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Integrating Working Memory Exercises With Nursing Home Rehabilitation to Achieve “Better, Faster” Functional Outcomes

Mansbach, William E. PhD; Mace, Ryan A. MS; Tanner, Melissa A. PhD; Knoepfel, Erin M. MS, CCC-SLP; Maxwell, Robert MA, CCC-SLP; Chew, Felicia MS, OTR/L, FAOTA

Author Information
Topics in Geriatric Rehabilitation: January/March 2020 - Volume 36 - Issue 1 - p 60-68
doi: 10.1097/TGR.0000000000000256


The post–acute landscape is undergoing seismic change. Increasingly, post–acute facilities, including skilled nursing facilities (SNFs), are being integrated with large health systems and hospitals. Vertical integration of post–acute care has arisen as a strategy to improve quality and cut costs by enhancing care coordination, reducing rehospitalization rates, and capitalizing on the value-based reimbursement reform introduced by the Centers for Medicare & Medicaid Services and other influential payers. Indeed, vertical integration between hospitals and SNFs has been shown to increase Medicare payments and reduce rehospitalization rates.1 Despite this trend, full integration across the health care continuum has been elusive, and SNFs have struggled to adapt older models of care to newer realities.2 Hospital discharge patterns reflecting fewer admissions and more direct home discharges are causing downstream financial hardship for SNFs. Median net margins for SNFs have decreased steadily over the last few years, pushing many facilities toward insolvency.3 One issue is clear; whether integrated with large health systems or as stand-alone facilities, SNFs and their rehabilitation departments are under pressure to produce “better, faster” outcomes to ensure financial survival.

Although the switch from a prospective payment system to a value-based reimbursement model is creating financial stress for SNFs, it also provides an opportunity for a positive paradigm shift in how rehabilitation services are delivered. “Better, faster” care delivery models require enhancement, if not substantial reorganization, of current approaches to rehabilitating functional deficits. One way to improve functional outcomes in a shorter time frame is through rapid integration of cognitive rehabilitation with traditional functional deficit remediation. Under this care delivery model, cognitive and direct functional remediation occurs simultaneously. Cognitive rehabilitation focuses on improving deficits in attention, memory, and executive functions, using evidence-based cognitive interventions that are associated with basic activities of daily living (ADLs) and/or instrumental activities of daily living (IADLs).4 There is strong neuropsychological theory and empirical support linking cognitive domains to functional skills. The role cognitive control plays in coordinating goal-directed behavior is particularly well established.5–7 At a more granular level, working memory is linked to both executive skills and ADL/IADL abilities.8–10

Cognitive rehabilitation was pioneered by Diller and his colleagues in the 1970s.11–13 Although use of standardized cognitive remediation interventions to improve functional outcomes is not new, it is certainly not widespread in its adoption by post–acute SNF rehabilitation models. Given the high base rate of cognitive impairment among post–acute SNF patients,14,15 it is imperative that rehabilitation therapists employ cognitive remediation, or at least use training interventions with demonstrated efficacy for people who have cognitive deficits. There is a small but growing body of evidence that cognitive rehabilitation can improve functional outcomes in patients with mild to moderate cognitive deficits.16–18 However, the majority of existing studies exploring the efficacy of cognitive rehabilitation on functional outcomes are focused on older adults in the community,19 in day centers,20 and in hospital settings,21 not post–acute SNF centers. Therefore, it is challenging to deduce whether cognitive rehabilitation programs could, in fact, facilitate the SNF mission of “better, faster” outcomes.

Our goal was to investigate whether working memory exercises (WME), applied concurrently with traditional rehabilitation therapy, would be associated with improvements in basic functional outcomes in post–acute SNF participants. We assessed ADLs that are common treatment targets in SNF rehabilitation gyms: bathing, dressing, toileting, functional transfers, continence, and feeding. We hypothesized that participants in the WME group would demonstrate significantly greater increases in ADL functioning from baseline to posttesting than control participants. A significant group × time interaction for WME would indicate that “better, faster” rehabilitation of ADLs could be achieved by simultaneously targeting both cognitive skills and functional deficits in SNF patients. Our study was unique in that speech-language pathologists utilized both prescriptive computer and analogue (workbook) WME as the cognitive interventions and it was conducted in multiple SNFs in different US states.



Older adult patients in 19 Genesis Rehabilitation Services skilled nursing facilities in multiple US states were prospectively recruited for this study (October 2016 to July 2017). All nursing home patients were short stay admissions (<100 days) who were receiving post–acute rehabilitation following a hospitalization with plans to discharge to the community. The initial goal was for each facility to identify 20 patients eligible for study randomization. In practice, this was difficult to achieve due to low census rates at participating facilities and intermittent inability to obtain patient's power of attorney necessary for completing the consent agreement.

Seventy patients were identified upon rolling admission to participating facilities. As part of a “universal cognitive screening” process, patients referred to physical therapy completed an informed consent agreement and a Brief Cognitive Assessment Tool—Short Form (BCAT-SF)8 administered by a physical therapist. Patients were excluded if they were younger than 50 years (n = 6, 8.57%); were not proficient in English; had medical, physical, or psychiatric limitations that would interfere with completing the study measures or WME; had BCAT-SF scores indicative of no cognitive impairment (19-21) or moderate to severe dementia (0-11); or were improperly randomized (n = 1; 1.43%). Patients who met eligibility criteria (N = 63) were added to an enumerated participant list. To prevent assignment bias, each facility submitted an anonymized version of its participant list to study investigators for randomization. Study investigators, who had no knowledge of any identifying characteristics, assigned participants to a WME intervention or the control group using a pseudorandom number generator.


All study procedures were approved by the Genesis Rehabilitation Services Internal Research Review Committee. Each facility identified a speech-language therapist to administer the measures (baseline and posttest) and facilitate the WME. The speech-language therapists had no knowledge of the study hypotheses. Participants completed the Brief Cognitive Assessment Tool (BCAT),22 Katz Index of Independence in Activities of Daily Living (Katz ADL),23 and Brief Anxiety and Depression Scale (BADS)24 with the speech-language therapist at baseline. Facility occupational therapists assisted in the completion of the Katz ADL. Next, participants entered the WME or control period based on their random group assignment. Within 72 hours following the last WME session (or 3 weeks after the baseline assessment for the control group), the speech-language therapist re-administered the BCAT, Katz ADL, and BADS for posttesting. All assessment results were submitted to the study investigators for data entry and analysis. To maximize the benefit of their efforts, the rehabilitation therapists were encouraged to use the results of the measures as part of the participants' discharge planning process, as clinically appropriate.

Rehabilitation therapists

Participating rehabilitation therapists had an average of 14.02 (SD = 8.84) years of geriatrics experience and 11.26 (SD = 7.88) years of experience in short-term rehabilitation settings. All therapists participated in a training call with the study investigators to (1) learn the study methodology and (2) standardize administration of the measures (cognitive, functional) and WME.

WME group

The WME group consisted of a 3-week, 9-session course, with each session lasting approximately 30 minutes. This format was based on evidence that cognitive interventions involving fewer total sessions (6-20) and shorter durations (≤12 weeks) are more cost-effective and attenuate attrition without sacrificing treatment efficacy.25 Working memory exercises participants completed cognitive tasks from either the Memory Match or the Working Memory Exercise Book.26,27 Both were designed for rehabilitation therapists and are commonly used in post–acute settings. We selected both digital (online) and analogue (hard copy workbook) WME for a practical purpose; not all rehabilitation gyms have Internet access, and therapists would be less likely to use an online cognitive rehabilitation treatment in such settings. Memory Match was selected because of previous evidence of its efficacy as a computerized WME for older rehabilitation patients with milder cognitive deficits.28 The Working Memory Exercise Book was selected as an analogous intervention that does not require Internet access for administration. Working memory exercises sessions were conducted by the speech-language therapists in the facility's rehabilitation clinic. Given that the functional measures were the primary outcomes, data on individual cognitive task performances are not available. Because therapists may use a combination of analogue and digital WME in actual practice, we combined the Memory Match and Working Memory Exercise Book groups into a single treatment group.

Memory Match26 is an evidence-based, online cognitive rehabilitation module that targets attention and visual working memory. Administration required a mobile device with Internet access. The task challenges participants to visually pair matching pictures by recalling their spatial location. Each trial of Memory Match ends when the participant correctly matches all of the pairs or is unable to do so after 10 minutes. The organization and paring of matches are generated randomly for each game, which required participants to generate novel solutions for each session. The speech therapist administered the easy (level 1) and medium (level 2) difficulty levels of Memory Match, which served as the practice and treatment trials, respectively. Level 2 was readministered until the 30-minute session was completed. In a previous pilot study, older rehabilitation patients who completed Memory Match (n = 20) had significantly higher BCAT scores (medium-large effect size) at posttest than control group patients (n = 18).28

The Working Memory Exercise Book27 is an evidence-based cognitive rehabilitation workbook designed to enhance attention and working memory. The exercises are intended to help patients develop cognitive communication skills and strengthen strategies for learning and memory. Speech therapists administered a standardized set of paper-and-pencil cognitive exercises from the workbook for each session. The cognitive exercises required participants to sequence alphanumeric symbols, sort pictures or words, manipulate visuospatial stimuli, recall visual (faces) and verbal information (brief stories), or process and execute a list of instructions. Similar to Memory Match, participants completed 2 difficulties levels, basic (practice trials) and complex (treatment trials), for each 30-minute session.

Control group

The purpose of the control group was to compare the WME with the usual and customary rehabilitation therapy that post–acute patients receive at SNFs (ie, treatment as usual). Participants assigned to the control group did not complete the WME. After the initial screening and consent, control participants completed the baseline measures and were retested 3 weeks later. The 3-week pre-/posttesting period was designed to match the length of the WME group.


Katz Index of Independence in Activities of Daily Living

The Katz ADL,23 which was originally developed for rehabilitation patients, is widely used across geriatrics to measure fundamental skills to meet physical needs.29,30 Facility therapists rated participants' ability to complete each of the 6 Katz ADL items at baseline and posttesting: bathing, dressing, toileting, functional transfers, continence, and feeding. Katz ADL items use a simple scoring system: 1 = independent (“no supervision, direction, or personal assistance”) or 0 = dependent (“with supervision, direction, personal assistance, or total care”). In addition to identifying specific ADL dependencies, the dichotomized Katz items were summed to estimate total ADL functioning.31,32 Psychometric studies have found the Katz ADL to have high internal consistency reliability,33,34 construct validity as a single factor,33 good content validity,35 and strong convergent validity.34 In this sample, internal consistency of the Katz ADL was strong at baseline and posttesting (Cronbach α = 0.83, 95% confidence interval [CI] = 0.77-0.89).

Supplementary measures

The BCAT,22 the longer version from which the BCAT-SF is based, is a multidomain cognitive instrument that emphasizes executive function, contextual memory, and attentional control. Total scores (21 items, range = 0-50) are sensitive to a continuum of cognitive functioning.14,22,36 The BCAT was included to categorize participants to control for baseline cognitive functioning in hypothesis testing. The BADS24 is an 8-item questionnaire designed to rapidly (3 minutes or less) assess symptoms of depression and anxiety in older adults. The BADS Anxiety Factor (range = 0-10) and Depression Factor (range = 0-6) are sensitive to generalized anxiety disorder and major depressive episode, respectively.24 The BADS was included to examine baseline between-groups differences in depression and anxiety prior to hypothesis testing.

Statistical analysis

Statistical analysis was performed in R using RStudio.37,38 The Appendix (Supplemental Digital Content 1, available at:, lists the R packages used. Study analyses adhered to the intention-to-treat concept: all randomized participants were included in hypothesis testing. Completers of Memory Match and the Working Memory Exercise Book were combined to capture the effects of WME on ADLs relative to control participants. Descriptive statistics were used to report participant characteristics and outcome measure scores. Independent-sample t tests, 1-way analysis of variance, and Pearson correlations were used to examine associations between the outcome measures and participant characteristics.

Linear mixed-effects modeling was conducted in the lme4 package.39 Advantages of mixed-effects modeling include (1) robustness to missing data, (2) consideration of both fixed and random effects, and (3) management of heteroscedasticity and nonspherical error variance for either participant or study items.40 A mixed-effects model was built to predict Katz ADL scores. Measurement period (baseline, posttest) and group assignment (WME, control) were entered as fixed effects. The period × group interaction tested the hypothesis that the WME group would be associated with “better, faster” ADL improvements during post–acute care. Intercepts for participants were added as a random effect. Omnibus statistics were summarized using the anova function and slopes for the 2-way interaction were estimated using the lmerTest package.41 Working memory exercises effects were further quantified by the percentage of participants with decreased, stable, or increased ADL functioning during the study.



Descriptive statistics for the 65 participants randomized to the WME (n = 40) and control (n = 25) groups are presented in Table 1. Ninety percent (n = 36) of WME group participants completed all 8 sessions. The remaining 4 intervention participants, who finished between 3 and 7 sessions, completed the posttests prematurely because of early facility discharge. Ninety percent of participants had at least 1 ADL dependence, the most common (>50% of the sample) were bathing (84.38%), toileting (64.06%), functional transfers (62.50%), and dressing (61.94%). Baseline ADLs were not significantly associated with age, cognition, depression, or anxiety (Ps > .05).

TABLE 1 - Descriptive Statistics and Baseline Participant Characteristics by Groupa
Variable Label Study Group P Effect Size
Intervention (n = 40) Control (n = 25)
Age, y 79.25 (SD = 11.08) 81.64 (SD = 8.62) .30 d = 0.25
Sex Female 24 (60.00%) 19 (76.00%) .30 V = 0.17
Male 16 (40.00%) 6 (24.00%)
Race White 37 (92.50%) 24 (96.00%) .57 V = 0.07
Black 3 (7.50%) 1 (4.00%)
Marital Single 5 (12.50%) 1 (1.54%) .50 V = 0.23
Married 9 (22.50%) 7 (4.00%)
Separated 0 (0.00%) 1 (4.00%)
Divorced 5 (12.50%) 2 (8.00%)
Widowed 20 (50.00%) 14 (56.00%)
Missing 1 (2.50%) 0 (0.00%)
Education <12 y 5 (12.50%) 8 (32.00%) .27 V = 0.31
12 y 16 (40.00%) 9 (36.00%)
13-15 y 12 (30.00%) 5 (20.00%)
16 y 3 (7.50%) 3 (12.00%)
>16 y 3 (7.50%) 0 (0.00%)
Missing 1 (2.50%) 0 (0.00%)
Cognition Normal 1 (2.50%) 0 (0.00%) .43 V = 0.21
MCI 15 (37.5%) 6 (24.00%)
Dementia 21 (52.50%) 18 (72.00%)
Missing 3 (7.50%) 1 (4.00%)
Depression 17 (42.50%) 16 (64.00) .20 V = 0.22
Anxiety 14 (35.00%) 10 (40.00) .69 V = 0.11
Days 20.58 (SD = 12.95) 18.29 (SD = 7.34) .40 d = 0.23
bbreviation: MCI, mild cognitive impairment.
Cognitive levels were determined by Brief Cognitive Assessment Tool score ranges. Clinically significant depression and anxiety were identified by the Brief Anxiety and Depression Scale. Days = number of days enrolled in the study.

Performance on the study measures (Katz ADL, BCAT, BADS) by group at baseline and posttesting is presented in Table 2. Working memory exercises participants had higher cognition (M = 32.00, SD = 7.13) than control participants (M = 28.08, SD = 6.54), t59= 2.16, P = .03. The effect size for this baseline difference was medium (d = 0.58), and BCAT scores were retained as a covariate in subsequent modeling. Activities of daily living, rates of depression or anxiety (BADS), number of days enrolled in the study, and demographics (age, sex, education, marital status, race) did not significantly differ between the 2 groups (Ps > .05). Evidence for a gender bias in ADL ratings was not found as baseline Katz scores did not significantly differ between male and female participants (P > .05).42

TABLE 2 - Descriptive Statistics for the Study Measures by Group
Time Measure n Mean SD Median Minimum Maximum Skew Kurtosis
Baseline Intervention Cognition 37 32.00 7.13 33.00 16.00 49.00 −0.19 −0.35
ADL 40 2.60 1.98 2.00 0.00 6.00 0.55 −1.11
Anxiety 39 3.26 3.09 2.00 0.00 9.00 0.42 −1.40
Depression 39 2.46 2.01 2.00 0.00 6.00 0.26 −1.32
Control Cognition 24 28.08 6.54 28.00 17.00 40.00 0.11 −1.08
ADL 25 2.84 1.99 3.00 0.00 6.00 0.15 −1.59
Anxiety 25 3.84 3.22 4.00 0.00 10.00 0.19 −1.37
Depression 25 3.16 1.91 3.00 0.00 6.00 −0.08 −1.08
Posttest Intervention Cognition 34 35.68 7.26 37.50 19.00 50.00 −0.49 −0.42
ADL 40 3.45 2.26 3.50 0.00 6.00 −0.24 −1.50
Anxiety 33 2.58 2.67 2.00 0.00 9.00 0.88 −0.23
Depression 33 2.12 1.85 2.00 0.00 6.00 0.46 −1.12
Control Cognition 21 32.76 7.22 33.00 18.00 46.00 −0.34 −0.52
ADL 25 2.56 2.36 2.00 0.00 6.00 0.38 −1.59
Anxiety 20 2.05 2.91 1.00 0.00 9.00 1.21 −0.04
Depression 20 2.50 1.99 2.00 0.00 6.00 0.44 −0.97
bbreviations: ADL, Katz Activities of Daily Living (ADL); Anxiety, Brief Anxiety Depression Scale (BADS), anxiety factor; Cognition, Brief Cognitive Assessment Tool (BCAT); Depression, BADS, depression factor.

Mixed-effects modeling

Total ADLs

Results from the mixed-effects model predicting ADLs are reported in Table 3. Number of days enrolled in the study (B = −0.01, 95% CI = −0.05 to 0.03, P = .57) and baseline BCAT scores (B = 0.08, 95% CI = 0.03-0.14, P = .06) did not significantly predict posttest ADL performance. The significant group × time interaction predicting ADL performance (P = .02) provided support for the “better, faster” hypothesis of WME on basic functional outcomes. On average, WME participants' ADL performance increased by 1.59 points (95% CI = 0.69-2.49, p < .001) from baseline to posttesting compared with a 0.05-point decrease (95% CI= −1.09 to 0.99, P = .92) for the control group over the same period. By the end of their study involvement, WME participants (Madj= 4.30, 95% CI = 3.53-5.06) had 1.25 points (95% CI = 0.15-2.34, P = .03) greater ADL performance than control group participants (Madj= 3.05, 95% CI = 2.19-3.91). The Figure illustrates the significant effect of the WME on ADL performance.

TABLE 3 - Summary of the Mixed-Effects Models Predicting ADLs
Predictor Sum sq Mean sq Num df Den df F P
Time 13.67 13.67 1 51.9 5.05 .03a
Group 2.64 2.64 1 74.8 0.98 .33
Days in study 0.88 0.88 1 83.4 0.32 .57
Cognition 10.09 10.09 1 68.3 3.73 .06
Group × Time 15.5 15.5 1 51.9 5.73 .02a
bbreviations: ADL, Katz Activities of Daily Living (ADL); cognition, baseline Brief Cognitive Assessment Tool (BCAT) scores; Den df, denominator degree of freedom; group, intervention, control; mean sq, mean square; num df, numerator degree of freedom; sum sq, sum of squares; time, baseline, posttest.
P < .05.

Effect of the cognitive intervention on Katz ADLs. Adjusted means (black dots) and 95% confidence interval (error bars) were generated from the mixed-effects model predicting ADL functioning. The group × time interaction was significant (P = .02). ADL indicates activity of daily living.

Specific ADLs

To better understand the effect of WME on functional outcomes, rates of decreased and increased functioning from baseline to posttesting were calculated for each ADL. As presented in Table 4, a greater proportion of patients in the treatment group progressed from dependent to independent on continence (27.09%; WME = 32.35%, control = 5.26%), dressing (13.53%; WME = 23.53%, control = 10.00%), feeding (11.76%; WME = 11.76%, control = 0.00%), functional transfers (11.47%; WME = 26.47%, control = 15.00%), and toileting (8.53%; WME = 23.53%, control = 15.00%). Conversely, 20.00% of control participants had decreased independence on toileting over the study period compared with 0.00% for WME participants.

TABLE 4 - Rates of Change in Functioning by ADL and Study Group
ADL Group Decreased Stable Increased
1. Bathing Intervention 0.00% 70.59% 29.41%
Control 5.00% 65.00% 30.00%
2. Dressing Intervention 0.00% 76.47% 23.53%
Control 10.00% 80.00% 10.00%
3. Toileting Intervention 0.00% 76.47% 23.53%
Control 20.00% 65.00% 15.00%
4. Functional transfers Intervention 0.00% 73.53% 26.47%
Control 10.00% 75.00% 15.00%
5. Continence Intervention 8.82% 58.82% 32.35%
Control 10.53% 84.21% 5.26%
6. Feeding Intervention 0.00% 88.24% 11.76%
Control 5.00% 95.00% 0.00%
bbreviation: ADL, Katz Activities of Daily Living (ADL) items.


This study evidenced “better, faster” functional outcomes in post–acute rehabilitation associated with the integration of WME and functional deficit remediation. As hypothesized, the significant group by time interaction indicated that simultaneously targeting both cognitive skills and functional deficits was associated with greater improvements in ADLs than targeting functional deficits alone. Working memory exercises were associated with a 1.59-point ADL increase, representing an average gain in functional independence by one-quarter of the ADLs assessed by the Katz. At posttesting, the WME group demonstrated independence on 1.3 more ADLs than the control group. The “better, faster” finding for cognitive rehabilitation in conjunction with functional remediation was observed in 5individual ADLs, with a greater proportion of patients in the treatment group progressing from dependent to independent for continence, dressing, feeding, functional transfers, and toileting.

This is an encouraging finding that has real implications for improving functional outcomes and safe discharges to the community. Discharging patients with significantly improved ADL skills should improve independence, reduce caregiver burden, and decrease the risk of unnecessary hospital readmission. This last point is of paramount importance to hospitals and post–acute SNFs that may incur financial penalties when discharged patients prematurely return to the hospital. There is growing evidence that older adults with ADL disability are particularly vulnerable to hospital readmission.43 Hence, integration of a prescriptive WME regimen as a key component to post–acute SNF rehabilitation could reduce health care costs and improve the discharge process.

Although focusing on the significant implications of the study findings for patients, their families, post–acute SNF rehabilitation, and the health care system at large is timely, it is also important to carefully consider the mechanisms by which these outcomes were produced. How do we understand why the integration of WME with traditional rehabilitation therapies produced significant gains in ADL functions? One explanation may be found in examining a set of well-documented positive associations: between working memory and executive functions, and between each of these cognitive abilities and daily functioning. In the seminal Baddeley and Hitch5 working memory model, the “central executive” is considered an executive function and conceptualized to have a supervisory role in the attentional system.44 Perhaps this explains the strong positive association between working memory and executive functions reported by McCabe and colleagues.9 A strong link between functional skills with executive functions and memory is also well established.14,22,31,45 It stands to reason that cognitive rehabilitation targeting working memory would consequently improve ADLs. In the post–acute rehabilitation gym, WME may give patients an added boost to traditional ADL remediation therapies. Future research is needed to identify mechanisms by which WME could optimize remediation of basic functional outcomes in SNF post–acute care.

It should be noted that the treatment and control groups did not differ significantly on demographic variables, days spent in study, or baseline mood and functional scores. There was a small-medium effect for the between-groups difference in baseline BCAT scores, but this difference was not clinically significant as average scores for both groups fell in the range of mild dementia. The sample was predominantly white; therefore, it will be important to investigate the efficacy of WME for producing “better, faster” ADL outcomes in more racially diverse samples. A strength of this sample is that it was distributed fairly evenly across number of years of education. Furthermore, it retained a fairly high completion rate, with 90% of those in the treatment group completing all 8 sessions. This suggests that the WME were well tolerated by SNF patients with cognitive impairment.

In addition to replicating the findings with more multiculturally diverse populations, it would be useful to evaluate the effectiveness of this WME program with more cognitively diverse populations. Being cognitively intact and having more severe cognitive deficits, as measured by the BCAT-SF, were used as exclusionary criteria for this study. Given that people with more severe cognitive impairment present to post–acute rehabilitation settings, it would be beneficial to explore whether the WME effects on ADLs could generalize to them and, if not, whether the program should be adapted for better outcomes. We did not test whether this program will result in “better, faster, and sustained” outcomes, although a next step in our research is to investigate whether the benefits of WME on ADLs found in this study are durable.

Returning to the issue of financial viability of SNFs, the shift from fee-for-service to value-based payment transfers focuses from quantity to quality of services, making revenue dependent on clinical outcomes. In combination with the financial penalties associated with hospital readmissions, SNFs and their rehabilitation departments are under considerable financial pressure, given that patients referred for post–acute rehabilitation are at an especially high risk for hospital readmission.46 Vertical integration between hospitals and post–acute care facilities is one proposed solution to this financial challenge, but it remains elusive and limited in scope, as it does not address patient care directly.

Innovation in care delivery models is required to produce “better, faster” outcomes that will help SNFs capitalize on value-based reimbursement and, ideally, reduce hospital readmission rates. Simultaneous delivery of WME with functional deficit remediation represents an innovative pathway toward improving basic functional outcomes in a shorter time frame. Right-sizing rehabilitation service through the integration of an evidence-based, prescriptive cognitive treatment protocol is in alignment with value-based care delivery. Skilled nursing facilities are positioned to maximize value-based reimbursement by integrating cognitive and functional remediation. Given that level of functional impairment is associated with increased risk of 30-day hospital readmission,47 integrated cognitive and functional remediation could reduce risk for rehospitalization.

Skilled nursing facilities are facing severe financial pressure, necessitating a shift from the usual and customary approach to post–acute care. Revamping the existing delivery model of rehabilitation services by applying a prescriptive cognitive rehabilitation, such as the WME program, could result in “better, faster” functional outcomes, thereby ensuring the financial survival of post–acute care facilities. This preliminary evidence has wide-reaching clinical and financial implications, warranting further exploration across a broader range of patient populations, treatment settings, and time frames.


1. Konetzka RT, Stuart EA, Werner RM. The effect of integration of hospitals and post-acute care providers on Medicare payment and patient outcomes. J Health Econ. 2018;61:244–258. doi:10.1016/j.jhealeco.2018.01.005.
2. Compton-Phillips A, Mohta SA. Strengthening the post-acute care connection. NEJM Catalyst. Published November 10, 2016. Accessed August 21, 2018.
3. Regan T. SNF occupancy, operating margins continued to drop in 2016. Skilled Nursing News. Published December 20, 2017. Accessed August 21, 2018.
4. Nair RD, Lincoln NB. Cognitive rehabilitation for memory deficits following stroke. Cochrane Database Syst Rev. 2007;3:CD002293. doi:10.1002/14651858.CD002293.pub2.
5. Baddeley AD, Hitch G. Working memory. In: Bower GH, ed. Psychology of Learning and Motivation. Vol 8. Cambridge, MA: Academic Press; 1974:47–89. doi:10.1016/S0079-7421(08)60452-1.
6. Balota DA, Law MB, Zevin JD. The attentional control of lexical processing pathways: reversing the word frequency effect. Mem Cognit. 2000;28(7):1081–1089. doi:10.3758/BF03211809.
7. Braver TS, Gray JR, Burgess GC. Explaining the many varieties of working memory variation: dual mechanisms of cognitive control. In: Variation in Working Memory. New York, NY: Oxford University Press; 2007:76–106.
8. Mansbach WE, MacDougall EE. Development and validation of the short form of the Brief Cognitive Assessment Tool (BCAT-SF). Aging Ment Health. 2012;16(8):1065–1071. doi:10.1080/13607863.2012.702729.
9. McCabe DP, Roediger HL, McDaniel MA, Balota DA, Hambrick DZ. The relationship between working memory capacity and executive functioning: evidence for a common executive attention construct. Neuropsychology. 2010;24(2):222–243. doi:10.1037/a0017619.
10. Mograbi DC, Faria Cde A, Fichman HC, Paradela EMP, Lourenço RA. Relationship between activities of daily living and cognitive ability in a sample of older adults with heterogeneous educational level. Ann Indian Acad Neurol. 2014;17(1):71–76. doi:10.4103/0972-2327.128558.
11. Diller L. A model for cognitive retraining in rehabilitation. Clin Psychol. 1976;29(2):13–15.
12. Diller L, Ben-Yishay Y, Gerstman LJ, Goodkin R, Gordon W, Weinberg J. Studies in Cognition and Rehabilitation in Hemiplegia (Rehabilitation Mono Graph No, 50). New York, NY: University Medical Center, Institute of Rehabilitation Medicine; 1974.
13. Weinberg J, Diller L, Gordon WA, et alVisual scanning training effect on reading-related tasks in acquired right brain damage. Arch Phys Med Rehabil. 1977;58(11):479–486.
14. Mace RA, Mansbach WE. Validity of Brief Cognitive Assessment Tool modifications for older adults with visual and motor limitations. J Clin Exp Neuropsychol. 2018;40(7):715–721. doi:10.1080/13803395.2017.1423041.
15. Mansbach WE, Mace RA, Clark KM, Firth IM. A comparison of cognitive functioning in long-term care and short-stay nursing home residents. Ageing Soc. 2017;37(1):1–13. doi:10.1017/S0144686X15000926.
16. Avila R, Bottino CMC, Carvalho IAM, Santos CB, Seral C, Miotto EC. Neuropsychological rehabilitation of memory deficits and activities of daily living in patients with Alzheimer's disease: a pilot study. Braz J Med Biol Res. 2004;37(11):1721–1729. doi:S0100-879X2004001100018.
17. Sitzer DI, Twamley EW, Jeste DV. Cognitive training in Alzheimer's disease: a meta-analysis of the literature. Acta Psychiatr Scand. 2006;114(2):75–90. doi:10.1111/j.1600-0447.2006.00789.x.
18. Thivierge S, Jean L, Simard M. A randomized cross-over controlled study on cognitive rehabilitation of instrumental activities of daily living in Alzheimer disease. Am J Geriatr Psychiatry. 2014;22(11):1188–1199. doi:10.1016/j.jagp.2013.03.008.
19. Rebok GW, Ball K, Guey LT, et alTen-year effects of the advanced cognitive training for independent and vital elderly cognitive training trial on cognition and everyday functioning in older adults. J Am Geriatr Soc. 2014;62(1):16–24. doi:10.1111/jgs.12607.
20. Kounti F, Bakoglidou E, Agogiatou C, Lombardo NBE, Serper LL, Tsolaki M. RHEA,* a nonpharmacological cognitive training intervention in patients with mild cognitive impairment: a pilot study. Top Geriatr Rehabil. 2011;27(4):289. doi:10.1097/TGR.0b013e31821e59a9.
21. Carter SL, Shore D, Harnadek MCS, Kubu CS. Normative data and interrater reliability of the design fluency test. Clin Neuropsychol. 1998;12(4):531–534. doi:10.1076/clin.12.4.531.7239.
22. Mansbach WE, MacDougall EE, Rosenzweig AS. The Brief Cognitive Assessment Tool (BCAT): a new test emphasizing contextual memory, executive functions, attentional capacity, and the prediction of instrumental activities of daily living. J Clin Exp Neuropsychol. 2012;34(2):183–194. doi:10.1080/13803395.2011.630649.
23. Katz S. Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living. J Am Geriatr Soc. 1983;31(12):721–727.
24. Mansbach WE, Mace RA, Clark KM. The Brief Anxiety and Depression Scale (BADS): a new instrument for detecting anxiety and depression in long-term care residents. Int Psychogeriatr. 2015;27(4):673–681. doi:10.1017/S1041610214002397.
25. Jean L, Bergeron M-E, Thivierge S, Simard M. Cognitive intervention programs for individuals with mild cognitive impairment: systematic review of the literature. Am J Geriatr Psychiatry. 2010;18(4):281–296. doi:10.1097/JGP.0b013e3181c37ce9.
26. Mansbach Health Tools, LLC. Brain rehabilitation exercises: memory match. Published 2011. Accessed October 11, 2018.
27. Mansbach Health Tools, LLC. The BCAT working memory exercise book. Published 2014. Accessed October 11, 2018.
28. Mansbach WE, Mace RA, Clark KM. The efficacy of a computer-assisted cognitive rehabilitation program for patients with mild cognitive deficits: a pilot study. Exp Aging Res. 2017;43(1):94–104. doi:10.1080/0361073X.2017.1258256.
29. Mlinac ME, Feng MC. Assessment of activities of daily living, self-care, and independence. Arch Clin Neuropsychol. 2016;31(6):506–516. doi:10.1093/arclin/acw049.
30. Wallace M, Shelkey M. Katz Index of Independence in Activities of Daily Living (ADL). Boltz M, Greenberg SA, eds. 2007;(2). Accessed October 11, 2018.
31. Royall DR, Lauterbach EC, Kaufer D, Malloy P, Coburn KL, Black KJ. The cognitive correlates of functional status: a review from the committee on research of the American Neuropsychiatric Association. J Neuropsychiatry Clin Neurosci. 2007;19(3):249–265. doi:10.1176/jnp.2007.19.3.249.
32. Vittengl JR, White CN, McGovern RJ, Morton BJ. Comparative validity of seven scoring systems for the instrumental activities of daily living scale in rural elders. Aging Ment Health. 2006;10(1):40–47. doi:10.1080/13607860500307944.
33. Ciesla JR, Shi L, Stoskopf CH, Samuels ME. Reliability of Katz's Activities of Daily Living Scale when used in telephone interviews. Eval Health Prof. 1993;16(2):190–203. doi:10.1177/016327879301600204.
34. Hamrin E, Lindmark B. Evaluation of functional capacity after stroke as a basis for active intervention. Scand J Caring Sci. 1988;2(3):113–122. doi:10.1111/j.1471-6712.1988.tb00357.x.
35. Law M, Letts L. A critical review of scales of activities of daily living. Am J Occup Ther. 1989;43(8):522–528. doi:10.5014/ajot.43.8.522.
36. Mansbach WE, Mace RA, Clark KM. Differentiating levels of cognitive functioning: a comparison of the Brief Interview for Mental Status (BIMS) and the Brief Cognitive Assessment Tool (BCAT) in a nursing home sample. Aging Ment Health. 2014;18(7):921–928. doi:10.1080/13607863.2014.899971.
37. R Core Team. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; 2017. Accessed October 11, 2018.
38. RStudio Team. RStudio: Integrated Development for R. Boston, MA: RStudio Team; 2016. Accessed October 23, 2018.
39. Bates D, Mächler M, Bolker B, Walker S. Fitting linear mixed-effects models using lme4. J Stat Softw. 2015;67(1). doi:10.18637/jss.v067.i01.
40. Baayen RH, Davidson DJ, Bates DM. Mixed-effects modeling with crossed random effects for subjects and items. J Mem Lang. 2008;59(4):390–412. doi:10.1016/j.jml.2007.12.005.
41. Kuznetsova A, Brockhoff PB, Christensen RHB. lmerTest package: tests in linear mixed effects models. J Stat Softw. 2017;82(13). doi:10.18637/jss.v082.i13.
42. Graf C. The Lawton Instrumental Activities of Daily Living Scale. Am J Nurs. 2008;108(4):52. doi:10.1097/01.NAJ.0000314810.46029.74.
43. Depalma G, Xu H, Covinsky KE, et alHospital readmission among older adults who return home with unmet need for ADL disability. Gerontologist. 2013;53(3):454–461. doi:10.1093/geront/gns103.
44. Baddeley A. Working Memory. New York, NY: Clarendon Press/Oxford University Press; 1986.
45. Marshall GA, Rentz DM, Frey MT, Locascio JJ, Johnson KA, Sperling RA. Executive function and instrumental activities of daily living in mild cognitive impairment and Alzheimer's disease. Alzheimers Dement. 2011;7(3):300–308. doi:10.1016/j.jalz.2010.04.005.
46. Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. Washington, DC: Medicare Payment Advisory Commission; 2013. Accessed October 5, 2018.
47. Greysen SR, Stijacic Cenzer I, Auerbach AD, Covinsky KE. Functional impairment and hospital readmission in Medicare seniors. JAMA Intern Med. 2015;175(4):559. doi:10.1001/jamainternmed.2014.7756.

activities of daily living; cognitive impairment; rehabilitation; skilled nursing; working memory exercises

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