Advancing Rehabilitation Paradigms for Older Adults in Skilled Nursing Facilities

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Project Summary/Abstract In the U.S., 8.37 million adults over age 65 will experience a hospital stay during the next year, which often has serious and long-lasting consequences including profound deterioration in physical function. Following a hospital stay, around 1.35 million patients with deconditioning require rehabilitation in a skilled nursing facility (SNF) each year to address the deleterious musculoskeletal and functional deficits from deconditioning. Unfortunately, current rehabilitation paradigms in SNFs do not adequately restore physical function, which directly contributes to poor community discharge rates. Strikingly, only 52% of all patients admitted to SNFs are discharged to a community setting (e.g., home), which suggests a paradigm shift is required to optimize rehabilitation within SNFs. Currently, usual care rehabilitation in SNFs consists of low-intensity rehabilitation interventions, which are physiologically inadequate to induce meaningful changes in skeletal muscle strength and physical function. To address these pitfalls, a high-intensity resistance rehabilitation paradigm has been shown to improve outcomes including better physical function, increased community discharge rates, and cost-effective reductions in length of stay. The proposed pragmatic study seeks to apply this rehabilitation paradigm to multiple SNFs to further evaluate the effectiveness of high-intensity resistance rehabilitation (Aim 1), while evaluating processes, mechanisms, and determinants of successful implementation (Aim 2). We propose a cluster randomized pragmatic trial design in which a high-intensity intervention (15 SNFs) will be compared to usual care (15 SNFs). Effectiveness in terms of physical function will be determined via change in patient gait speed (primary outcome) from admission to discharge. Implementation strategies will be evaluated by reach (proportion of patients treated with the intervention), adoption (proportion of therapists appropriately adopting the intervention), implementation (fidelity assessments), and maintenance (long-term fidelity assessments) of the intervention. This study will provide the first large-scale evaluation of high- intensity rehabilitation for patients admitted to SNFs following hospitalization. Additionally, through systematic comparison and in-depth analysis of implementation across a variety of SNFs, this study will provide critical insight regarding barriers and facilitators of implementation. Overall findings from this study have the potential to 1) shift SNF rehabilitation care paradigms; 2) optimize patient outcomes and independence and 3) critically inform future work aimed at wide-scale implementation of high-intensity rehabilitation across post-acute settings.