Strategic use of rehabilitation services cut more than three full days out of the average hospital stay.
At Rusk Rehabilitation, part of NYU Langone Medical Center in New York City, clinical leaders have launched several initiatives to provide patients with earlier rehabilitation therapy. These initiatives have shortened length of stay (LOS) in several units and reduced utilization in high-cost settings.
LOS Reduction Across the Board
In 2014, Rusk clinicians launched the ICU Early Mobilization project. “This pilot project focused on patients in the medical ICU and the surgical ICU, who are really the sickest of the sick,” says Geoffrey Hall, who served as administrator of Rusk Rehabilitation from 2009 to 2016. “These patients are medically fragile and unable to move much, and many of them are on ventilators. They require the highest level of care, so they are the most expensive patients in the hospital.”
Under the project, patients received an average of 60 minutes of therapy each day in the ICU. Interventions included both physical and occupational therapy as well as speech-language pathology services. “We found that starting therapy early with this population was effective,” Hall says. “Even simple acts like sitting up, doing exercises in bed, and taking a few steps had a profound impact on their recovery.”
Project leaders compared the study group with historical data controlled for patient condition. ICU LOS decreased approximately 20 percent from 4.6 days to 3.7 days. In addition, LOS on regular nursing floors decreased about 40 percent from 6.0 days to 3.4 days. All told, early rehab cut more than three full days out of the average hospital stay.
“Early mobilization in critical care has yielded tremendous cost savings,” Hall says. “We have reduced direct care costs for these patients by more than 29 percent, or about $2.2 million.” After subtracting increased labor costs, net cost savings were $1.5 million. “And these figures do not even consider the financial opportunity from backfilling these beds with additional patient volume.”
The impact of the ICU Early Mobilization project goes beyond inpatient costs. According to Hall, discharges to acute rehabilitation declined from 24 percent to 13 percent, and discharges to subacute care were reduced from 6 percent to 1 percent. Discharges home without additional services increased from 18 percent to 41 percent. “Patients who received early rehabilitation were much more independent at discharge,” Hall says. “They needed less supportive care such as home care nursing and home aides, which are also cost drivers.”
Reduced Use of High-Cost Services
Clinical leaders at Rusk have extended the early mobilization concept to several departments and service lines. Major initiatives include the following.
Early mobilization for heart valve patients. This project grew out of the medical center’s participation in the Centers for Medicare & Medicaid Services (CMS) Bundled Payments for Care Improvement initiative. “What we recognized when we initiated the bundle is that 60 percent of patients who had valve surgery in our institution were coming to inpatient rehabilitation,” says Jonathan Whiteson, MD, assistant professor of rehabilitation medicine. Expensive acute rehabilitation services significantly increased costs under the cardiac bundle. “So, similar to what we did for critical care patients, we created an early mobilization intervention.”
Now, patients who undergo valve surgery receive twice-daily therapy services in both the intensive care unit and the regular surgical floors. This up-front therapy has reduced inpatient rehabilitation admissions from 60 percent to 10 percent. “In other words, 90 percent of valve patients are now discharged directly home, as opposed to 40 percent in the past,” Whiteson says.
Coordinated rehabilitation for same-day hip replacement. Early rehabilitation services have also been key to achieving a significant milestone—same-day discharge for hip replacement patients. The department of orthopedic surgery at NYU Langone pioneered a new surgical approach that requires close collaboration with the department of rehabilitation to ensure success.
“In this initiative, rehabilitation has partnered with orthopedic surgery to do a pre-evaluation of patients requiring surgery,” Hall says. The evaluation covers physical function and abilities as well as the psychosocial factors that are important to same-day discharge. “The initiative also focuses on helping patients transition to the home setting while maintaining care coordination. We partner very closely with visiting nurse services to ensure they receive the patient at home within the first 24 hours after discharge.” Rusk staff also ensure that patients go home with a robust set of exercises they can perform independently. “In addition, we want to make sure the patient gets into ambulatory care without a gap, so the patient’s first outpatient appointment is scheduled even before surgery happens.”
NYU Langone launched same-day discharge for hip replacement patients in 2015—the first hospital to do so in New York City. During year one of the program, 55 patients went through the same-day protocol with zero readmissions.
Current Priorities, Future Directions
Decreased utilization and cost reductions are not the only benefits of early rehabilitation. According to Hall, enhanced rehabilitation can support several objectives that are important to value-based initiatives.
“Not only are outcomes better, but patient satisfaction tends to be higher because rehabilitation makes patients a part of the process,” Hall says. “And for our same-day hip patients and other patient populations, getting home earlier is definitely a patient satisfier.”
Hall also argues that rehabilitation services are key to reducing opioid use. “In terms of pain management, physical therapy can be an effective intervention,” he says. “It treats the pain directly and also strengthens the core muscles, which helps patients get better without pain medications.” In fact, NYU Langone critical care patients who received early mobilization therapy required less sedation while reporting no increase in pain measures.
Hall believes that rehabilitation medicine is a largely untapped resource that could help transform outcomes and control costs in several areas of healthcare. “One emerging area is cancer rehabilitation, and there is a lot of research showing that rehabilitation is a significant missing element in post-cancer treatment recovery and survivorship,” he says. “As people begin to talk about the ‘ Cancer Moonshot,’ including rehabilitation in that push will be extremely important.”
In the years ahead, the key to leveraging rehabilitation will be increasingly through enhanced outpatient services. “There will always be a need for acute inpatient rehabilitation, but our strategy in terms of payment reform is to make rehabilitation more accessible,” Hall says. “After discharge, it’s not always convenient for patients to come back to the hospital three times a week. So to meet these needs, we need to extend outpatient rehabilitative care to places where patients live and work.”
Whiteson points out that the government is recognizing the value of rehabilitation medicine and cost control. He noted the Cardiac Rehabilitation Incentive Payment Model recently proposed by CMS for heart attack and bypass surgery patients. Under this model, hospitals will receive enhanced reimbursement for patients who receive between 12 and 36 cardiac rehabilitation services in the 90 days following discharge. “CMS has looked at the data on patients enrolled in outpatient cardiac rehab and they have recognized the benefit to patient well-being as well as the reduction in healthcare utilization, including readmissions,” Whiteson says.
Rehabilitation and Reform
Hall believes rehabilitation is key to success under healthcare reform. “If we can intervene early with rehabilitation services, we can reduce big cost drivers like length of stay. And we know outpatient rehabilitation services are a lot less expensive than readmissions,” he says. “It really helps deliver on one of the major goals of the Triple Aim—driving down costs while maintaining high-quality outcomes.”
Interviewed for this article:
Geoffrey Hall, MSW, FACHE, was formerly administrator at Rusk Rehabilitation, New York, N.Y. He is currently CEO at Edwin Shaw Rehabilitation Hospital, Cuyahoga Falls, Ohio.
Jonathan Whiteson, MD, is assistant professor of rehabilitation medicine and vice chair for clinical operations at Rusk Rehabilitation, NYU Langone Medical Center, New York, N.Y.