key: cord-0727486-gru43wzo
authors: Reddy, Ann; Resnik, Linda; Freburger, Janet; Ciolek, Daniel E.; Gifford, David R.; Whitten, Margarite J.; Baier, Rosa R.
title: Rapid changes in the provision of rehabilitation care in post-acute and long-term care settings during the COVID-19 pandemic
date: 2021-08-27
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2021.08.022
sha: db875125df6783b2966b2cbf17675b3612f2acfc
doc_id: 727486
cord_uid: gru43wzo

Objectives Little is known about how the COVID-19 pandemic has affected rehabilitation care in post-acute and long-term care. As part of a process to assess research priorities, we surveyed professionals in these settings to assess the impact of the pandemic and related research needs. Design Qualitative analysis of open-ended survey results. Setting and Participants 30 clinical and administrative staff working in post-acute and long-term care. Methods From June 24 through July 10, 2020, we used professional connections to disseminate an electronic survey to a convenience sample of clinical and administrative staff. We conducted an inductive thematic analysis of the data. Results We identified four themes, related to (1) rapid changes in care delivery, (2) negative impact on patients’ motivation and physical function, (3) new access barriers and increased costs, and (4) uncertainty about sustaining changes in delivery and payment. Rapid changes: Respondents described how infection control policies and practices shifted rehabilitation from group sessions and communal gyms to the bedside and telehealth. Negative impact: Respondents felt that patients’ isolation, particularly in residential care settings, affected their motivation for rehabilitation and their physical function. Access and costs: Respondents expressed concerns about increased costs (e.g., for personal protective equipment) and decreased patient volume, as well as access issues. Uncertainty: At the same time, respondents described how telehealth and Medicare waivers enabled new ways to connect with patients and wondered whether waivers would be extended after the public health emergency. Conclusions and Implications Survey results highlight rapid changes to rehabilitation in post-acute and long-term care during the height of the COVID-19 pandemic. Because staff vaccine coverage remains low and patients vulnerable in residential care settings, changes such as infection precautions are likely to persist. Future research should evaluate the impact on care, outcomes, and costs.

example, house 1% of the US population but, at times, accounted for about 4% of cases and 31 38% of all deaths. 1 Even patients not infected by SAS-CoV-2 were affected by the strict infection 32 precautions, including restrictions that prevented family visits, eliminated many social activities 33 and restricted many residents to their rooms. Many infection precautions persist, including use 34 of either source control masks for full personal protective equipment (PPE; i.e., mask, gown, 35 and gloves, with or without face shields) and the periodic need to quarantine after exposure. 2 

Throughout the pandemic, post-acute and long-term care providers have faced the challenge of 37 providing vulnerable patients with daily close-contact care for everything from routine activities 38 of daily living to physical rehabilitation. 3 Rehabilitation care is important in these settings-39 especially in residential care, where people may go when recovering from an acute event and 40

where disabled and older patients need help maintaining physical function. The importance of 41 rehabilitation was arguably heightened during the pandemic, as providers began caring both for 42 patients whose physical activity was severely curtailed as a result of strict precautions and for 43 those recovering from COVID-19. 4, 5 Much has been published and reported specifically about 44 the burden of COVID-19 disease borne by post-acute and long-term care patients, benefits of 45 rehabilitation for patients recovering from COVID-19, and the policies providers implemented 46 to prevent transmission. While some rehabilitation care delivery shifted to telerehabilitation during the early waves of the pandemic, 6, 7, 8 little is known about how the provision of 48 affected the provision of rehabilitation, we administered an electronic survey to a convenience 50 sample of clinical and administrative staff. This brief report presents themes derived from 51 respondents' responses to open-ended questions. 52

At the [redacted name], a multi-institution initiative, we fund and support stakeholder-54 partnered research designed to improve the quality of rehabilitation care and services. 9 In late 55

June 2020, two of the authors sent a link for the electronic survey to groups convened by their 56 organization that include professionals with rehabilitation and nursing experience who work in 57 post-acute and long-term care settings. The settings represented in these groups include 58 different ownership (independent, corporate, and profit status) and sizes (small and large 59 corporations). Some provide in-house rehabilitation and others use contract rehabilitation. We 60 asked each group to share the survey with members using their usual communication vehicles 61 (e.g., email, newsletters, or blog posts). This was done as part of a [redacted name] process to 62 assess research priorities. Our goal was to elicit perspectives from a convenience sample of 63 stakeholders regarding rehabilitation care during the pandemic and related research needs, as 64 a first step towards identifying and prioritizing these needs. The survey was open for responses 65 from June 24 through July 10, 2020. 66

The survey instrument included four open-ended questions about rehabilitation care delivery 67 and research needs during the pandemic, as well as two close-ended questions regarding 68 respondents' primary role (i.e., rehabilitation, nursing, administration, or other) and the 69 nursing, long-term care, or other). Six members of the research team used a thematic analysis 71 using an inductive approach to individually code the survey data and generate initial themes, 72 which they noted in writing. The group then met three times to review and refine initial 73 themes, define and name each, and identify illustrative quotes. 74

Because provider staff responded to the survey in a professional capacity and did not provide 75 personal information, this analysis was not considered human subjects research or subject to 76

Institutional Review Board approval. 77

We received 30 responses. Most respondents were rehabilitation clinicians (e.g., physical 79 therapists, occupational therapists, or speech language pathologists) (n=11, 36.7%) or 80 administrators (n=13, 43.3%); the remainder (n=6, 20.0%) were in nursing (n=3) or in another 81 role (n=3). Respondents most frequently reported working with residents in assisted living 82 communities (n=13, 43.3%) or nursing homes (skilled nursing: n=29, 93.3%; long-term care: 83 n=25, 83.3%). A small percentage reported working with patients in their homes (n=7, 23.3%). 84

We identified four themes (Table 1) . 85 be. This has improved rehab care. This has also improved the team approach." (Other) 96

"I think that outcomes as far as mobility will be better, due to not having 25% of patients 97 Services did extend its telehealth coverage for physical therapy, occupational therapy, and 194 speech-language pathology, but did so only until the end of the public health emergency. 12 And 195 while respondents described increased expenses, there were no changes in reimbursement to 196 compensate for the shift from group therapy to one-on-one rehabilitation, investments in 197 telehealth platforms, or purchase of additional PPE and other supplies. In fact, the Centers for 198

Medicare & Medicaid decreased Part B physical therapy, occupational therapy, and speech-199 language pathology rates in January 2021 and plans to do so again in January 2022. 13 200 Of particular concern, survey respondents worried about assisted living and nursing home 201 residents suffering from reduced support and habilitation when quarantined or separated from 202 friends and family due to visitation restrictions. The experiences they described are supported 203 by prior research linking reduced mobility, for example, with loss of strength and muscle 204 function. 14 Similarly, research links social isolation and loneliness with poor outcomes such as 205 negatively affect patients' participation in rehabilitation and related outcomes. 207

While our findings highlight important changes in rehabilitation care in post-acute and long-208 term care during the pandemic, we note several limitations. This was a convenience sample. 209

Although respondents were recruited via professional groups with membership reflecting 210 multiple sizes, types of ownership, and methods of providing rehabilitation (in-house vs. 211 contract), they may not be representative of a broader population. We were unable to calculate 212 a response rate, because we disseminated the survey through means that preclude ascertaining 213 the number of people who received the survey. We relied on survey respondents to self-report 214 their profession and care setting. Finally, we were unable to ask follow-up questions to clarify 215 responses, for example to better understand which setting a respondent was referencing. 216

However, we used rigorous methods to generate the themes reported here: six investigators 217 reviewed survey responses independently before meeting to compare coding and 218 interpretations, and to reach consensus on themes. 219

We undertook this survey to elicit contextual information necessary to prioritize and inform 221 research, because the process of engaging stakeholders to capture such information is vitally 222 important to establish successful research partnerships. These findings demonstrate the 223 importance of eliciting stakeholder perspectives to ensure research is grounded in and 224 responsive to real-world considerations --context that, according to these findings, changed and negatively, such as resident isolation. Because infection precautions and other policies, 228 such as periodic quarantine, are likely to persist in residential care as the pandemic wanes 229 elsewhere, future research will be needed to evaluate the impact of all such changes on 230 rehabilitation care, outcomes, and costs. 231 Table 1 

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