The Relation Between Therapy Intensity and Outcomes of Rehabilitation in Skilled Nursing Facilities Diane U. Jette, PT, DSc, Reg L. Warren, PhD, Christopher Wirtalla, BA ABSTRACT. Jette DU, Warren RL, Wirtalla C. The relation between therapy intensity and outcomes of rehabilitation in skilled nursing facilities. Arch Phys Med Rehabil 2005;86: 373-9. Objective: To examine the relation between therapy inten- sity, including physical therapy (PT), occupational therapy (OT), and speech and language therapy (SLT), provided in a skilled nursing facility (SNF) setting and patients’ outcomes as measured by length of stay (LOS) and stage of functional independence as measured by the FIM instrument. Design: A retrospective analysis of secondary data from an administrative dataset compiled and owned by SeniorMetrix Inc. Setting: Seventy SNFs under contract with SeniorMetrix health plan clients. Participants: Patients with stroke, orthopedic conditions, and cardiovascular and pulmonary conditions (N=4988) covered by Medicare+Choice plans, and admitted to an SNF in 2002. Interventions: Not applicable. Main Outcomes Measures: LOS and improvement in stage of independence in the mobility, activities of daily living (ADLs), and executive control domains of function as deter- mined by the FIM instrument. Results: Higher therapy intensity was associated with shorter LOS (P.05). Higher PT and OT intensities were associated with greater odds of improving by at least 1 stage in mobility and ADL functional independence across each con- dition (P.05). The OT intensity was associated with an im- proved executive control stage for patients with stroke, and PT and OT intensities were associated with improved executive control stage for patients with cardiovascular and pulmonary conditions (P.05). The SLT intensity was associated with improved motor and executive control functional stages for patients with stroke (P.05). Therapy intensities accounted for small proportions of model variances in all outcomes. Conclusions: Higher therapy intensity was associated with better outcomes as they relate to LOS and functional improve- ment for patients who have stroke, orthopedic conditions, and cardiovascular and pulmonary conditions and are receiving rehabilitation in the SNF setting. Key Words: Occupational therapy; Physical therapy; Reha- bilitation; Skilled nursing facilities; Speech therapy. © 2005 by American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation C OMMON GOALS OF REHABILITATION are to de- crease individuals’ impairments and to improve their func- tioning in mobility, activities of daily living (ADLs), and/or cognition. Physical therapy (PT), occupational therapy (OT), and speech and language therapies (SLT) play a role in pro- viding services that address those goals. Over the past decade, with Medicare’s shift to a prospective payment system (PPS) for skilled nursing facilities (SNFs) and encourage- ment of incentives for health maintenance organizations (HMOs) to provide care under contract with Medicare (Medicare+Choice), there has been a decrease in the duration and intensity of therapy provided to patients in SNFs. 1 Although patients in SNF settings must receive daily reha- bilitative services such as PT, OT, or SLT, no time requirement for that therapy is imposed. 2 Because there is no time require- ment, decisions about how much therapy to provide and how long a patient stays in an SNF are largely determined by the health care professionals in the institution. These decisions are based not only on patients’ rehabilitation needs, but also on reimbursement. Given cost constraints, a need exists to under- stand the dosage or intensity of therapy that is associated with outcomes, such as cost and function, that are relevant to both providers and patients. In 1997, Keith 3 proposed that examination of treatment specifications, including intensity, was central to understanding rehabilitation outcomes. Reports since that time, and before, on the relation between therapy intensity in rehabilitation settings and patients’ outcomes are few and are not entirely consistent in their findings. Chen et al 4 found that, for patients treated in the subacute rehabilitation setting, the relation between therapy intensity and improvement in function as measured by scores on the FIM instrument differed depending on patients’ medical conditions and the FIM domain examined. Regardless of the medical condition, however, therapy intensity (total 15-min units of therapy divided by the length of stay [LOS]) was related to improvements in cognition but not to improvements in mobility. Additionally, for patients receiving SLT, intensity of SLT was not related to cognitive gains. Alternatively, Kirk- Sanchez and Roach 5 found that, for patients with orthopedic conditions, total hours of PT and OT, controlled for LOS, predicted FIM mobility scores at discharge from an acute rehabilitation setting. Chiodo et al 6 found that patients in nurs- ing homes who received more than a minimal amount of PT (ie, at least once weekly or duration 4wk) were more likely to have improvement in strength, endurance, or ADLs than those patients with less therapy. In a randomized controlled trial examining the effect of therapy intensity on impairments and function in patients with stroke, Kwakkel et al 7 found that patients who received more therapy improved to a greater extent than those who received less. In studies in which pa- tients’ outcomes have varied by reimbursement type 8 or reha- bilitation setting, 9,10 the variations have been partly attributed to differences in therapy intensity. In other studies, however, a relation between therapy intensity and outcomes has not been demonstrated for patients receiving rehabilitation for traumatic brain injury (TBI), 11,12 spinal cord injury (SCI), 11,12 or stroke. 12-14 From Physical Therapy, Simmons College, Boston, MA (Jette); and SeniorMetrix Inc, Nashville, TN (Warren, Wirtalla). When this study was conducted, Jette was affiliated with Boston University, Boston, MA. No commercial party having a direct interest in the results of the research support- ing this article has or will confer a benefit on the author(s) or on any organization with which the author(s) is/are associated. Correspondence to Diane U. Jette, PT, DSc, Physical Therapy, Simmons College, 300 The Fenway, Boston, MA 02115, e-mail: diane.jette@simmons.edu. Reprints are not available from the author. 0003-9993/05/8603-9013$30.00/0 doi:10.1016/j.apmr.2004.10.018 373 Arch Phys Med Rehabil Vol 86, March 2005