Hello, everyone. Good afternoon. Welcome to this session that we have called Thinking Rehabilitation Out of the Box, or basically Expanding Rehabilitation Beyond the Rehabilitation Unit. So I appreciate everyone joining us this afternoon and listening a little bit about the experience that we have had here in Hopkins with this concept of bringing rehabilitation to the acute care setting. So for this session, there are three speakers. I'm going to be starting the presentation. I'm Pablo Selnick. I am the director of the Department of Physical Medicine and Rehabilitation here at Hopkins. I am a physiatrist, and I have grown here in Hopkins for many, many years. Then I'm going to be followed by Annette Labesa. Annette is an occupational therapist. She's the director of Rehabilitation Therapy Services in the Johns Hopkins Hospital. And Annette is, again, also has been in Hopkins for many years. I think we started kind of together almost here. And she's in charge, again, of all rehab services in the acute care setting of Johns Hopkins Hospital. And then we're going to have Dr. April Bruschi, who is also a physiatrist. And she's the medical director of the consult team for rehabilitation. So she oversees the consult activities in multiple different hospitals. But today, we're going to be focusing on the activities that happen at Johns Hopkins Hospital. So I'm going to ask everyone to just listen through the talks and write down questions in the chat. And we hope that we estimated that we're going to finish with enough time for us to have a Q&A session at the end. So during the talk, just go ahead and put your questions in the chat, and then we will address them when we're finished. So without further ado, then, let's just move on to the next slide. And I'm going to tell you a little bit about these concepts of rehab in the acute setting. So first, we have no financial disclosures and no funny jokes about that. So let's talk a little bit about the big picture of rehabilitation and why we started to do these activities in the acute care setting. You know, if you think about what the goals of rehab are, you know, we all know these, but just to remind ourselves why we are physiatrists, you know, regardless of where we do and where we practice, the intent here is that we aim to minimize disability. We want to help patients achieve an optimal level of function, regardless of where you work in the hospital, in the MSK setting or pain or whatever. We want to facilitate the patient's return to their prior level of activities. And we foster patients' return as full members of society. So ultimately, we want everybody, you know, when we treat patients, is that we want them to go back to the community, society, and to the level of function that they were doing before, or the closest possible, and to be an active member of the community. So next slide. So let me tell you a little bit of a perspective, a historical perspective on rehabilitation. You can find this in the AAPM NARA website or other websites. But basically, the story of rehabilitation, as you probably, most of you know, developed in the early 1920s with the first survivors of the First World War. But then rehabilitation also expanded from there with the polio epidemics and many, many patients not dying and surviving and having significant disability. And people may remember the iron lungs for those who have respiratory issues for a long time. And again, there's a significant growth spur in rehabilitation with the Second World War. But the interesting thing is, as rehabilitation is developing, we started to focus on creating specialty units and or free standard rehabilitation facilities to provide rehabilitation. So we started to develop a significant infrastructure to bring our patients to care for them. So while we do that, or while we were doing that, the reality is that there was not a big, big effort to develop rehabilitation, the acute hospital. So the development in that space has been historically has been very limited or underdeveloped. We were just focusing on, OK, let's bring the patients once they are taken care of, once they are stable, let's bring them to the rehab unit or the freestand rehab hospital. And we manage them there. But we are not participating a lot in the acute care setting. And a lot of activities that happen in the acute care setting have been mostly to navigate the patients to the next level of care. So, you know, rather than delivering rehabilitation interventions in the acute hospital, we, you know, again, with the goal of preventing or reducing disability, we have been doing a little bit of the triaging and traffic control. So taking care of the patients, making sure they're OK, and then bringing them to the rehabilitation unit. Now, the reality is then that what happened in the acute hospital has been fairly underdeveloped. Now, if you think about it, for a lot of the medical conditions that we treat, we know that if we have earlier interventions, we will have a bigger impact in the outcome of the patients. We know that if we can start the rehabilitation process earlier, we could make a difference for those patients. And a little bit with that concept, in 2008, at John Hopkins Hospital, we developed a quality, this was at the beginning, just a quality improvement project. And the idea was to assess whether rehabilitation in the critical care unit makes a difference. And actually, it was extremely successful that to the point that now is, you know, these programs of ICU rehabilitations are known all over the world. And people have been doing this in a consistent manner. So, you know, ICU rehab really had a significant impact on the patients. We found that the average length of stay in that QI project in the MICU, in the medical ICU was reduced to 4.9 days versus seven days. And the impact was even beyond the, after discharge to the MICU, to the regular floor with a reduction of the length of stay in those patients. Next. So, we found that rehabilitation in the ICU had many, many different benefits for the patient. You know, we were able to improve their strength and improve physical function and improve quality of life. But we also were able to reduce length of stay, the cost associated to the hospitalization, the duration on vents. We reduced delirium. We had to minimize sedation. So, the impact for the patients were really, very profound. And I think because of that is that ICU rehab really took off. Now, interestingly, we were doing more rehabilitation here in Hopkins in the ICU than in the regular floor. So, people were having a lot of rehab interventions in the ICU, were discharged to the regular floors, and they were not, you know, we're seeing like any other hospital by a consult service. And then they were, if they needed, they would move to the inpatient rehab setting. So, with that in mind, then we started to say, okay, well, we need to do something else. And a couple of programs came about from this, stem out from this ICU rehab. One was this activity immobility program, what we call the AMP. And this is a program to address the harms of immobility in the hospital. So, this is to encourage patients in the general hospital to be active and moving, getting out of bed and moving about. And a program that also can impact length of stay, but I will not, we will not be talking much about that here today. We want to spotlight today, this other program, what we call ARISE or the Acute Rehabilitation Intensive Service. So, today we're going to be spending quite a bit of time discussing our experience in this ARISE model of care, the idea of bringing rehabilitation interventions that we normally do in the inpatient rehab unit, but now you put in the medical acute unit. And we had tested this concept now in three different patient populations, transplant patients, stroke patients, and the COVID-19 patients. Next. So, next. So, going beyond this ICU, we know that the interventions that, going beyond the ICU, the interventions that happen in the ICU are very impactful and can affect the framework of hospitalization, but we wanted to improve that. And the concept was, can we do coordinated rehabilitation, the acute hospital, targeting the special patients? We do not want to do this for everybody, only for those patients in need. And we thought that introducing early rehabilitation has the potential of preventing the worsening of impairment and delaying recovery, as discussed at the beginning. And the concept is that it is patient-centered care. What we are doing is actually bringing rehabilitation to the patient rather than bringing the patient to the rehabilitation unit. So, that's the overall concept, but we need to carefully select what patients are the ones who are going to benefit from this. Not different that we select the patients that you're going to bring to the inpatient rehab unit. And we think that this transformational approach to rehabilitation has the potential to impact the value of medicine. So, the value of medicine, as we described, is the idea that we can improve patient satisfaction and improve patient outcomes, and at the same time, reduce cost of care. If we can change something about patient satisfaction or patient outcomes at the same cost of care or maintain those two elements but reduce cost of care, the value of medicine is improved. So, we think that this model of bringing rehab to the acute setting could be helpful in that regard. So, now I'm going to pass the baton or the microphone here to my colleague, Annette La Besa, who's going to explain how we can pivot the therapy services from the consultation to an intervention model of care. Thank you, Dr. Celnik. So, I think we should start by talking about what the therapists traditionally do in the hospital setting. And we've really, in the past, thought about therapists providing this consultation for a discharge recommendation. And often, that's what we look to provide. The focus is really on moving the patient to the next level of care. We'll take care of their rehab needs at that next level. And there's really this limited focus on intervention. Now, part of this challenge, as I talk to my colleagues in the world of therapy, has been this concept that do we have the resources to really provide the interventions, and what interventions should we be providing? Next slide. So, if we talk about the goals of rehabilitation in the acute care setting, so one is to evaluate functional needs. The second, next, is to establish a plan of care. And that plan of care should include some follow-up in the inpatient setting. But how much we do and how often we're able to provide that is really contingent sort of on your environment, your staffing, and your model for which you deliver care. Next. And then we recommend and prepare that patient for the next level of care. We explain what a rehab facility will look like, or we prepare them to go home. So, one of the things that we really needed to do in our traditional model of care was to think about what kind of care should we be delivering patients? And so, we have created a delivery of care model. Next slide. Where we evaluate a patient for therapy needs, and we then aim to provide follow-up at a level that is consistent with how far they are from their baseline. And there's complexities in these models. This is really contingent on your patient populations, who you're seeing. So, if your facility has more patients with hip and knee replacements, your model of care might be different. But what we chose to look at is a model that looked at deviation from baseline and trying to get to those patients at a more frequent level, right? So, if you're very far from baseline, can we see you five to seven times a week? That is often still aspirational in our staffing model. It is difficult to think about being able to provide that level of care to the number of patients who come through, but with all of the competing priorities. There's the priority of being able to get that recommendation in just so we can facilitate hospital throughput, but there's also this priority of we really want to be able to rehabilitate our patients and start that process early. So, one of the things we needed to do was look at our profile of patients. Next slide. We are fortunate in our facility that the nurses and the therapist all use a standard outcome measure of the AMPAC, basic activity and mobility inpatient short forms. And the nurses score those and the therapists score those. And it allows us to have a common language to communicate with each other about the level of impairment that a patient has. When we first started looking at how do we provide care to patients at a higher level of care, how do we even meet our own standard, we saw this profile of patients that you're seeing on the screen now, where a lot of our resources were being expended when patients who on that tool, that outcome tool, showed us that the patients had no impairments. There was this belief by providers that we needed to sort of sign off on the case. And so you can see that there's a large column where we're spending resources seeing patients. And wouldn't it be fantastic if we could pivot from seeing those patients to seeing patients who have less, more impairment. And so if we could repurpose those therapists and repurpose those visits, then potentially we could increase the amount of time and the amount of intervention that we were able to give to our patients. So next slide. So in 2014 and 2015, we worked with the Department of Neurology on a project that we termed, we thought about it as a choosing wisely project. And we, at that point, 13.8% of our neurology consults for PT and OT were what we use the term of low value. So those were patients who had scored this functional outcome score as the highest score. They'd scored as having no impairments, but yet a therapist still went and performed a consult. At that time, we were responding to consults within 24 hours, and we were doing admittedly less intervention than we would have liked and certainly less intervention than providers would have liked. We put some systems in place where therapy held consults when we could see that the nurses had scored a patient as independent in their functional mobility and daily activity skills. And we held those consults and we didn't respond to them until we had a discussion with the providers. We provided education back to the teams. We talked about this routinely in rounds, but because we had a common language that we were all talking through this functional outcome measure, it really allowed us to leverage that and use that to sort of drive some of our decisions. After our interventions and following six months later, we were able to look back and we had a significant decrease in the number of times that we were called to provide consults for patients who were really identified as not having an impairment. We continued to hold those consults until rounds, but I think for this talk, what's really important is that we increased the amount of intervention we were able to provide to patients with the highest impairment. So patients with the lowest impact scores, the most impaired patients, were able to get more intervention. And so this really sort of opened up the door for us to think about if we could do this with one team, could we go do this beyond? So next slide. So we chose to incorporate the results of this and work across the institution with deploying this as a strategy for how we could think about being most efficient with our resources. So when we receive an order, one of the things we do is we look for those nursing impact scores, and we look for anyone who has scored greater than a 23, a 23 or 24, which is relative independence on those tools, and we hold those consults. Now, our goal is never, never that we should be at zero, right? There are patients who have scores that are high on these screening measures who still need therapy interventions, and we absolutely should still be providing those. But for those, it does capture for those patients who are relatively independent, they're up, they're walking around the unit, they're getting dressed, do we really need therapists to go in and say, check, yes, you're fine? Would it be better suited for us to target our resources to patients who are more impaired and start their rehabilitation care very early? And that's really the goal of what we're trying to do here. So if we think about, we have this model being more efficient and more aligned in how we deliver therapy services. Can we take the results of that and deploy it to patient populations, next slide, and implement it in this ARISE program where we're providing enhanced rehabilitation to patients. So we're really leveraging these low value consults, pivoting them so that we're seeing patients with the greatest impairment, providing a higher intensity, progressing them through acute care and really doing rehabilitation at the bedside. So let's start with one of the first populations that we worked with, which were the transplant patients. So these are liver transplant patients. And one of our inclusion criteria for ARISE was that these patients would have an AMPAC, inpatient basic mobility score of less than 18. So these are patients who, when we think about that graph I showed earlier, are falling in that middle bucket of patients, the middle bucket of impairment. We included them in this group, next slide. For ARISE for transplant, there's three components. There's enhanced rehabilitation, PM&R consultation on every patient, and rehabilitation huddles. So next slide. For therapy intervention for this population, we provided therapy five times a week and we alternated PT and OT every weekday. And each patient had a physiatry consultation. Next slide. In addition, that team met twice a week to talk about these patients and to think about their rehabilitation care. This was really something that was very different for our therapists and for our physiatrists to collaborate with that much frequency for a patient on the medical side of the hospital. And so using that environment to talk about functional status, are they improving, plateauing, declining? What can we do differently? What are the barriers to their progress? Any pharmacologic interventions and need for other consultation? Now, these huddles and this interaction with the rehab team was done separate from the traditional multidisciplinary rounds that we talk about in an acute care setting. So these were separate meetings that the rehab team was having. And then taking that information back to the multidisciplinary team so that they understood that there was a rehab approach for this patient in the medical setting. So our next group that we started thinking about a rise for was for our stroke patients. And for this, we broadened the net. So when we talked about transplant, we talked about how it was really based on that AMPAC score. In this model, we thought about, we needed to look at all patients who were admitted to the neurology service and they're evaluated within 24 hours by a therapist. And you'll see that that 24 hours is more based on our staffing than on a rule that we have to be there. Patients, again, enhanced therapy, PM&R consultation and huddle. But you'll notice in this model, next slide, that what we're providing is different. So the big bucket of a rise is that you get these three components, enhanced therapy, PM&R consultation and huddles, but the deployment of what happens for each of those might be slightly different, right? Based on that population. So for our stroke patients, they're receiving PT, OT and SLP twice a day, Monday through Friday. And on weekend, they have daily therapy, mostly alternating disciplines. Physiatry is consulted on every patient. So let's talk a little bit about the interventions. Why did we choose BID and why do we, why are we targeting that as our goal? So one is the 2016 AVERT suggesting that shorter, more frequent sessions might help with regaining independence after stroke. So what do we do in those sessions? Next slide. The literature really supports that we should be doing remediation with our patients early, right? We need to capitalize on neuroplasticity early. But what happens is we're in the hospital and we're very worried about moving people through the system and so we immediately pivot to compensation. And so what we have tried to do for stroke is we ask the therapist, they're doing two sessions a day. One of them needs to be remediation. We need to be focused on restoring function. We need to deploy the principles of neurorehabilitation in one of those sessions. The other session might, for practicality, have to be a compensation session. I really do just need to learn how to compensate and get my shirt on today. But later on, I'm gonna have a remediation session. We ask all three disciplines to split their sessions this way. So swallowing exercises might also, might be one of the speech sessions and the other might be a language session. But we need to make sure that we're focusing on both pieces and not losing sight of the fact that we should start these remediation tasks in the acute care setting. In a similar to transplant, we're doing rehabilitation huddles for stroke. The big difference here is that for our stroke patients, we're meeting every day to do the rehabilitation huddle. Same things are being talked about, talking about current status, barriers, pharmacologic interventions, additional consultations, but we're doing it daily. The acute care setting pace is very quick. And so it's important that we're all together. And we have physiatry in the room, PT, OT, and speech are all there. And again, that's an opportunity that is in addition to traditional multidisciplinary rounds. And so it is really important to have a united rehabilitation approach for these patients. And this huddle has gone a long way to be helping us create that. So I'm gonna hand it off now to Dr. April Persky, who is going to talk to you a little bit more in detail about the data that comes from this. Thank you, Annette. Next, we're going to look at the Johns Hopkins affiliates to further describe what this change to the stroke rehabilitation model looked like. The ARISE Stroke Model of Care at Johns Hopkins began in January of 2019. We will be looking at a six month timeframe of stroke discharges from June 1st, 2019 to December 31st of 2019. We will be focusing on two of the hospitals. The Johns Hopkins Hospital and the Johns Hopkins Bayview Campus. Bayview Medical Center, labeled BMC, and Johns Hopkins Hospital, labeled JHH, are both comprehensive stroke centers with similar numbers of strokes and patient discharges in the six month timeframe study. The ARISE program is specifically at Johns Hopkins Hospital. Both hospitals have all three therapy disciplines and the availability of physiatry services. Looking at the table, at Bayview Medical Center, there were 262 patients discharged with a diagnosis of stroke. Of those 262, 226 patients, or 86%, received a therapy visit. 72 of those patients were seen by a physiatrist. At the Johns Hopkins Hospital, there were 263 patients discharged from Johns Hopkins Hospital, with 241 patients, or 92%, being seen by therapy services. 57% of those patients were seen by a physiatrist. Looking at the average length of stay, we can see that both Johns Hopkins Hospital and Bayview Medical Center each have comparable median lengths of stay of five days. The average length of stay at Bayview is slightly lower at 7.9 days, but compared with Johns Hopkins, which is 8.1 days. Looking at the therapy visits total, there is significantly increased amounts of therapy given at Johns Hopkins of 5,382 visits compared to Bayview's 1,708. Patients at Johns Hopkins Hospital service received approximately three times more therapy visits as compared with Bayview. Looking at the bar graphs, green is occupational therapy, gray is physical therapy, and blue is speech-language pathology. You can see that there is a more even amount of PT, OT, and speech given in the total number of visits at Johns Hopkins Hospital as compared with Bayview, which provides less speech-language pathology services to patients. Looking at the physiatry visits, only 27% of stroke patients were seen by a Kaminar specialist at Bayview Medical Center, while at Johns Hopkins Hospital, 57% of patients were seen by a physiatrist. Looking further into the physiatry visits, patients at Johns Hopkins Hospital had approximately four times more visits than patients at Bayview Medical Center. Of the patients seen on average, Johns Hopkins Hospital, they were seen three times, while at Bayview, patients were seen twice. At Johns Hopkins Hospital, one patient was seen up to 10 times during their acute stroke stay, and at Bayview, the maximum Kaminar follow-up was four visits. Looking at the discharge disposition, the orange and yellow represents discharge to post-acute rehab care. The orange represents discharge to subacute rehab, while the yellow represents acute rehab. At Bayview, 27.5% of patients were discharged to subacute rehab, while only 14.1% of patients were discharged to subacute at Johns Hopkins. More patients were sent to acute rehab at Johns Hopkins than Bayview. The green represents home. Over half the patients in this timeframe were discharged from Johns Hopkins Hospital to home, as compared with 39.3% of patients discharged from Bayview. To summarize what we're seeing thus far, acute rehabilitation interventions in the ARISE model of care seems to improve the rate of discharge home for patients with stroke. Their level of care, this level of care, can reduce inpatient rehabilitation needs and improve hospital throughput. We also have an opportunity to improve patient satisfaction by getting more patients home in a similar length of stay. Let's switch gears to discuss the ARISE program for COVID patients. Rehab services are now well-established in the ICU, and we know that early mobility programming can reduce the length of stay, costs, delirium, sedation, duration on the mechanical ventilator. But here we are taking things beyond just the ICU setting. We are targeting a patient population starting in the ICU and then sustaining that effort onto the medical floor. Beyond this, we are not just providing early mobilization. We are providing a coordinated rehabilitation team that consists of a physiatrist and all three disciplines of therapy. We ask ourselves the question, can an interdisciplinary approach with targeted and coordinated rehabilitation services that meet a patient's rehabilitation need impact length of stay and patient disposition? The components of the ARISE program for COVID includes enhanced therapy with physical therapy, occupational therapy, and speech-language pathology. For those patients who met the ARISE criteria, PMR can be involved for medical and rehabilitation management and care coordination. Rather than continuing in-person frequent huddles due to the increased amount of ARISE COVID patients at the height of the pandemic, a virtual huddle was created for patients through a medical record chat, which allowed for ongoing coordinated efforts. It was important for us to develop a system that efficiently utilizes our rehabilitation resources to provide care for patients with the different functional abilities. Patients who met criteria to be a part of the ARISE program had impacts of 13 to 21 mobility raw score for PT and 13 to 21 activity raw score for OT. For speech-language pathology, patients were either NPO, pureed diet, thickened liquids till they progressed to a mince and moist diet and thin liquids, or they had new onset cognitive deficits. Patients in the ARISE group were seen at least once a day by all relevant rehabilitation disciplines as tolerated until they had an impact greater than 21 or they tolerated a diet progression. A physiatrist was involved for care coordination of medical and rehab care and to plan for post-acute care needs. The main focus of this ARISE program for COVID patients was to prevent any further functional deterioration due to their illness and hasten the functional recovery with the goal of returning home with home care services or improve their function to a point that they can transition to inpatient rehab setting. For our analysis, we were able to identify 132 patients who received multidisciplinary therapy services. Of those 132 patients, 42.4% of the patients were seen by a physiatrist. We, however, are unable to capture in this data how many charts were reviewed by a physiatrist as we really had two levels of physiatry involvement. The first level of physiatry involved screening charts early in the ICU to initiate early mobilization programs. And the second level of physiatry services included care coordination with rehabilitation and medical teams, as well as early physiatry management of patients. We compared the ARISE COVID patients to 86 patients that were admitted to the Johns Hopkins Affiliates of Bayview, Howard County, and Suburban Hospital. The participants who were part of the Johns Hopkins Hospital ARISE program were matched to individuals at the Johns Hopkins Affiliate by their age, by their gender, by their initial SOFA score. And SOFA is the sequential organ failure assessment score that predicts ICU mortality. It's based on lab values and clinical data. They were matched based on body mass index, on their comorbidity count, ADI, which stands for area deprivation index. It's a multidimensional evaluation of a region's socioeconomic conditions, which has been linked to health outcomes. They were matched based on their prior settings, such as being from home, and if they were in the ICU or on a vent within the first two days. When we compared the number of therapy visits for two groups in the ICU, there was no significant difference. We use the measure therapy visits divided by length of stay to control for the length of stay. You can see that within the ICU, the two groups did not vary with the amount of therapy visits. However, outside of the ICU, on the medical floor, the ARISE group received more therapy visits compared with the control group. In other words, patients outside the ICU received higher amounts of therapy. Additionally, the patients in the ARISE group had higher initial SOFA scores, CAM positive days, and total vent days. This data poll was from April to June of 2020. It reflects a time of uncertainty in the post-acute discharge available locations. We did not know if acute or subacute rehabilitations would take COVID patients to the facilities. However, despite this, patients met the functional ability to be appropriately recommended for discharge home. We found there was a 20% odds of going home if a patient was admitted and received the specialized coordinated approach at Johns Hopkins Hospital. Additionally, the likelihood of being discharged home without affecting length of stay is higher in hospitalized patients with COVID-19 receiving the ARISE program. In conclusion, the ARISE model of care is a novel model of care that is at Johns Hopkins Hospital outside of the traditional rehab unit to the acute hospital. ARISE in patients with stroke can improve the rate of discharge home and potentially reduce the need for post-acute care placement. Similarly, ARISE in patients with COVID-19 seem to be helpful to improve. Similarly, ARISE in patients with COVID-19 seems to be helpful to improve throughput and home discharge. Lastly, rehabilitation interventions deployed earlier in the medical process have the opportunity to be more efficient for helping patients as well as medical institutions. The work across our ARISE program takes a lot of coordinated efforts and there are many people to thank. This will be ending our presentation and moving to our Q&A. Please place questions in the chat. Okay, very good. Thank you, everybody, for attending this session, and we appreciate that people have been putting questions in the chat, so we're going to be reading those questions and addressing them. So, Dr. Solnick, we'll have you answer the first one, which is there's a question in here that other facilities have thought about doing BID therapy care, but then insurance is concerned that if they can engage in that in the acute care setting, why should they send them to an acute inpatient rehab facility so they avoid intensity that comes close to the inpatient rehab level, unless that patient is going to be able to get a couple of sessions and go home. So, can you address the issue of how this impacts movement to the rehab facilities? Yeah, absolutely. I think this is very treasured. I'm going to ask folks to mute themselves in the meantime. So, that's an interesting comment, and the impact of, you know, of potentially developing these type of programs is, it could be significant depending on the type of patient population. So, I think that we may think that delivering this level of intensive rehabilitation services in the acute hospital may reduce the number of patients going to a freestanding rehab facility. It may be the case that in some patients that are receiving actually care earlier may really skip altogether in a mission to inpatient rehab or subacute rehab, or put them better from a subacute to an acute rehabilitation, or move them directly to the ambulatory setting where patients will need some form of either home healthcare or outpatient services. The interesting thing that I should contextualize here is that we live in Maryland, and Maryland has a very different healthcare system than the rest of the U.S. We are in a mode of care where the cost of the activities that happen in the hospital are already all included. So, we already have in the budget the number of therapies and the number of, you know, that they are working in the hospital setting. If I were to increase the number of therapies, I will not be compensated extra. If I were to, so, for us, it's an issue of making those therapies more efficient, and that's what Annette was explaining at the beginning when she said that we took the therapies who were doing consoles that are kind of not very important and moved them to this type of care that we think is much more relevant. At the same time, in Maryland, we have a problem of not enough capacity in our inpatient rehab facilities. A lot of patients in our hospitals are getting stuck in the hospital because they cannot be discharged to freestandard rehab places and so on. So, this model of care solves a little bit for those problems. One, to help throughput and don't wait for capacity in the freestandard rehab facility. On the other hand, we do not get penalized because we do two sessions of therapy in a day as long as we have a workforce to deliver that level of care. I think that there are a couple of comments, and I can talk for a long time, but I don't want to do that. One is that we know that the model of care that happens in Maryland has been exported to other parts of the country because the primary goal of that is cost containment where hospitals have a fixed budget and they need to deal with a patient with a fixed budget. And we know that that model by CMS is being exported to other areas like in Pennsylvania, Massachusetts, and beyond. Now, we also know that we have a lot of pressure to reduce the number of admissions that we get to freestandard rehab facilities. So, in healthcare systems where we have control of the entire healthcare system, the entire continuum, it makes sense to develop these interventions earlier because it's still within the scope of the rehabilitation professionals. And it's a way to provide patient-centered care and make us prevalent and value in the acute care setting. The economics of this are interesting and much to be discussed on that. Dr. Pruski, how many consult PM&R attendings are there for the hospital and how did we manage to do these programs with the resources we have? So, we have a few consult attendings. We have one physiatrist who's dedicated just to the stroke service and provides care there. We have one general consult physiatrist who manages some of the disposition consults, also works with an advanced practice provider, and then also takes on some specialty consults that may come into us from a spasticity perspective or TBI management early perspective. And then during COVID, we ended up increasing our consultant number to meet the need and demand of the COVID ARISE program that we had to create. And we actually increased to having three attending physiatrists. Now, while COVID has gone away, we are now redeploying that physiatrist to continue to do this sort of specialty work with these populations, whether it's in the MICU working with patients to the liver transplant service still, to assisting with any of the physiatry specific questions. And the reason we also have this many physiatry consultants is because Johns Hopkins is a pretty big hospital. It's about a thousand vetted hospital. So, we really needed to make sure that we can meet the demand. And as these patient populations arise, there are many more therapists than there are physiatrists. And we wanted to make sure that we're able to care coordinate with the patients that need the most care coordination with the therapists. Thank you, Dr. Kurski. For the stroke patients, were those patients matched by NIHSS? For the stroke population, the data poll was just a retrospective pool from two of our affiliate hospitals. They were not matched based on the NIHSS score. They were just how many strokes were pulled from that January, the June to December of 2019 date. Let me jump into that. I think that, like April mentioned, they are not matched. This is just an analysis of the admissions in the hospital. But for those who do not know our setting, Bayview and Johns Hopkins Hospital are like four miles apart. Both are stroke centers of excellence denominated in the area. We don't have any strong ideas why this population may be different. We think that there should not be, for the most part, any difference. But clearly, we should be able to check on the data to see if there's any differences in stroke severity across the two settings. It's a good question. Dr. Kurski, what was the impact of the program on length of stay in the acute care hospital? I think we talked about that for COVID. Specifically for COVID, what we saw is when we were comparing length of stay in the acute hospital between us and our affiliates, we noticed that the program did not change the length of stay for a patient, but it did change their disposition. Even though this length of stay were equal for both, patients were being discharged around the same day, more patients were going home. We haven't made that analysis yet for our stroke patients, but that is a direction we will be looking in as well. Just to add a little bit to that, for COVID-19, I wonder how it was experienced in other places, but in Maryland, it was very difficult to discharge patients from the acute hospital to other facilities, post-acute care facilities with patients with COVID-19. So, patients were really kind of stuck, if you like, in the hospital. A lot of rehab places and acute places did not want to admit these patients. So, developing this program was critical to help the hospital operations and ensures throughput. So, part of the story is that, and I'm glad that the data show that, is that we didn't see an increase in length of stay because we're doing rehab in acute settings. I can tell you that hospital leadership has been very satisfied with this intervention because of the improvement in terms of the charges, but also not worsening length of stay in the acute hospital. But also, the experience of our colleagues in internal medicine was very well-received, this type of program, because we're not only helping managing these patients, but we're really facilitating the management and the discharge of these patients. And maybe if I could just add to that, I think that it's a very interesting work to do as a consultant on the PM&R service, because I think most of the time, when people think about physiatrists coming along, they think, well, they tell me that they're good for my rehab unit or not. Not will they be able to coordinate some of my care early on. And so, like Dr. Selnick mentioned, the internal medicine department was really happy with us when we were doing this program. And when we had the second wave, it was actually the internal medicine leadership reaching out to Annette and I and saying, hey, quick question, are you guys going to be doing this again? Because this really helped us. We really felt like this was a benefit to our patients. Like, are you able to maintain this level of service? And I think across all of these programs that we do, the amount of excitement that we receive from our consultants is really empowering to the field of physiatry, that even for the liver transplant patients, they start to view therapy services and physiatry services very differently. For example, they now want us to be more involved in a prehabilitation clinic. So rather than thinking about us just on the back end, oh, I don't know what to do with my patient anymore, please take over their care. They're saying, well, I think you guys are very useful. Can you guys start early on with us? And the same thing goes for our stroke program. When the stroke program was taking off at JHH, people, the attendings who were running the program over at Bayview were saying, well, when can we get physiatry services over here? When can we coordinate this level of effort? And there was just a lot of excitement and enthusiasm around this. So I'll just add one from the therapy side that creating this program has really helped the therapists to feel valuable in an acute care setting, where before they felt like they were checking a box and all anybody wanted to read was their discharge recommendation. We now feel, they now feel like they are making a difference for patients. They're seeing people get better. They feel valued by the PM&R consultant team. Their opinions seem to matter. So I think while I can't measure it, one of the unintended consequences is I feel like my staff is more engaged and invested in being in acute care. You know, we have had experiences where you start sort of starting acute care and then you move to rehab. You don't have to move to rehab if we can do it at the bedside. So I think that that's an unintended consequence that has been really lovely. There's one more question in the chat and it relates to the impact this might have had on home health utilization and or readmissions. And I can ask Dr. Salnick to answer that, but I believe those are two things that we would need to continue to evaluate the impact on. I don't think we have the answer to that today. Absolutely. Those are great questions. And we think that this is an important metrics for us to follow. We do have a home health care, part of Hopkins and so on. And so we will be looking into that. I don't think there was at least anecdotally that there was a shift and increase of the demand for home health care. And we also will be looking at issues of readmission rate. As a first pass, and you can correct me if I'm wrong, but I believe when we were looking at this in transplant early on, we didn't see that discharging these patients this way, they were modifying readmission, meaning patients have a similar readmission rate after going through this program. So we were not making them, putting them more at risk to return to the hospital. So it looks like one final question popped in and I think it is a good place for us to end probably, which is thanking us for the presentation, but also will your work and outcomes be published? And Dr. Pruski. Yeah. So both the stroke data and the COVID data are papers that we're actively working on. So hopefully in the next couple of months, there'll be the data to share out there in the literature. So thank you so much for your time today. Um, Dr. Solnick, did you want to say any closing words? You were doing a fantastic job on it. Okay. I didn't mean to shy you out with my, I'm muting myself. You did not. So thanks everyone again for, for joining, uh, for joining us. I hope that, uh, you appreciate the experience that we're having. And I think that there is a lot more to learn from this type of, uh, changes in model of care. And I am, I truly believe that, uh, this is an aspect of rehabilitation, a great opportunity for rehabilitation to grow into a new space, uh, that currently we haven't been, uh, very well organized or occupying. And it should not be instead of, it should be in addition to. So with that, uh, I hope you all enjoy the rest of the conference and thanks again. And if you have more questions, take care everyone. Thank you.

rehabilitation interventions

acute care setting

ARISE model of care

enhanced rehabilitation

stroke

COVID-19 patients

discharge disposition

hospital throughput

patient outcomes