1. Rising Acuity in Inpatient Rehabilitation Facilities
Post-Acute Care Collaborative
Rising Acuity in Inpatient Rehabilitation Facilities

2. A Closer Look at Patient Acuity
Defining “High-Acuity” for Post-Acute Settings
High-acuity patients have clinical needs requiring above-average intensity of support or nursing care
VOLUME x PRICE
Key Threats to Quality
Complex Patients
Patients with numerous comorbidities, often including behavioral health challenges
High prevalence of these patients requires extensive staff time
Staff understand how to care for each diagnosis separately, but struggle to manage all conditions together
New Patient Types
Patients with conditions or requiring treatments not previously seen in a setting
Even a single patient of a new type requires extensive staff knowledge
Staff lack skills and experience managing patients with specific diagnoses or treatment regimens
Patient deterioration occurs suddenly and unexpectedly; early signs can go un-observed by overwhelmed caregivers
Staff implement care plans for select clinical needs which conflict with the patient’s other clinical needs
Source: Post-Acute Care Collaborative interviews and analysis.
Broadly, high-acuity means a patient whose clinical needs are above-average for a given setting.
Acuity generally manifests in two ways for skilled nursing providers: highly complex patients and new patient types.
Highly complex patients are those who have conditions that staff are familiar with, but have many comorbidities so staff have to contend with a long list of treatment needs simultaneously. These patients are generally difficult to handle because of the time investment and critical thinking they require.
New patient types are patients with conditions or equipment that staff are unfamiliar with, making staff unsure of the proper clinical response.
This is a good time to bring up any particular acuity challenges for your organization specifically. For instance, are you seeing more comorbidities among your patient population? New patient types?
Throughout this presentation, we’ll discuss the evidence that patient acuity is on the rise in the IRF setting.

3. Baby Boomer Surge Beginning
Number of Medicare Beneficiaries to Increase Dramatically
2011 US Population Distribution, by Age
Aging of Population
Medicare-Eligible Population
75M Baby Boomers
~7,000/day
23%
Percentage of population covered by Medicare in 2030
Newly eligible Medicare beneficiaries
Source: U.S. Census Bureau, available at: accessed on September 13, 2011; Kaiser Family Foundation, available at: accessed on September 13, 2011; Health Care Advisory Board interviews and analysis.
As we know, the elderly are often the highest-acuity, highest-need patient group. They also make up a large portion of our inpatient rehab patients.
And as we see here, the elderly are making up an increasingly large proportion of the population. According to projections from the U.S. Census Bureau, 55 million Americans will be 65 or older by And by 2030, 23% of the population will be covered by Medicare.
On the one hand, this means a continuing rise in demand for our services. However, it also means that the patients we serve will be older, and likely sicker, than our traditional cohort.

4. Chronic Disease Increasingly Taking a Toll
Projected Growth of Population with Chronic Disease
Projected Number of Adults with Diabetes
(Percentage Growth Compared to 2013)
(In Millions)
2019
2025
Body Mass Index; projected figures for 2010 and 2020.
Source: Dall T, et al, “An aging population and growing disease burden will require a large and specialized health care workforce by 2025,” Health Affairs, 32, no. 11 (2013): ; Boyle JP, et al., “Projection of the year 2050 burden of diabetes in the US adult population,” Population Health Metrics, 2010, 8, 29-41; CDC; Advisory Board interviews and analysis.
As a nation, we’re aging and we’re also ailing—as shown on this slide.
On the left, you can see that rates of select chronic disease are only expected to grow. These figures show estimated increases in the portion of Americans with cardiovascular disease, hypertension, and asthma, as compared to 2013 rates.
The chart on the right-hand side shows projected rates of diabetes in the population. Again, we see an upward trend all the way until 2050.
This trend may be particularly challenging for rehab. The combination of these demographic changes along with continued tightening of the 60% rule means patients will need both intensive rehabilitation and intensive medical support. We will need to support our staff so that they are ready to contend with a rising level of acuity.

5. Complications and Comorbidities in Inpatient Rehab
Proportion of Medicare Patients Discharged to IRF with Major Complications and Comorbidities
34%
33%
32%
31%
30%
29%
28%
27%
33%
32%
31%
29%
Source: Post-Acute Care Collaborative analysis of MedPAR discharge data file,
As the last few slides have shown, the American population overall is becoming older and sicker. But what does this mean for us as a sector?
Inpatient rehab has seen a steady rise in patient acuity over the past few years. This graph shows the increase in the proportion of fee-for-service Medicare beneficiaries admitted to IRFs who have major complications and comorbidities. While a rise of 4% may not seem significant, this represents an additional 24, 065 patients nationwide.

6. Shifting Volumes Across Service Lines
Change in Number of Medicare Beneficiaries Referred to IRF After Inpatient Hospital Stay, by Service Line
20%
19%
19%
18%
12% 9% 8% 7% 7% 7% 7% 7% 5% 4%
Other Trauma
-2%
Cardiac Services
ENT
General Medicine
General Surgery
Gynecology
Neurology
Neurosurgery
Oncology/Hematology
Ophthalmology
Rehabilitation
Spine
Thoracic Surgery
Urology
-8%
Vascular Services
Orthopedics
Source: Post-Acute Care Collaborative analysis of MedPAR discharge data file,
The type of patients being seen by IRFs is also changing. This data shows the change in volume of Medicare beneficiaries discharged to inpatient rehab after hospital treatment across each of the major service lines from 2010 to 2013.
Across most service lines there has been an increase in discharges to IRFs. We see major increases in referrals from general medicine, trauma, and thoracic surgery. Not surprisingly, there has been a decrease in the volume of orthopedics patients coming to the IRF setting. This is likely a result of changes to the 60% rule as well as increased cost pressure encouraging referrers to send orthopedics patients to skilled nursing or home health whenever clinically possible.
This is a good opportunity to discuss whether your organization has seen volume increases from these service lines. What challenges does that pose for your organization and your staff?

7. Declining Volumes for Orthopedic Patients
Bilateral or Multiple Major Joint Procedures of Lower Extremity (DRGs 461, 462)
2010 PAC volume: 117,750; 2013 PAC volume: 111,975
53%
32%
15%
50%
35%
15%
Major Joint Replacement or Reattachment of Lower Extremity (DRGs 469, 470)
2010 PAC volume: 117,750; 2013 PAC volume: 111,975
14%
46%
40%
11%
46%
43%
Source: Post-Acute Care Collaborative analysis of MedPAR discharge data file,
A more detailed perspective shows us shifts in orthopedic referrals at the DRG-level. From 2010 to 2013 we can see decreased referrals to the IRF setting for these patients. Orthopedics patients are traditionally relatively uncomplicated; those patients are being treated instead in SNF or home health, causing IRFs to need to take on higher-acuity patients to maintain their census.
This slide is a good chance to discuss new patient types coming to your specific organization. Are you seeing growing referrals for a certain type of patient?
Note: the DRGs presented here were chosen because they show a larger volume shift relative to other DRGs and because they represent conditions that have been under scrutiny as conditions that may be sent to an unnecessarily high-acuity setting.

8. Rising Patient Needs, Acuity
Average Hours per Case, by Staff Type
Average Patient Case-Mix Index
.83
.84
.78
.80
.81
.77
.70
We recommend ending the presentation with your organization’s own information on rising patient needs and acuity. This will allow you to show that the industry-wide trends discussed earlier are actually having a direct effect on your facility. If patient needs and acuity are rising, this suggests a potential increase in costs of care and a need to further prepare your clinical staff.
Input your organization’s data to customize these graphs. Right-click on each graphic and choose “Edit Data,” then input your organization’s data into the Excel document. If appropriate, change the titles or legends of the graphs to reflect measurements most applicable for your setting, such as nursing hours per patient day or average patient ADL need.