CLINICAL INVESTIGATION
Home Health Rehabilitation Utilization Among Medicare
Beneficiaries Following Critical Illness
Jason R. Falvey, DPT, PhD,*† Terrence E. Murphy, PhD,* Thomas M. Gill, MD,*
Jennifer E. Stevens-Lapsley, MPT, PhD,‡§ and Lauren E. Ferrante, MD, MHS¶
OBJECTIVES: Medicare beneficiaries recovering from a crit-
ical illness are increasingly being discharged home instead of
to post-acute care facilities. Rehabilitation services are com-
monly recommended for intensive care unit (ICU) survivors;
however, little is known about the frequency and dose of
home-based rehabilitation in this population.
DESIGN: Retrospective analysis of 2012 Medicare hospital
and home health (HH) claims data, linked with assessment data
from the Medicare Outcomes and Assessment Information Set.
SETTING: Participant homes.
PARTICIPANTS: Medicare beneficiaries recovering from
an ICU stay longer than 24 hours, who were discharged
directly home with HH services within 7 days of discharge
and survived without readmission or hospice transfer for at
least 30 days (n = 3,176).
MEASUREMENTS: Count of rehabilitation visits received
during HH care episode.
RESULTS: A total of 19,564 rehabilitation visits were
delivered to ICU survivors over 118,145 person-days in
HH settings, a rate of 1.16 visits per week. One-third of
ICU survivors received no rehabilitation visits during HH
care. In adjusted models, those with the highest baseline dis-
ability received 30% more visits (rate ratio [RR] = 1.30;
From the *Section of Geriatrics, Department of Internal Medicine, Yale
School of Medicine, New Haven, Connecticut; †Rocky Mountain Regional
Veterans Affairs Medical Center, Aurora, Colorado; ‡Physical Therapy
Program, Department of Physical Medicine and Rehabilitation, University
of Colorado Anschutz Medical Campus, Aurora, Colorado; §Veterans
Affairs Eastern Colorado Geriatric Research, Education and Clinical
Center, Aurora, Colorado; and the ¶Section of Pulmonary, Critical Care,
and Sleep Medicine, Department of Internal Medicine, Yale School of
Medicine, New Haven, Connecticut.
Address correspondence to Jason R. Falvey, DPT, PhD, Yale University,
School of Medicine, Division of Geriatrics, 367 Cedar Street, New Haven,
CT 06510. E-mail: jason.falvey@yale.edu. Twitter: @JRayFalvey
Twitter handles for co-authors: @MrDisability; @LFerranteMD;
@JSLapsley
Preliminary results from this work were presented in poster form at the
2019 American Geriatrics Society Annual Meeting in Portland, OR.
DOI: 10.1111/jgs.16412
JAGS 68:1512-1519, 2020
© 2020 The American Geriatrics Society
95% confidence interval [CI] = 1.17-1.45) than those with
the least disability. Conversely, an inverse relationship was
found between multimorbidity (Elixhauser scores) and
count of rehabilitation visits received; those with the highest
tertile of Elixhauser scores received 11% fewer visits
(RR = .89; 95% CI = .81-.99) than those in the lowest ter-
tile. Participants living in a rural setting (vs urban) received
6% fewer visits (RR = .94; 95% CI = .91-.98); those who
lived alone received 11% fewer visits (RR = .89; 95%
CI = .82-.96) than those who lived with others.
CONCLUSION: On average, Medicare beneficiaries dis-
charged home after a critical illness receive few rehabilita-
tion visits in the early post-hospitalization period. Those
who had more comorbidities, who lived alone, or who lived
in rural settings received even fewer visits, suggesting a need
for their consideration during discharge planning. J Am
Geriatr Soc 68:1512-1519, 2020.
Keywords: home health; critical illness; physical therapy;
occupational therapy; post-hospital rehabilitation
S
killed physical, occupational, and speech therapy ser-
vices (collectively, rehabilitation therapies) are an inte-
gral part of the medical care that Medicare beneficiaries
(generally, those ≥65 y) receive during a stay in the intensive
care unit (ICU).1 Yet functional deficits that occur as a
result of ICU stays are often unresolved at hospital
discharge,2-4 suggesting that ongoing rehabilitation after
hospital discharge is necessary to optimize recovery.5 Func-
tional recovery after an ICU stay often takes 3 to 6 months,
and even then almost one-half of older survivors are unable
to regain their prior level of function.2 Participation in post-
hospital rehabilitation is strongly recommended to improve
functional recovery,6 but it is unclear how frequently older
survivors of critical illness receive these services after hospi-
tal discharge.
0002-8614/20/$15.00
JAGS JULY 2020-VOL. 68, NO. 7 HOME HEALTH REHABILITATION AFTER CRITICAL ILLNESS 1513

Increasingly, ICU survivors are discharged home

Table 1. Sample Demographics of Intensive Care Unit
instead of to post-acute care facilities,7 despite high levels of Survivors Discharged to Home Health Care
disability and mobility impairment that hamper participa-
tion in rehabilitation.8 High disability contributes to nearly Variable Total sample (n = 3,176)
25% of survivors requiring home health (HH) care services
after discharge.7,9 Patients receiving HH are generally Age, y, n (%)
assessed by a registered nurse, and then subsequently they <65 482 (15.2)
can receive any combination of nursing care, skilled rehabil- 65-75 1,108 (35.0)
itation services, and social work services deemed necessary 76-84 977 (30.8)
for recovery with 100% coverage from Medicare.10 How- >85 609 (19.2)
ever, little is known about the number of rehabilitation Race, n (%)
visits received by older ICU survivors in HH programs and Black 309 (9.7)
what factors are associated with use of rehabilitation. White 2,612 (82.2)
Addressing this knowledge gap may identify populations Other 255 (8.0)
Medicaid beneficiary, n (%) 709 (22.3)
for whom rehabilitation care needs to be targeted.11
Lives alone, n (%) 606 (19.0)
Our primary objective was to characterize the number
Rural residence, n (%)a 772 (24.3)
of rehabilitation visits received by older ICU survivors in
US Census region, n (%)
HH rehabilitation programs. Our secondary objective was
New England 181 (5.7)
to evaluate factors associated with the number of rehabilita-
Mid Atlantic 484 (15.2)
tion visits received among ICU survivors who use HH.
South Atlantic 803 (25.2)
East South Central 256 (8.1)
West South Central 308 (9.7)
METHODS East North Central 522 (16.4)
This was a retrospective analysis of the 2012 Medicare 5% West North Central 193 (6.1)
claims file for HH users that was subsequently linked to the Pacific 291 (9.2)
Medicare Outcomes and Assessment Information Set Mountain 138 (4.4)
(OASIS) file, the Medicare Provider Analysis and Review Elixhauser score, n (%)
(MEDPAR) file, and the Medicare Master Beneficiary Sum- 0-2 516 (16.3)
mary File. Briefly, the HH claims file includes billing and 3-5 1,695 (53.4)
payment information (including rehabilitation service use); 6+ 965 (30.4)
Hospital LOS, d
the OASIS file includes comprehensive patient assessment
0-5 1,056 (33.3)
data from face-to-face patient interviews conducted in the
6-10 1,470 (46.3)
home within 48 hours of hospital discharge and at the time
≥11 650 (20.5)
of patient discharge, death, or transfer to institutional facili-
Mechanically ventilated, n (%) 466 (14.7)
ties or hospice. The MEDPAR file includes details from the
ADL disability score, n (%)b
index hospitalization including procedures, comorbidities,
≤5/16 767 (24.2)
and length of stay in the hospital and ICU, as well as post-
6/16-9/16 1,763 (55.5)
acute care claims for skilled nursing facilities (SNFs), inpa-
≥10/16 646 (20.3)
tient rehabilitation facilities (IRFs), and long-term Cognitive impairment, n (%)c 1,151 (36.2)
acute care hospitals (LTACHs). Detailed beneficiary Moderate/severe dyspnea, n (%)d 811 (25.5)
sociodemographic information including Medicaid dual eli- Daily/constant anxiety, n (%)e 602 (19.0)
gibility and county of residence were extracted from the Daily/constant pain, n (%)f 1814 (57.1)
Master Beneficiary Summary File. Lastly, the Medicare Pro-
vider of Services (POS) file was used to extract ownership Abbreviations: ADL, activities of daily living; LOS, length of stay.
a
and geographic information about the HH agency treating Rural/Urban status was determined by 2012 Medicare core-based statisti-
each patient. cal areas.
b
Post-hospital disability on eight ADL tasks (upper and lower body dress-
With our database of Medicare beneficiaries using HH
ing, bathing, transfers, ambulation, toileting and toileting hygiene, and
services, we identified those who initiated HH services in the grooming) scored at initial home health assessment as either 0 (indepen-
United States (excluding US territories such as Puerto Rico) dent), 1 (requires minor human assistance or an assistive device), or
within 7 days of an acute hospitalization with a nested ICU 2 (totally dependent or unable to perform the task). The sum disability
stay of longer than 24 hours. We excluded those who had score was calculated for each patient on a 0 to 16 scale.
c
MEDPAR claims for institutional post-acute care services From the Medicare Outcomes Assessment and Information Set (OASIS)
(SNF, IRF, or LTACH) before initiating HH care. We also item M1700 (0-4 scale). Scores 1 to 4 indicate requirement for human
excluded patients who received care in a psychiatric or inter- assistance due to cognitive impairment.
d
From the Medicare OASIS item M1400 (0-4 scale). Scores of 3 to 4 indicate
mediate ICU, or who were readmitted, transferred to hospice,
dyspnea occurs with light activity or at rest.
or died within 30 days of discharge (Supplementary e
From the Medicare OASIS item M1420 (0-3 scale). Scores of 2 to 3 indicate
Figure S1). This project was completed with institutional presence of daily or constant anxiety.
review board (IRB) approval from the University of Colorado f
From the Medicare OASIS item M1242 (0-4 scale). Scores of 3 to 4 indicate
Multiple IRB. activity-limiting pain occurs daily or constantly.
1514 FALVEY ET AL.
Primary Outcome
The primary outcome of the study was the number of reha-
bilitation visits received per patient within the first HH epi-
sode of care (up to 60 d). We calculated rehabilitation visits
by extracting individual revenue codes associated with
physical therapy (042×), occupational therapy (043×), and
speech therapy (044×) from the HH claims file, and sum-
ming the total count of visits delivered.
Candidate Variables
Candidate variables from four main domains were selected
for inclusion in our models based on the judgment of an
expert geriatrician (T.M.G.), critical care physician (L.E.F.),
and HH physical therapist (J.R.F.). These domains were
patient sociodemographic characteristics, post-hospital dis-
ability, medical complexity, and symptom burden.
Although higher disability is a primary reason in current
HH payment models to engage rehabilitation services, mul-
tiple studies have shown that home care service delivery
varies across Census Bureau regions.12-14 From a clinical
perspective, higher medical complexity and symptom bur-
den (such as pain) may limit participation in rehabilitation.
We also accounted for agency ownership in the models.
Sociodemographic Characteristics
Patient age, race, Census Bureau geographic region, Medic-
aid dual eligibility, and sex were extracted from the Medi-
care Master Beneficiary Summary File. Age was categorized
as younger than 65 years (ie, disability entitlement to Medi-
care), 65 to 75 years, 76 to 84 years, or older than
85 years. We categorized the patient as living alone vs living
Figure 1. Distribution of rehabilitation visits over the first episode of home health for 3,176 Medicare beneficiaries who survived
an intensive care unit stay and were discharged directly home. [Color figure can be viewed at wileyonlinelibrary.com]
JULY 2020-VOL. 68, NO. 7 JAGS
with either a caregiver or in a congregate living situation
(ie, assisted living facility). We also captured whether a
patient resided in a rural area (vs urban) by mapping the
patient’s state and county code of residence to Medicare’s
Core-Based Statistical Areas (from 2012). To control for
potential differences in HH care availability, we also used
the POS file linked with publicly available 2012 Census
population data to summarize the number of HH agencies
per 100,000 at the county level.
Post-Hospital Disability
At the first HH visit after hospital discharge, functional sta-
tus on eight activities of daily living tasks (upper and lower
body dressing, bathing, transfers, ambulation, toileting and
toileting hygiene, and grooming) was captured on the Medi-
care OASIS and scored as either 0 (independent), 1 (requires
minor human assistance or an assistive device), or 2 (totally
dependent or unable to perform the task). The sum OASIS
disability score was calculated for each patient on a 0 to
16 scale.
Medical Complexity
Total hospital and ICU length of stay were extracted from
the MEDPAR file, and time spent under the care of the HH
agency was extracted from the OASIS file. A dichotomous
variable for whether or not an older adult was mechanically
ventilated was created based on the presence or absence of
the associated International Classification of Diseases,
Ninth Revision (ICD-9) procedure code (96.7×).15 Mul-
timorbidity was assessed using the Elixhauser Comorbidity
index, calculated using a validated algorithm from ICD-9
codes on the acute hospitalization claim.16 Because the
JAGS JULY 2020-VOL. 68, NO. 7 HOME HEALTH REHABILITATION AFTER CRITICAL ILLNESS 1515

OASIS has no psychometrically validated measures of cog-
nition, cognitive impairment was categorized dichoto-
mously for this study as whether or not an older adult
required human assistance for management of daily activi-
ties in the home due to cognitive dysfunction, as assessed
by the evaluating therapist.
length of stay in HH care was 30 (IQR = 19-50) days. There
was also significant variability in the use of rehabilitation
observed among ICU survivors (Figure 1). A total of 2,075
survivors (65.3%) received physical therapy, 729 (22.9%)
received occupational therapy, and 144 (4.5%) received
speech therapy. Of the 2,137 rehabilitation users (one or more

Symptom Burden
We assessed symptom burden from the OASIS assessment, Table 2. Unadjusted Variable Associations with Rehabil-
focusing on three key symptoms that may impact participa- itation Visit Count
tion in rehabilitation: dyspnea (5-item OASIS question
Variable RR (95% CI)
M1400), anxiety (5-item OASIS question M1720), and pain
(5-item OASIS question M1242). For dyspnea, the OASIS Age, y
question prompts clinicians to record when the patient is dys- <65 Ref.
pneic or noticeably short of breath. Moderate to severe dys- <76 .99 (.89-1.11)
pnea was categorized as dyspnea that occurs with light 76-84 1.20 (1.08-1.34)
activity (such as talking; score 3/4) or at rest (score 4/4). For >85 1.14 (1.02-1.27)
the OASIS pain item, the frequency of activity-limiting pain Race
was dichotomized as occurring daily (score 3/4) or constantly White Ref.
(score 4/4) vs never or less than daily. For anxiety, OASIS Black 1.06 (.95-1.18)
item M1720 asks clinicians to record how frequently the Other 1.02 (.90-1.14)
patient is anxious. Patients were considered to have daily/con- Medicaid beneficiary .90 (.83-.97)
stant anxiety if episodes of anxiety reported by the patient Lives alone .85 (.78-.93)
occurred daily (score of 3/4) or all of the time (score of 4/4). Rural residence .90 (.84-.98)
Elixhauser score
0-2 Ref.
Data Analysis 3-5 .95 (.86-1.04)
All analyses were conducted using SAS software v.9.4 (SAS 6+ .93 (.83-1.02)
Institute Inc, Cary, NC, USA) and R software v.1.1.463 Hospital LOS, d
(R Foundation, Vienna, Austria). Sample demographics were 0-5 Ref.
assessed for all HH participants in the analytic sample, and the 6-10 1.00 (.93-1.09)
proportions of HH users who used rehabilitation services was ≥11 1.07 (.97-1.17)
calculated. We then evaluated the distribution of total rehabili- Mechanically ventilated .99 (.91-1.09)
tation visits across the initial 60-day episode of HH care. Next, ADL disability scorea
we modeled the bivariate association of each candidate variable ≤5/16 Ref.
on episode rehabilitation visits using a zero-inflated negative 6/16-9/16 1.20 (1.10-1.32)
binomial regression model, with a log link function with offset ≥10/16 1.34 (1.20-1.49)
set as the natural logarithm of HH length of stay. A zero- Cognitive impairmentb 1.06 (.99-1.13)
inflated negative binomial model was chosen to account for the Moderate/severe dyspneac 1.07 (.99-1.16)
high number of older adults who received no rehabilitation Daily/Constant anxietyd .98 (.90-1.07)
visits and for the overdispersion of the count data. Lastly, a Daily/Constant paine 1.02 (.96-1.09)
For-profit agency .90 (.97-1.04)
multivariable model, controlling for all candidate variables,
Agencies per 100,000 population, county level
was calculated. For both bivariate and multivariable models,
Lowest tertile Ref.
rate ratios (RRs) for each candidate variable, showing the pro-
Middle tertile 1.01 (.93-1.09)
portional difference in the number of rehabilitation visits for
Highest tertile 1.02 (.94-1.12)
each level of the variable, were estimated. A RR less than 1 indi-
cates that a candidate variable was associated with fewer reha- Abbreviations: ADL, activities of daily living; CI, confidence interval; ICU,
bilitation visits than the reference category, and a RR greater intensive care unit; LOS, length of stay; RR, rate ratio.
a
than 1 indicates a greater utilization of rehabilitation. Statistical Post-hospital disability on eight ADL tasks (upper and lower body dress-
significance was defined as a two-tailed P value less than .05. ing, bathing, transfers, ambulation, toileting and toileting hygiene, and
grooming) scored at initial home health assessment as either 0 (indepen-
dent), 1 (requires minor human assistance or an assistive device), or
RESULTS 2 (totally dependent or unable to perform the task). The sum disability
score was calculated for each patient on a 0 to 16 scale.
b
Most of the 3,176 patients in the sample were female and From the Medicare Outcomes Assessment and Information Set (OASIS)
white, and most lived in urban settings (Table 1). Patients item M1700 (0-4 scale). Scores 1 to 4 indicate requirement for human
started HH care within a median of 1 (interquartile range assistance due to cognitive impairment.
c
From the Medicare OASIS item M1400 (0-4 scale). Scores of 3 to 4 indicate
[IQR] = 1-2) days after hospital discharge. Overall, 2,137
significant dyspnea occurs with light activity or at rest.
(67%) older adult ICU survivors received one or more home d
From the Medicare OASIS item M1420 (0-3 scale). Scores of 2 to 3 indicate
rehabilitation visits after hospital discharge. A total of 19,564 presence of daily or constant anxiety.
rehabilitation visits were delivered over 118,145 person-days e
From the Medicare OASIS item M1242 (0-4 scale). Scores of 3 to 4 indicate
in HH settings, averaging 1.16 visits per 7 days. The median activity-limiting pain occurs daily or constantly.
1516 FALVEY ET AL. JULY 2020-VOL. 68, NO. 7 JAGS

visits from any discipline), 1,413 (66%) patients received care
from only a single rehabilitation discipline, 637 (30%) from
two disciplines, and 87 (4%) received care from all three reha-
bilitation disciplines.
In bivariate analysis, older age and higher OASIS dis-
ability scores were associated with higher use of rehabilita-
tion services. Conversely, higher Elixhauser score, living
alone, living in a rural area, and Medicaid dual eligibility
were all associated with lower rehabilitation use. Symptom
burden (anxiety, pain, or dyspnea), mechanical ventilation,
patient race, and cognitive impairment were not signifi-
cantly associated with rehabilitation utilization in bivariate
Figure 2. Unadjusted count of rehabilitation visits per home
health episode for Medicare beneficiaries who survived an
intensive care unit (ICU) stay and were discharged directly
home, presented by Census Bureau region.
analysis (Table 2). Significant geographic variability was
also observed across Census Bureau regions (Figure 2), with
nearly threefold differences between the region with the
highest number of rehabilitation visits (East South Cen-
tral = 9.6 visits per episode) and the region with the lowest
number of visits (New England = 3.4 visits/episode).
In the fully adjusted multivariable models (Figure 3),
older age and higher post-hospital disability scores contin-
ued to be associated with receiving more rehabilitation
visits. Compared with those younger than 65 years,
patients aged 65 to 75 received 16% (RR = 1.16; 95%
confidence interval [CI] = 1.04-1.30) more rehabilitation
visits and those aged older than 85 years received 10%
(RR = 1.10; 95% CI = .98-1.24) more. Those in the
highest tertile of post-hospital disability received 30%
(RR = 1.30; 95% CI = 1.17-1.46) more visits relative to
the lowest tertile. The presence of moderate to severe dys-
pnea was also associated with receiving 12% (RR = 1.12;
95% CI = 1.04-1.20) more rehabilitation visits in the mul-
tivariable model.
Conversely, living alone was associated with receiving
11% fewer visits (RR = .89; 95% CI = .82-.96), and living
in a rural area was associated with receiving 6% (RR = .94;
95% CI = .91-.98) fewer visits. In addition, those in the
highest Elixhauser score tertile received 11% (RR = .89;
95%CI = .81-.99) fewer rehabilitation visits compared with
those in the lowest tertile. Patterns of geographic variability
observed in the fully adjusted model was largely consistent
with bivariate results (Supplementary Figure S2), with
patients in the East South Central region (Kentucky, Ala-
bama, Mississippi, and Tennessee) predicted to receive
nearly twofold the number of rehabilitation visits as com-
pared with patients in New England.

Figure 3. Adjusted negative binomial regression results presented as rate ratios (RRs) for the impact of each variable on rehabilita-
tion utilization. RRs greater than 1 indicate a positive impact on number of rehabilitation visits received; RRs less than 1 indicate a
negative impact. Model was adjusted for all figure variables and additionally for Census Bureau region and county-level count of
home health agencies per 100,000 population. LOS, length of stay. [Color figure can be viewed at wileyonlinelibrary.com]
JAGS JULY 2020-VOL. 68, NO. 7
DISCUSSION
In this analysis of HH rehabilitation use among Medicare
beneficiaries who survived an ICU stay, we found that only
two-thirds of patients receive any skilled therapy visits
immediately following hospitalization, and the average
patient received only one visit per week. We also observed
substantial geographic variability in the receipt of rehabilita-
tion services, with both regional variability and rural/urban
disparities present. Although some factors reflecting greater
rehabilitation needs (advanced age, greater post-hospital dis-
ability, and higher baseline dyspnea) were associated with
more rehabilitation visits, other factors indicating potential
risk for adverse outcomes (living alone, having a greater
number of comorbidities, and living in a rural setting) were
all associated with receiving fewer rehabilitation visits. These
potential disparities have significant implications for dis-
charge planning in this vulnerable population. To our
knowledge, this is the first nationally representative study
describing patterns of rehabilitation use and characteristics
associated with HH rehabilitation dose received by Medicare
beneficiaries who survive an ICU stay.
Importantly, ICU survivors in HH settings may be the
subset of critically ill older adults most likely to respond to
restorative interventions targeting physical function, that is,
sick enough to require post-acute care services after a hospi-
talization, yet healthy enough to be discharged directly
home. Post-hospital rehabilitation is believed to be an
important part of post-ICU functional recovery.5,6,11,17-19
Yet we found that 1 of every 3 critical illness survivors
never receives restorative rehabilitation during their episode
of HH care, and among those who do, the number of reha-
bilitation visits is relatively small, and few involve disci-
plines other than physical therapy.
Low therapy utilization is perhaps more striking because
Medicare beneficiaries receiving HH care have at least one obvi-
ous need for rehabilitation service: all are considered home-
bound, meaning they leave home infrequently and are unable to
do so without a difficult and taxing effort. Recent data also
suggested that the high levels of new-onset disability, dysphagia,
and vocal cord injury associated with intensive care unit stays are
commonly observed outside the hospital setting,3,20,21 suggesting
a role for rehabilitation in screening all older ICU survivors after
hospital discharge. Although stringent rehabilitation protocols
are often followed for patients after major medical events such as
hip fracture or joint replacement, no such guidelines exist for
older adults recovering from an ICU stay. Loose guidelines for
physical therapy goals, outcomes measures, and interventions
after critical illness have been published,6 yet no concrete recom-
mendations for rehabilitation frequency, duration, and total dose
were provided. A lack of concrete guidelines may partially
explain the substantial regional variability observed in our study.
Clearly more evidence is needed to determine the optimal dose
and mode of rehabilitation for older adult ICU survivors.
An unexpected finding was that those patients who
lived alone or in rural settings received significantly fewer
rehabilitation visits. In the adjusted models, an 11% reduc-
tion in therapy use was observed among those who lived
alone relative to those who lived with others. Patients who
live with others may receive more encouragement or sup-
port to participate in rehabilitation. Conversely, it is possi-
ble that those who live alone may be viewed by HH agency
HOME HEALTH REHABILITATION AFTER CRITICAL ILLNESS 1517
staff as more functionally able than those who live with
caregivers or in congregate living situations, and they are
subsequently offered fewer rehabilitation services. Alterna-
tively, caregivers of older adults may provide unique
insights into the nature of physical deficits and be strong
advocates for rehabilitation involvement.
Beyond differences based on living arrangement, rural-
dwelling Medicare beneficiaries also received significantly fewer
HH rehabilitation visits than comparable patients living in urban
settings. This disparity was previously observed for homebound
Medicare beneficiaries recovering from total joint replacement,13
and it may hint at an explanation for larger problems with access
to restorative care interventions for disabled older adults in rural
America.22 Taken together, these findings highlight the impor-
tance of social determinants of health that may need to be
addressed in future interventions for Medicare beneficiaries dis-
charged directly home after critical illness.
Our findings build on consensus statements from ICU
survivorship stakeholder groups that physical therapy and
other important post-hospital rehabilitation services are
likely fragmented and underutilized in the immediate post-
hospitalization period.17,18,23 This underutilization of post-
hospital rehabilitation appears particularly significant for
patients with the most comorbidities, a finding that needs
to be explored more fully in future studies. One prior study
within a large cohort of younger critical illness survivors
defined a single “dose” of rehabilitation to be six visits,
with many receiving two and three “doses” of rehabilita-
tion over the course of the recovery process.24 In contrast,
older ICU survivors in our cohort received approximately
one visit per week of skilled rehabilitation in the early HH
period, and they generally only received care for 30 days.
Prior data suggest that the likelihood that older ICU survi-
vors attend outpatient rehabilitation clinics after HH ends
is low.8 Indeed, the observed patient characteristics, such as
multimorbidity, living alone, or living in rural settings that
negatively influence rehabilitation use in HH settings (where
rehabilitation professionals travel to patients) are magnified
when these patients are asked to travel physically to therapy
clinics. Overall, low use of rehabilitation in HH likely shifts
the burden of functional recovery onto informal or family
caregivers; these caregivers may need to take added respon-
sibility for engaging patients in home exercise programs or
physical activity with unknown impacts on outcomes.
This study is the first to provide nationally representa-
tive estimates of rehabilitation dose received among Medi-
care beneficiaries who survive an ICU stay. Another strength
is the linkage of claims data with robust patient-level assess-
ment variables from OASIS such as symptom burden that
are not available in hospitalization claims. This provides the
most granular assessment to date of the factors associated
with utilization of rehabilitation in post-ICU settings.
Our study also has limitations. First, the use of 2012 data
may not reflect the most contemporary trends in practice, given
shifts in the number of referrals for home care use related to the
Affordable Care Act. However, although the hospital
readmission reduction program had small impacts on the total
number of patients referred to HH care settings, this program
did not have a direct impact on how much care older adults
received during a HH episode of care, which is the focus of this
study. Medicare Payment Advisory Commission reports indi-
cate that the number of total visits provided to Medicare
1518 FALVEY ET AL.
beneficiaries requiring HH care services has dropped by only .1
visits between 2012 and 2017 (from 16.7 to 16.6 visits) with
no change in overall patient complexity.25,26
Second, of those Medicare beneficiaries who did not
receive rehabilitation, it is difficult to determine whether
these patients were medically unable or simply unwilling to
participate. Such evaluations will need to be made in a
future prospective or qualitative study. Third, these data
only evaluate Medicare fee-for-service beneficiaries and
may not be representative of older managed Medicare bene-
ficiaries or those with private insurance.
Fourth, because of the sample size, we were unable to
generate reliable estimates of county-level variability or vari-
ability at the hospital referral region level, thereby leaving our
estimates of geographic variability more coarsely defined at
the Census Bureau region. It is therefore difficult to assess
whether the factors driving higher utilization in southern
states are related to unmeasured patient factors, such as body
mass index, that may be different in these regions or reflect
true regional differences in care delivery. Future research with
larger samples is needed to shed light on other geographic and
market-level factors that may drive differences in utilization.
In summary, most older adult ICU survivors discharged
home received approximately one visit of rehabilitation per
week for the first 30 days. Rehabilitation use is highly vari-
able across geographic regions, and it is significantly lower
for older adults who have multiple chronic conditions, who
live in rural settings, or who live alone. Future work should
evaluate the optimal timing, intensity, and dose of HH
rehabilitation for older ICU survivors and investigate ways
to address disparities in the quantity of HH rehabilitation
received among older ICU survivors.
ACKNOWLEDGMENTS
Financial Disclosure: Jason R. Falvey received grant support
from a Health Services Research Pipeline Grant from the Foun-
dation for Physical Therapy Research and a National Institute
on Aging (NIA) training grant (T32AG019134). Jason
R. Falvey and Jennifer E. Stevens-Lapsley received grant sup-
port from the Center on Health Services Training and Research
and the American Physical Therapy Association Home Health
Section. Jennifer E. Stevens-Lapsley is supported by the Vet-
erans Affairs Eastern Colorado Geriatric Research, Education
and Clinical Center. Terrence E. Murphy is supported by the
Yale Claude D. Pepper Older Americans Independence Center
of the NIA [P30AG021342]. Thomas M. Gillis is the recipient
of an Academic Leadership Award [K07AG043587] from the
NIA. Lauren E. Ferrante is supported by a Paul B. Beeson
Emerging Leaders Career Development Award in Aging from
the NIA (K76AG057023).
Support for VA/CMS data was provided by the Depart-
ment of Veterans Affairs, VA Health Services Research and
Development Services, VA Information Resource Center
(project nos. SDR-02-237 and 98-004). The views
expressed in this article are those of the authors and do not
necessarily reflect the position or policy of the Department
of Veterans Affairs or the US government.
Conflict of Interest: The authors have declared no con-
flicts of interest for this article.
Author Contributions: Study design: Falvey, Gill, Mur-
phy, and Ferrante. Methods: Falvey, Murphy, and Ferrante.
JULY 2020-VOL. 68, NO. 7 JAGS
Subjects recruitment/Data acquisition: Falvey and Stevens-
Lapsley. Data collection: Falvey and Stevens-Lapsley. Analysis/
Interpretation: All authors. Preparation of article: All authors.
Sponsor’s Role: The funding agencies had no role in
the design, methods, recruitment, data collection, analysis,
or preparation of the manuscript.
REFERENCES
1. Connolly B, OʼNeill B, Salisbury L, Blackwood B. Physical rehabilitation
interventions for adult patients during critical illness: an overview of system-
atic reviews. Thorax. 2016;71(10):881-890.
2. Ferrante LE, Pisani MA, Murphy TE, Gahbauer EA, Leo-Summers LS,
Gill TM. Factors associated with functional recovery among older intensive
care unit survivors. Am J Respir Crit Care Med. 2016;194(3):299-307.
3. Ferrante LE, Pisani MA, Murphy TE, Gahbauer EA, Leo-Summers LS,
Gill TM. Functional trajectories among older persons before and after critical
illness. JAMA Intern Med. 2015;175(4):523-529.
4. Mehlhorn J, Freytag A, Schmidt K, et al. Rehabilitation interventions for
postintensive care syndrome: a systematic review. Crit Care Med. 2014;42
(5):1263-1271.
5. Prescott HC, Angus DC. Enhancing recovery from sepsis: a review. JAMA.
2018;319(1):62-75.
6. Major ME, Kwakman R, Kho ME, et al. Surviving critical illness: what is
next? An expert consensus statement on physical rehabilitation after hospital
discharge. Crit Care. 2016;20(1):354.
7. Lee JT, Mikkelsen ME, Qi M, Werner RM. Trends in post-acute care use
after admissions for sepsis. Ann Am Thorac Soc. 2020;17(1):118-121.
8. Rosa RG, Kochhann R, Berto P, et al. More than the tip of the iceberg: asso-
ciation between disabilities and inability to attend a clinic-based post-ICU
follow-up and how it may impact on health inequalities. Intensive Care Med.
2018;44(8):1352-1354.
9. Jones TK, Fuchs BD, Small DS, et al. Post-acute care use and hospital
readmission after sepsis. Ann Am Thorac Soc. 2015;12(6):904-913.
10. Villa P, Pintado MC, Luján J, et al. Functional status and quality of life in
elderly intensive care unit survivors. J Am Geriatr Soc. 2016;64(3):536-542.
11. Rosa RG, Ferreira GE, Viola TW, et al. Effects of post-ICU follow-up on subject
outcomes: a systematic review and meta-analysis. J Crit Care. 2019;52:115-125.
12. Burke RE, Jones CD, Coleman EA, Falvey JR, Stevens-Lapsley JE,
Ginde AA. Use of post-acute care after hospital discharge in urban and rural
hospitals. Am J Accountable Care. 2017;5(1):16-22.
13. Falvey JR, Bade MJ, Forster JE, et al. Home-health-care physical therapy
improves early functional recovery of Medicare beneficiaries after total knee
arthroplasty. J Bone Joint Surg Am. 2018;100(20):1728-1734.
14. Jones CD, Wald HL, Boxer RS, et al. Characteristics associated with home
health care referrals at hospital discharge: results from the 2012 national
inpatient sample. Health Serv Res. 2017;52(2):879-894.
15. Kerlin MP, Weissman GE, Wonneberger KA, et al. Validation of administra-
tive definitions of invasive mechanical ventilation across 30 intensive care
units. Am J Respir Crit Care Med. 2016;194(12):1548-1552.
16. Quan H, Sundararajan V, Halfon P, et al. Coding algorithms for defining
comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care.
2005;43(11):1130-1139.
17. Elliott D, Davidson JE, Harvey MA, et al. Exploring the scope of post-
intensive care syndrome therapy and care: engagement of non-critical care
providers and survivors in a second stakeholders meeting. Crit Care Med.
2014;42(12):2518-2526.
18. Needham DM, Davidson J, Cohen H, et al. Improving long-term outcomes
after discharge from intensive care unit: report from a stakeholders’ confer-
ence. Crit Care Med. 2012;40(2):502-509.
19. Kwakman RCH, Major ME, Dettling-Ihnenfeldt DS, Nollet F,
Engelbert RHH, van der Schaaf M. Physiotherapy treatment approaches for
survivors of critical illness: a proposal from a Delphi study. Physiother The-
ory Pract. 2019;1:1-11. https://doi.org/10.1080/09593985.2019.
20. Shinn JR, Kimura KS, Campbell BR, et al. Incidence and outcomes of acute
laryngeal injury after prolonged mechanical ventilation. Crit Care Med.
2019;47(12):1699-1706.
21. Zuercher P, Moret CS, Dziewas R, Schefold JC. Dysphagia in the intensive
care unit: epidemiology, mechanisms, and clinical management. Crit Care.
2019;23(1):103.
22. Kosar CM, Loomer L, Ferdows NB, Trivedi AN, Panagiotou OA,
Rahman M. Assessment of rural-urban differences in postacute care utiliza-
tion and outcomes among older US adults. JAMA Netw Open. 2020;3(1):
e1918738.
JAGS JULY 2020-VOL. 68, NO. 7 HOME HEALTH REHABILITATION AFTER CRITICAL ILLNESS 1519

23. Bemis-Dougherty AR, Smith JM. What follows survival of critical illness? SUPPORTING INFORMATION
Physical therapists’ management of patients with post-intensive care syn-
drome. Phys Ther. 2013;93(2):179-185. Additional Supporting Information may be found in the
24. Chao PW, Shih CJ, Lee YJ, et al. Association of postdischarge rehabilitation
online version of this article.
with mortality in intensive care unit survivors of sepsis. Am J Respir Crit
Care Med. 2014;190(9):1003-1011.
25. Medicare Payment Advisory Commission. Home Health Care Services (2019 Supplementary Figure S1: Development of the analytic
Report). http://www.medpac.gov/docs/default-source/reports/mar19_medpac_ sample.
ch9_sec_rev.pdf. Accessed January 10, 2020.
26. Medicare Payment Advisory Commission. Home Health Care Services (2015
Supplementary Figure S2: Adjusted geographic variabil-
Report). http://www.medpac.gov/docs/default-source/reports/chapter-9-home- ity in home health rehabilitation use.
health-care-services-march-2015-report-.pdf. Accessed January 10, 2020.