Advancing Rehabilitation Paradigms for Older Adults in Skilled Nursing Facilities

项目摘要/摘要 在美国，837万65岁以上的成年人将在明年住院，这通常是 具有严重和长期的后果，包括身体功能的严重恶化。在此之后 住院期间，约有135万名解除条件的患者需要在熟练的护理机构进行康复 每年(SNF)，以解决解除调理所造成的有害的肌肉骨骼和功能缺陷。 不幸的是，目前SNF的康复范例不能充分恢复身体功能，这 直接导致较低的社区排污率。令人惊讶的是，只有52%的患者接受了SNF 被释放到社区环境(例如，家)，这表明需要转变范式来优化 在SNF内康复。目前，SNF的常规护理康复包括低强度康复 生理上不足以引起骨骼肌力有意义变化的干预措施 和身体机能。为了解决这些缺陷，一种高强度的抵抗康复范例 显示出改善结果，包括更好的身体功能，增加社区出院率，以及 以符合成本效益的方式缩短停留时间。拟议的语用研究试图将这种恢复应用于 范式到多个SNF，以进一步评估高强度抵抗康复的有效性(AIM 1)，同时评估成功实施的进程、机制和决定因素(目标2)。我们 提出一种整群随机实用试验设计，其中高强度干预(15个SNF)将 与通常的护理(15个SNF)相比。身体机能方面的有效性将通过改变来确定 患者从入院到出院的步态速度(主要结果)。实施战略将是 通过REACH(接受干预的患者的比例)、采用(治疗师的比例)进行评估 适当采取干预)、实施(保真度评估)和维护(长期 对干预的忠诚度评估)。这项研究将提供第一次大规模的高 入院后SNF患者的强度康复。此外，通过系统化 比较和深入分析各种SNF的实施情况，这项研究将提供关键 对实施障碍和促进者的洞察。这项研究的总体发现有可能 1)转变SNF康复护理模式；2)优化患者结局和独立性；3)关键 通报今后旨在广泛实施高强度康复的未来工作 设置。

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.