Functional status outcomes in rehabilitation. Implications for prospective payment

Previous studies have demonstrated that functional status is a significant predictor of resource utilization for rehabilitation patients. Before implementing a prospective payment system (PPS) for rehabilitation, it is important to first: 1) develop an underlying conceptual framework of rehabilitation resource use; and 2) understand how the role of functional status may vary by rehabilitation condition. In this study, a theoretical model of rehabilitation is presented that proposes relationships between patient and provider characteristics, rehabilitation treatment, costs, and clinical outcomes of rehabilitation. Also presented are regression analyses based on this model for a key outcome of rehabilitation, change in functional status, for nine rehabilitation conditions using variables that minimize adverse incentives by providers in selecting patients for admission to rehabilitation. The change-in-functional-status model explained the most variance for back injury, cardiopulmonary, and arthritis, and less variance for stroke, spinal cord injury, and neurologic impairment. The significant predictors of change in functional status varied by condition. Results support the use of functional status measurements in a PPS for rehabilitation services, the need to refine the measurement of functional status, and the use of condition-specific activities of daily living (ADL) items to include in summary indices.     

A multisite comparison of supported housing for chronically homeless adults: “housing first” versus “residential treatment first”.

Both direct placement in supported community housing and pretreatment with time-limited residential treatment are used as approaches to helping chronically homeless adults exit from homelessness, but relative effectiveness and cost remains untested. The current observational study utilized data from a national, multisite housing project to determine whether clients who receive residential treatment or transitional housing before being placed into independent housing achieve superior outcomes than clients who are immediately placed into independent housing, and whether they incur greater health care costs. A total of 709 participants (131 and 578 participants in the respective groups) were assessed every 3 months for 2 years on housing outcomes, community adjustment, work and income, mental and physical health, and health service costs. Clients who received immediate, independent housing had more days in their own place, less days incarcerated, and reported having more choice over treatment, but no differences on other clinical or community adjustment outcomes. In this observational study, there were no clinical advantages for clients who had residential treatment or transitional housing prior to entry into community housing, but they incurred higher substance abuse service costs. Studies using randomized controlled trials of these conditions are needed to establish causation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Rehabilitation and outcome of right-hemisphere stroke patients: Challenges to traditional diagnostic and treatment methods.

Examined 3 case studies involving right-hemisphere brain injury in terms of vocational, behavioral, and social outcomes following the rehabilitation process. Results indicate that standard neuropsychological tests and other measures of cognitive and speech and language function tend to underestimate the impact of right-hemisphere syndrome on a patient's judgment and social skills, relationship to the family system, ability to perform functional living activities, and ultimate ability to return to productive work. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Self-awareness, distress, and postacute rehabilitation outcome.

Objective: To examine changes in impaired self-awareness (ISA) and distress with participation in a brain injury comprehensive day treatment program (CDTP) and their relationship to treatment outcomes at program end and 1-year follow-up. Study Design and Participants: Ratings of ISA and distress by rehabilitation staff and their relationship to other outcome measures were examined for 62 consecutive program graduates. Measures: Ratings of ISA and distress from the Mayo-Portland Adaptability Inventory (MPAI); outcome measures included Rasch-transformed MPAI score, goal attainment scaling T score, the Vocational Independence Scale, and the Independent Living Scale. Results: Nonparametric analyses of change scores showed that ISA and distress diminished after program participation. Nonparametric correlational analysis indicated that reduced ISA did not correlate with increased distress at program end. Linear and logistic regression analyses revealed that lower ISA and distress correlated with more positive outcomes on most measures (i.e., independent living, goal attainment scaling, and other ratings of disability on the MPAI) but did not predict vocational outcome. Conclusions: Participation in a CDTP reduces ISA and distress. Lower ISA and distress are associated with positive behavioral changes and more independent living but are neither necessary nor sufficient conditions for employment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effectiveness of cognitive rehabilitation following acquired brain injury: A meta-analytic re-examination of Cicerone et al.'s (2000, 2005) systematic reviews.

The present study provides a meta-analysis of cognitive rehabilitation literature (K = 115, N = 2,014) that was originally reviewed by K. D. Cicerone et al. (2000, 2005) for the purpose of providing evidence-based practice guidelines for persons with acquired brain injury. The analysis yielded a small treatment effect size (ES = .30, d+ statistic) directly attributable to cognitive rehabilitation. A larger treatment effect (ES = .71) was found for single-group pretest to posttest outcomes; however, modest improvement was observed for nontreatment control groups as well (ES = .41). Correction for this effect, which was not attributable to cognitive treatments, resulted in the small, but significant, overall estimate. Treatment effects were moderated by cognitive domain treated, time postinjury, type of brain injury, and age. The meta-analysis revealed sufficient evidence for the effectiveness of attention training after traumatic brain injury and of language and visuospatial training for aphasia and neglect syndromes after stroke. Results provide important quantitative documentation of effective treatments, complementing recent systematic reviews. Findings also highlight gaps in the scientific evidence supporting cognitive rehabilitation, thereby indicating future research directions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A multicenter, randomized clinical trial of a cognitive remediation program for childhood survivors of a pediatric malignancy.

Survivors of childhood cancer whose malignancy and/or treatment involved the central nervous system may demonstrate a consistent pattern of neurocognitive deficits. The present study evaluated a randomized clinical trial of the Cognitive Remediation Program (CRP). Participants were 6- to 17-year-old survivors of childhood cancer (N = 161; 35% female, 18% Hispanic, 10% African American, 64% Caucasian, 8% other) who were at least 1 year off treatment and who manifested an attentional deficit. They were enrolled at 7 sites nationwide. Two thirds of the participants were randomly assigned to cognitive remediation. All participants were assessed using a battery of academic achievement/neurocognitive tests and parent/teacher measures of attention. The CRP resulted in parent report of improved attention and statistically significant increases in academic achievement. Effect sizes were modest but were comparable with those for other clinical trials of brain injury rehabilitation and for psychological interventions in general. The CRP is presented as a potentially beneficial treatment for many survivors of pediatric cancer. Long-term clinical significance remains unproven. Further work is needed to improve effect sizes and treatment compliance and to address the needs of other populations with pediatric brain injury. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Construct validity of an attention rating scale for traumatic brain injury.

Attention deficits are nearly ubiquitous after traumatic brain injury (TBI). In the subacute phase of moderate to severe TBI, these deficits may be difficult to measure with the precision needed to predict outcomes, assess degree of recovery, and monitor treatment response. This article reports the findings of four studies, three observational and one a randomized, controlled treatment trial of methylphenidate (MP), designed to provide construct validation of the Moss Attention Rating Scale (MARS), an observational measure of attention dysfunction following TBI. One hundred seven participants with moderate to severe TBI were enrolled during treatment on an inpatient rehabilitation unit. MARS scores were provided independently by four rehabilitation disciplines (Physical, Occupational and Speech Therapies and Nursing). Results indicated that the MARS: (1) is more strongly related to concurrent measures of cognitive versus physical disability, supporting its validity as a measure of cognition, (2) is more strongly related to concurrent psychometric measures of attention versus measures thought to rely less on attention, supporting its validity as a measure of attention; and (3) predicts 1-year outcomes of TBI better than psychometric measures of attention. However, the MARS (4) was not differentially affected by MP versus placebo treatment. Results support the construct validity and utility of the MARS, with further research needed to clarify its role in treatment outcome assessment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Home alone: the role of cognition in return to independent living

OBJECTIVE: To identify unique predictors of the ability to return to living alone in geriatric patients undergoing medical rehabilitation. DESIGN: Of 900 consecutive geriatric patients entering medical rehabilitation, 372 were identified as living alone before admission. Data were collected on functional status, cognition, demographics, and discharge disposition. SETTING: A freestanding medical rehabilitation facility. All patients were admitted to a geriatric rehabilitation unit. PATIENTS: Patients aged 60 to 99, identified as having lived alone before admission, were included. As standard procedure, patients underwent functional and cognitive assessment, and medical records were reviewed. MAIN OUTCOME MEASURE: Logistic regression analysis was used to evaluate predictors of discharge disposition, including demographic variables, medical burden, the Functional Independence Measure (FIM), and the Dementia Rating Scale (DRS). RESULTS: Both the FIM and DRS provided significant and unique variance in prediction of discharge disposition. Patients discharged home alone performed similarly to those discharged with supervision on FIM motor items but higher on FIM social cognition items, emphasizing the strong role of cognition in discharge disposition. Patients discharged home alone scored above suggested cutoff scores on the DRS, indicating generally intact cognitive functioning, whereas those discharged with supervision scored below suggested cutoffs. CONCLUSION: Results emphasize the importance of cognition in the ability to return to completely independent living after medical rehabilitation in geriatric patients.     

Effects of stress inoculation training on athletes' postsurgical pain and rehabilitation after orthopedic injury.

The efficacy of a cognitive-behavioral intervention ( stress inoculation training; SIT ) for postsurgical anxiety, pain, and physical rehabilitation in injured athletes was tested. Sixty male athletes who underwent arthroscopic surgery for miniscus injury in 1 knee were randomly assigned to either treatment (SIT and physical therapy) or control (physical therapy only) conditions. Results showed that participants in the treatment group demonstrated significantly less postsurgical pain and anxiety during the rehabilitation process, compared with controls. Additionally, treated participants required fewer days to return to criterion physical functioning, compared with nontreated participants. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A case-mix classification system for medical rehabilitation

Dissatisfaction with Medicare's current system of paying for rehabilitation care has led to proposals for a rehabilitation prospective payment system, but first a classification system for rehabilitation patients must be created. Data for 36,980 patients admitted to and discharged from 125 rehabilitation facilities between January 1, 1990, and April 19, 1991, were provided by the Uniform Data System for Medical Rehabilitation. Classification rules were formed using clinical judgment and a recursive partitioning algorithm. The Functional Independence Measure version of the Function Related Groups (FIM-FRGs) uses four predictor variables: diagnosis leading to disability, admission scores for motor and cognitive functional status subscales as measured by the Functional Independence Measure, and patient age. The system contains 53 FRGs and explains 31.3% of the variance in the natural logarithm length of stay for patients in a validation sample. The FIM-FRG classification system is conceptually simple and stable when tested on a validation sample. The classification system contains a manageable number of groups, and may represent a solution to the problem of classifying medical rehabilitation patients for payment, facility planning, and research on the outcomes, quality, and cost of rehabilitation.     

Care continuum in traumatic brain injury rehabilitation.

Discusses the range of services needed in traumatic brain injury (TBI) rehabilitation within the context of a services continuum owing to the nature of the recovery process. The TBI care continuum includes treatment during the following phases: injury onset, trauma center and emergency care, neurosurgery unit and acute hospitalization, coma stimulation, nursing home and long-term care programs, transitional living centers, day treatment and outpatient rehabilitation, supervised independent living center and support services, and vocational rehabilitation services. Obstacles to care continuity include funding concerns, lack of knowledge about TBI, the complex nature of TBI, and program accessibility issues. It is noted that major legislative, educational, and outreach efforts are under way to overcome these barriers to services provision. A comment by J. E. Sargent follows. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The cost-effectiveness of a multifactorial targeted prevention program for falls among community elderly persons

OBJECTIVES: Falls and fall injuries are common-potentially preventable-causes of morbidity, functional decline, and increased health-care use among elderly persons. The current analyses, performed on data obtained as part of a randomized controlled trial conducted within a health maintenance organization, describe the costs of a multifactorial, targeted prevention program for falls, present total net health-care costs, estimate the cost per fall prevented, and describe acute fall-related health-care costs. METHODS: The 301 participants were at least 70 years of age and possessed at least one of eight targeted risk factors for falling. The 153 participants randomized to the targeted intervention (TI) group received a combination of medication adjustment, behavioral recommendations, and exercises as determined by their baseline assessment. The 148 participants randomized to the usual care (UC) group received a series of home visits by a social work student. RESULTS: The mean intervention cost per TI participant was $925 (range $588 to $1,346). Total mean health-care costs were approximately $2,000 less in the TI than UC group, whereas median costs were approximately $1,100 higher in the TI than UC group. The TI strategy was unequivocally cost effective when mean costs were used because the intervention was associated with both lowered total health-care costs and fewer total and medical care falls. In sensitivity analyses, the cost-effectiveness of the TI strategy appeared robust to widely differing assumptions about total health-care costs (25th to 75th percentile of the actual distribution) and intervention costs (minimum to maximum costs). In subgroup analyses, the TI strategy showed its strongest effect among individuals at high risk of falling, defined as possession of at least four of the eight targeted risk factors. CONCLUSIONS: Consideration should be given toward incorporating and reimbursing the cost of fall-prevention programs within the usual health care of community-living elderly persons, particularly for those persons at high risk for falling.     

Measurement in neurologic rehabilitation

The increasing emphasis on evaluating outcomes has led to the development of standardized health status measures. Before using one it is vital to check its suitability for the intended purpose. Will the measure detect the change or difference expected? Other more specific measures should be considered. Some focus on common impairments, such as cognitive dysfunction, whereas others focus on disabilities seen with specific pathologies such as head injury. Developing new measures is difficult and should be avoided if possible.     

Evaluation of a voluntary military-style residential treatment program for youths with conduct problems: 6- and 36-month outcomes.

The authors investigated the socioemotional and behavioral outcomes of adolescents referred to voluntary military-style residential treatment. Adolescents (N = 232) with conduct problems were classified into three groups: adolescents who completed treatment, adolescents who withdrew from treatment, and wait list controls. Six months after treatment, boys and girls who completed military-style residential treatment showed fewer externalizing problems, greater adaptive skills, and better behavioral outcomes (e.g., high school completion, employment, lower recidivism) than comparison youths. Results were not maintained at 36-month follow-up. Adolescents who enlisted in the military after treatment showed better outcomes at 36-month follow-up than youths who returned home after treatment. Results indicate that the benefits of treatment might be tangible but short-lived for adolescents who return to their communities. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Current concepts: spinal injuries and rehabilitation

Spinal cord injuries and their catastrophic effects require a treatment infrastructure able to provide an integrated process of management, including rehabilitation from injury and on an ongoing basis. This is particularly important because the incidence of spinal cord injuries is small. Better outcomes and cost efficiency with such an infrastructure have been established, but further knowledge is required to solve the remaining controversies in some aspects of management.     

Effect of a video intervention on functional recovery following hip replacement and hip fracture repair

Although much research has documented the functional outcomes in hip repair surgery, few studies have identified effective interventions to improve functional outcomes. The purpose of this study was to test the use of generic and individualized videos on patients' return to preoperative levels of independent functioning, increased physical performance, improved coping ability, and enhanced perception of ability to care for self. Two rehabilitation units in separate acute care facilities were used to recruit subjects. Data were collected on 82 participants on admission to the study, on discharge from rehabilitation, 1 week after discharge, and 3 months post discharge. The results indicate that video intervention has some benefit to persons recovering from hip repair surgery. The benefits were realized in physical performance as evidenced by a significant difference in the distance walked and time walked of participants in the treatment group.     

Computer-assisted cognitive rehabilitation for the treatment of patients with substance use disorders: A randomized clinical trial.

The purpose of this study was to examine the comparative efficacy of cognitive rehabilitation as an intervention for substance misuse. Patients with substance use disorders entering long-term residential care (N = 160) were randomly assigned to one of two conditions: (a) standard treatment plus computer-assisted cognitive rehabilitation (CACR), which was designed to improve cognitive performance in areas such as problem solving, attention, memory, and information processing speed; and (b) an equally intensive attention control condition consisting of standard treatment plus a computer-assisted typing tutorial (CATT). Participants were assessed at baseline, during treatment, at treatment completion, and 3-, 6-, 9-, and 12-month follow-up. Intent-to-treat analyses showed that, compared with those randomized to CATT, patients who received CACR were significantly more engaged in treatment (e.g., higher ratings of positive participation by treatment staff, higher ratings of therapeutic alliance), more committed to treatment (e.g., longer stays in residence) and reported better long-term outcomes (e.g., higher percentage of days abstinent after treatment). Mediational analyses revealed the positive comparative effect of CACR on abstinence during the year after treatment was mediated by treatment engagement and length of stay in residence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Religion and spirituality in rehabilitation outcomes among individuals with traumatic brain injury.

Objective: The long-term consequences of traumatic brain injury affect millions of Americans, many of whom report using religion and spirituality to cope. Little research, however, has investigated how various elements of the religious and spiritual belief systems affect rehabilitation outcomes. The present study sought to assess the use of specifically defined elements of religion and spirituality as psychosocial resources in a sample of traumatically brain injured adults. Participants: The sample included 88 adults with brain injury from 1 to 20 years post injury and their knowledgeable significant others (SOs). The majority of the participants with brain injury were male (76%), African American (75%) and Christian (76%). Measures: Participants subjectively reported on their religious/spiritual beliefs and psychosocial resources as well as their current physical and psychological status. Significant others reported objective rehabilitation outcomes. Analyses: Hierarchical multiple regression analyses were used to determine the proportion of variance in outcomes accounted for by demographic, injury related, psychosocial and religious/spiritual variables. Results: The results indicate that religious well-being (a sense of connection to a higher power) was a unique predictor for life satisfaction, distress and functional ability whereas public religious practice and existential well-being were not. Conclusions: The findings of this project indicate that specific facets of religious and spiritual belief systems do play direct and unique roles in predicting rehabilitation outcomes whereas religious activity does not. Notably, a self-reported individual connection to a higher power was an extremely robust predictor of both subjective and objective outcome. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Predicting return to work. A long-term follow-up study of railroad workers after low back injuries

STUDY DESIGN: Evaluation of the long-term outcomes of 178 railroad employees with low back injury who had completed a multidisciplinary rehabilitation program. OBJECTIVES: To study two major areas: 1) outcomes of the rehabilitation program in terms of the patient's improvement in function and rate of return to work and 2) factors that predict long-term retention at work, both at the railroad and elsewhere. SUMMARY OF BACKGROUND DATA: Several studies have been published examining rehabilitation outcomes of individuals covered under workers' compensation law, but few exist that have examined railroad workers covered by the Federal Employers Liability Act, and few studies exist with follow-up periods longer than 3 years. METHODS: Physical/medical, self-reported, and employment/financial data were collected on each patient from medical and employment records. Follow-up data regarding employment status were obtained either from the employer or from the patient by telephone interview. RESULTS: On average, the patients improved in all objective and subjective measures after rehabilitation. Improvements in these measures were not predictive of return to work. At follow-up examination, 89% of the contacted patients were employed--61% still at the rail-road. The employment factors of lost work days and length of employment and the financial factor of wage rate were the most predictive of long-term work status. CONCLUSIONS: The multidisciplinary program in the current study was found to improve patient physical functioning and reduce pain. However, success in these measures was not predictive of long-term work status, suggesting that other factors have an impact on work status. Clinicians must be aware that employment and financial factors may have a strong influence on return-to-work outcomes.     

Beyond one-bun, two-shoe: recent advances in the psychological rehabilitation of memory disorders after acquired brain injury

Memory disorders are one of the most frequent types of cognitive impairment encountered in neurological populations. The more severe degrees of such impairment case major disability and handicap, and have a profound impact on a person's capacity to engage in independent living. To date, commonly used remediation strategies range from drills and practice, including computer-based tasks, to mnemonic techniques and memory notebooks. In general, these therapies have met with varying degrees of success. The last decade has seen exciting developments in remediation techniques for memory disorders, a number of which are based on implicit learning skills, as well as programmes tailored to an individual's unique pattern of deficits. The present paper provides an overview of this literature and discusses issues relating to their application in rehabilitation programmes.