new study suggests that by focusing on key patient characteristics associated with ADL improvement—from race and ethnicity to gender and prior inpatient hospital stays—home healthcare clinicians, policy makers and agencies could better meet their goals.

Zainab Toteh Osakwe ’06, Ph.D., is a nurse practitioner and former director of a certified home healthcare agency. Her research, which is generally based on analysis of large sets of home healthcare assessment data, focuses on home-based care delivery services for patients at risk for hospital readmissions, particularly the elderly.