We found that lower functional status at discharge was a leading predictor of LTCF readiness and death at 180 days post-discharge. Increasing age was the factor that most impacted outcomes beyond functional status. Our results suggest that routinely collected functional status at discharge meaningfully improves the prediction of post-discharge LTCF readiness and death, but not ED re-presentation or hospital re-admission. The routine assessment of functional status can inform ongoing health care needs, post-discharge service planning, and provide better targeting of care.
A ‘plateau’ effect was seen where those requiring at least maximal assistance with bADLs were no more likely to be LTCF ready than those requiring extensive or maximal assistance, which was likely driven by patients dying or being discharged to a palliative setting (rather than a LTCF). Patients with independent functional status at discharge were more likely to experience an outcome than those who required supervision to complete ADLs. This may have represented preferential coding of patients as independent on discharge, that supervision provides a safety benefit, or both. The smaller magnitude of change in outcomes across functional status compared to age for ED and hospital re-admission reflects that function may be a poor discriminator of these outcomes as well as the general stochasticity of these events.
Across the cohort, several findings were seen that are reflective of previous analyses. ICU admission was protective of each outcome; these patients had less comorbidity (lower Charlson comorbidity index, p < 0.01), a greater chance of surviving severe illness (p < 0.01), and were thus selected to be cared for there.(34) An increased usual provider index and number of recent family physician visits were protective for all except ED re-admission, reflecting that regular contact with the medical system may prevent acute decompensation.(24, 35) Heart failure and COPD were associated with increased odds of each outcome except LTCF readiness, indicating the additional prognostic burden they carry.
More heterogeneity is seen when contextualizing the prognostic value of function within previous studies. In terms of re-hospitalization, there has been conflicted data; smaller studies have demonstrated that functional data is helpful. Larger, database driven models, however, have generally not included functional measures.(5, 36–39) Smaller studies of ED re-presentation have also demonstrated the value of functional measurement in the prognostication of outcomes.(40, 41) A meta-analysis of factors contributing to LTCF readiness congruently found that requiring assistance with bADLs (1–2 bADLs OR 2.45, 2.02–2.97; 3 or more bADLs 3.25, 2.59–4.09) and prior nursing home use (OR 3.47, 1.88–6.37) were the factors most associated with LTCF admission.(3) There were several methods by which ADLs were assessed within the studies, suggesting that there can be flexibility in how function is measured. For mortality, function was only measured in non-database studies; where measured, functional deterioration was the greatest predictor of death.(4)
Collectively, these findings suggest that the greatest barrier to using functional measure within clinical care is not demonstrating its value, but rather the feasibility and routine practice of the collection of functional data itself. Future research should address this issue. While HOBIC data was collected by nurses during the program, its collection may be facilitated by looking to see if such information can be collected from assessments by physiotherapists and occupational therapists as well, who have traditionally addressed many of the HOBIC domains. Second, using such data to demonstrate how this data can change real world outcomes, such as ensuring senior friendly hospitals or reduced emergency applications to LTCFs, would reinforce the case for its routine collection.(42)
Limitations to this work largely relate to the deployment of the HOBIC program. Despite the use of liberal hospital inclusion criteria in the study, most hospitals were deemed ineligible due to an insufficient number of HOBIC assessments completed. Included hospitals were mostly urban, limiting the generalizability of this data in more rural settings. There was also poor capture of some comorbidities including delirium and dementia (though reasonable estimates of coronary artery disease, hypertension, diabetes, and chronic obstructive pulmonary disease).(43–46) Finally, this analysis does not include data concerning whether individuals received home care services post-discharge to support them remaining in the community, however, it was expected that the inclusion of such data would increase the magnitude of the association by demonstrating the necessity of these services for vulnerable individuals to remain alive and not LTCF ready.(47)
Functional status is an important predictor of LTCF readiness and death after acute hospitalization. Internal and external consistency of results validates the importance of assessing function in-hospital. Routinely collected functional status data has the potential to meaningfully inform future health care planning.