STAR Program Prehabilitation Roundtable Discussion...Case Study #1 Referred to prehab on 9/24/15; eval’d on 9/30/15 (6 days later). Discharged from prehab on 10/13/15 (14 days)

STAR Program Prehabilitation

Roundtable Discussion

Nicole Lynch, MSPTManager of Program Delivery, STAR Program

© Copyright All Rights Reserved, Oncology Rehab Partners, LLC

Objectives

1. Describe the 5 recommended elements of STAR Program

Prehabilitation

2. Describe the various ways that a program can define a

prehabilitation pilot population

3. Describe the unique prehabilitation models tested by the

STAR Program Prehabilitation Pilot sites

4. Identify commonly encountered barriers to implementation

and strategies to overcome those barriers

5. Open forum Q and A


Lung Prehab Pilot Participants

Participants from:

• Winchester Hospital (Winchester, MA)

• Lahey Hospital (Burlington, MA)

• Mercy Springfield/ Sister Caritas Cancer Center (Springfield, MA)

• Mary Washington (Fredericksburg, VA)

• Reston Hospital (Reston, VA)

• One Family of Care (Greenbay , WI)


Patient Demographics

• 81 patients with lung cancer from 5

facilities

– Aged 44 through 84 (avg. 69.85yo)

– 48 females, 33 males


Of the 80 patients,

• Only 4-6 had complete data sets for any outcomes

• 73 were referred to PT, 2 to OT, and 3 to SLP

• At entrance of prehab:• Average Pain level: 2.38/10

• Average Fatigue level: 3.94/10

• Average Distress: 2.87/10

• Average time to complete TUG: 13.42 secs

• Average FACIT Total 68.56 points

• Average 6-min Walk Test Distance: 424.5 meters

• Average PG-SGA: 4.33 points


Primary Data Collection Barriers

• This proves to be a very difficult period for capturing data

• Barriers to data collection:– 1 visit model

– Short prehab time period

– Patient status (dropping out of program)

– Specific outcome measures completed outside of rehab (PFT’s, LOS, Complication rate) and require additional resources (registry, RT, nursing, nutrition)

– Patient volumes

– Data tracking is resource intensive

– PFTs – timeframe too short for full data set

– Following the patients data through the rehab continuum

STAR Program Prehab

SurvivorSmoking Cessation

General Exercise

NutritionStress

Reduction

Targeted Exercise

Acute Cancer Treatment

Improving Coping Skills

Enhancing Pulmonary Function

Promoting Smoking Cessation

Improving Nutritional Status

Improving General Fitness

Multi ModalApproach


Prehab Pilot Models of Care

• Group education session

• Individual baseline measurements and education

Single Prehab Visit

• Mod-High Risk Patients 2-3 x/wk x 4-6 wksMultiple Rehab Sessions

• Low Risk Patients – intervention in pre-surgical space

• Mod-High Risk Patients – 4-week rehabilitation intervention program

2-tier model


Average timelines

• Average Period from Referral to Prehab Eval:

– 8.55 days for PT

– 5.5 days for OT

– 7.67 days for SLP

• Average Prehab Length of Service:

– 29.28 days


General Insights

• Because N is low, it is more helpful to look at individual patient outcomes

• Distress increasing in some cases pre surgically—this is predictable

• FACIT F getting worse in some cases as well…this may correlate w higher distress levels

• Early data suggesting that sicker patients with longer prehab time frames (2+ weeks) may do better

• Functional outcomes in general are looking positive

• Patient Satisfaction is looking positive

• True quality indicators and cost saving initiatives will be demonstrated from post hospital stay or post treatment outcomes. (LOS – readmissions – return to work – quality of life)


Case Study #1

68 yo male diagnosed

with mesothelioma

Moderate to High Risk Patient

Expected Hospital LOS:

6-8 weeks

Poor Surgical Candidate!!

Case Study #1

Referred to prehab on 9/24/15; eval’d on 9/30/15 (6 days later). Discharged from prehab on 10/13/15 (14 days).

Average pain reduction 50%

Improved Tug score by 4.3%

Improved Functional Well Being Domain on the FACIT F by 67%

Improved FACT G Domain of FACIT by 12%

Improved 6 MWT by 47 M

Improved PGA Nutrition Score from 3 to 0

Improved Across all Outcomes

Patient Satisfaction Survey

• Strongly Agrees

• Prehab program influenced his decision to receive treatment at facility

• Therapist and team were knowledgeable

• Strength has improved

• Function has improved

• Energy has improved

• Mental Outlook has improved

• Endurance has improved

• He would recommend this program to others


Case Study #1 – post-prehab

Transitioned to Surgical Candidate

Actual LOS: <4 weeks

Functional Well Being

Improved by 67%

Overall Improved QoL and

SURVIVAL!!


Case Study #2

Demographics

• 75 yo female diagnosed with stage 1A lung cancer

• Osteoarthritis and chronic knee and back pain

Patient Presentation

• Dyspnea at rest and with exertion

• Decreased functional mobility

Referred to STAR Program Prehab to:

• Address severe deconditioning

• Decrease surgical risk


Case Study #2

Prehab

• 6 weeks

• Strengthening, balance and endurance training

Surgery

• 3 day LOS

• D/C to HOME

Rehab

• 4 weeks of PT

• Transitioned to cancer exercise program


STAR PREHAB Program for Lung Cancer

STAR PREHAB

Physically and mentally stronger

patients before surgery leading to

faster healing after surgery

Decreased length of hospital stay

Positive financial impact

Statistics from Pilot Hospital:

Number of lung

cancer surgery cases

in 2014

55

Average no. of Prehab

visits12

Average total charges

per Prehab patient$ 1147.77

Average weighted cost

per day hospital stay $ 1989*

*2013 data


It’s all in the numbers!!

Financial Impact: Decreased Length of Stay

$0

$5,000

$10,000

$15,000

LOS: 3 days LOS: 4 days

Difference in profit per patientProfit

Cost

Average increase in profit per patient: $1989

$0

$300,000

$600,000

LOS: 3 days LOS: 4 days

Profit

Difference in profit for 55 cases

Average increase in profit for 55 patients: $ 109,395

Comparing profits for 3-day vs. 4-day Length of Stay (LOS)

$428,945

$319,550

DRG 164 and 165


Global Prehab Benefits

Health System

Decreased LOS

Cost Savings

Patient

Improved D/C disposition

Increased QoL

Physician

More treatment options = now

surgical candidates!

Patient compliance

indicator


Process Challenges

Scheduling/Patient Throughput

Insurance Coverage

Staffing Demands/Staffing Changes

Data capture through continuum of care

Timeliness of referrals

Appointment cancellations

Patient Buy-in

Documents

STAR Program Prehabilitation Roundtable Discussion...Case Study #1 Referred to prehab on 9/24/15; eval’d on 9/30/15 (6 days later). Discharged from prehab on 10/13/15 (14 days)