Rehabilitation Models of Care Overview of Literature Review
Rehabilitation Models of Care Overview of Literature Review Janelle Hearn Senior Project Officer Overview Background to literature review Rehabilitation definitions, the process, standards Models of care examples Diagnosis specific models of care Factors in effective rehabilitation Key points Literature Review Dept of Health commissioned NARI to complete a literature review on rehabilitation models of care Literature review questions: 1. What models of care exist for inreach, admitted and ambulatory rehabilitation? 2. What diagnosis specific models are used in rehabilitation settings?
3. What are the common elements of these models and how do they relate to the Victorian rehabilitation services? 4. What principles of a rehabilitation model of care promote best outcome? Rehabilitation A set of measures that assist individuals who experience, or are likely to experience, disability to achieve and maintain optimal functioning in interaction with their environment(WHO) Care in which the clinical purpose or treatment goal is to improve the functional status of a patient with an impairment, activity limitation or participation restriction (Dept of Health Subacute Planning Framework) Prevention & reduction of functional loss, activity limitation, participation restriction arising from impairments, the management of disability physical, psychological and vocational dimensions and improvement of function (AFRM, 2011) Rehabilitation Optimise activity and enable participation in order for the individual to live the life they wish (Gutenbrunner, 2007) Rehabilitation Problem solving process (WHO, Wade, 2005, Wade 2005) Assessment Identify needs/modifiable factors Goal setting Measurement, planning & implementation of interventions Evaluation of change & effectiveness
Model of Care Overarching design for the provision of a particular type of health care service that is shaped by theoretical basis, evidence based practice and defined standards (Davidson et al, 2006) Multidimensional, based on evidence and patient and provider needs (Queensland Health, 2000) Standards/Guidelines Specialised dedicated rehabilitation in an environment adapted for rehabilitation (AFRM, 2011, CCPR, 2012, MIRC Taskforce, Turner-Stokes et al, 2000) Rehabilitation process: Preadmission Ax Ax Treatment Regular review Discharge planning
Community integration Follow up Multidisciplinary/interdisciplinary team Frequency and intensity of therapy: 5 days per week (AFRM, 2011, MIRC taskforce) 3 hours minimum (MIRC Taskforce) 3 hours for those with capacity or less as per need/capacity (AFRM, 2011) Staffing ratios (AFRM, 2011, Turner-Stokes 2000) Rehabilitation Models of Care Western Australia Amputee Services & Rehab Stroke Rehab & Restorative Care
Elective Joint Replacement NSW Rehabilitation MOC Victoria South Australia Cardiac Rehabilitation Others: Transport Accident Commission Heads of Workers Compensation Authorities Department of Veteran Affairs Victorian Paediatric Rehab Service MOC Principles Common Rehabilitation MOC Principles 8 7
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pe rm c an m ei pr o m ve t en MOC Pathways Included in Dept of Health models of care Identify patient journey Most preadmission to community NSW - ready for rehab to community
Rehabilitation MOC NSW Source: Rehabilitation Redesign Project Final Report, NSW Health, 2010 Rehab Models of Care International Literature Literature is limited & broad Support biopsychosocial approach Multidisciplinary or interdisciplinary (Gutenbrunner, 2007, BSRM, 2009, Scottish Dept of Health, 2007, Chicago Rehab Inst, 2012) Early rehabilitation Equity of access Client centred Service integration Evidence based Components of Stroke Models Stroke unit
greater focus in acute stroke management geographically discrete units comprehensive ax MD team approach clear communication within team/family/patient promote early mobilisation strong engagement with carers/families staffed by professionals with special interest in stroke Components of Stroke Models Selection of patients for rehabilitation Variable (Bettger, 2007, Bettger et al, 2012, Gagnon et al 2006, Kennedy et al, 2012, Ilett et al, 2010 Bettger et al (2007) found 96.2% of admissions being reported to the stroke registry were assessed for stroke rehab in the acute setting variability in decision process on discharge age, social supports, ambulation/mobility, prognosis common factors influencing decision making Components of Stroke Models Timing of intervention
Mobilisation as early as possible (Wright et al, 2012) Geographic location and collocation with acute impact early mobilisation Optimal timing is not definitive Cost effectiveness with early rehabilitation & reduced costs at 3 & 12 mths post (Tay-Teo et al, 2008) Dutch study of physios adherence to early mobilisation 71% claim adherence, patients received 50% of guidelines Components of Stroke Models Frequency & intensity of intervention Intensity of therapy as much as possible within 6 months post stroke (Otterman et al, 2012) Clinical expertise & resource capacity determines timing and intensity (Otterman et al, 2012) Dutch study on feasibility of multiple physical therapy sessions weekdays and weekend therapy found low feasibility. Barriers were patient health status, policy and funding Dose response relationship with physio, circuit training (Haines, 2011, English, 2007) Literature lacks definition of intensity & exact content of therapy, therefore maximal intensity for change is not documented (Quinn et al, 2009, Karges, 2009, Kelly, 2009) Components of Stroke Models Early supported discharge
Including follow up with mobile stroke specific team reduced LOS, no change in readmission or home based/community service costs (Fjaertoft et al, 2005, Anderson et al, 2000, Bryer et al, 2011) NICE guidelines recommend ESD offered to all who can indep transfer & same intensity skill mix as in hospital (NSF, 2010, NICE, 2011) Implementation across England reinforced the need for appropriate processes and systems to ensure safety and communication prior to discharge Interdisciplinary or multidisciplinary approach Reduce beddays, mortality rates and likelihood of institutionalisation & disability whilst enhancing recovery (Bryer et al 2011, Langhorne, 2001, Miller et al, 2010) Mapped stroke continuum with case manager to navigate the system MD approach effective independent of model (NSF, 2010, Pollack, 2002, Wissell, 2011) Components of Stroke Models Telemedicine Aid ESD in rural areas (Chumbler et al, 2010, Cherney, 2012, Lai et al, 2004, NHS, 2004) American Stroke Association must be a substitute for specialised face to face care Can provide specific stroke rehabilitation Further development required Components of ABI Models
Multidisciplinary rehabilitation (Khan, 2003, Halliday, 2008, BSRM, 2003, Turner- Stokes, 2003) Reaccess in all settings Access to community or outpatient rehabilitation Systematic review on efficacy of community rehab found ID team, support grps & telephone counselling to have strongest evidence Components of ABI Models Early rehabilitation post ABI associated with better outcomes Greater gains shown in patients admitted within 6 months Reduced LOS with early rehabilitation (within 1-2 months of injury) No specific guidelines of intensity as much as patient is capable of
(BSRM, 2003) Gains still made 12 months post, therefore opportunity to reengage important (High et al 2006) Neurotrauma clinics can provide avenue for co-ordination & continuity of care Components of SCI Models Specialised SCI rehabilitation service (Hammel, 2007, Kirschbaum et al, 2007, New, 2011) Common services are fragmented with gaps between settings or services across the continuum (Riis, 2007, Kendall, 2003, Scivoletto et al, 2006) Reduced inpatient LOS with transitional model combining inpatient and outpatient rehabilitation as a continuum of recovery (Riis, 2007, Kendall, 2003, Vivo, 2007, Suddick, 2009) Interdisciplinary team Care co-ordination across settings Varied evidence to support early intervention, not defined Components of Ortho/Musc
Models Home based rehabilitation (Mahomed et al, 2008) Timing of rehabilitation rather than setting was predictive of efficient rehabilitation (Tian et al, 2012) Early mobilisation (Nielsen et al, 2008, Oldmeadow, 2004) Pre operative intervention (Nielsen et al, 2008, Oldmeadow, 2004, Rooks et al, 2006) Therapy intensity is referred to in terms of inpatient rehabilitation, this and 7 day frequency is associated with reduced LOS, improved FIM and short term recovery ( KirkSanchez, 2001, Pua et al, 2011) Interdisciplinary team and pain management Components of Cardiopulmonary Models Alternative models to address low uptake of cardiac rehab Home based rehabilitation (Canyon, 2008, Wachtel, 2008, Grace et al, 2005, Scalvini et al, 2009)
Referral pathways and access Communication impacts referral and success of cardiac rehab Cardiac rehab occurrence rather than timing Multidisciplinary approach Comparison of hybrid model (outpatient, home based, telemonitored) and standard outpatient rehabilitation found comparable results in physical capacity (Korzeniowska-Kubacka et al, 2011) Factors in Effective Rehabilitation Acute or early rehabilitation ideal timing unclear from literature Stucki (2005) Poulos (2011) Early supported discharge cost effective without reduction in outcome
(Miller, 2005) Setting home based and interface between settings Therapy intensity associated with better outcomes however maximal amount and content are not detailed Poulos (2010) Cifu (2003) Factors in Effective Rehabilitation Interdisciplinary care Multi and inter often used interchangeably in the literature Integrated and co-ordinated care essential in providing interventions in complex biopsychosocial model Effectiveness of teams research still uses high level measures such as LOS and mortality Strasser (2005) Goal setting
Holliday (2005) found goals were set in individual disciplines & shared at team mtgs 60% of patients didnt receive any record of their goals Greater patient involvement Levack et al (2006) found inconsistent evidence that goal planning influenced patient adherence to therapy Strong evidence that prescribed, specific, challenging goals can improve immediate patient performance Liu (2005) found client centred approach of discussing goals achieved greater agreement Understanding of rehabilitation process Key points Principles common in rehabilitation MOC: Client centred care Interdisciplinary approach Evidence based care Goal directed intervention Equitable access Other elements important in rehab MOC:
Care co-ordination Service integration & continuity of care Early intervention Setting Key points What primarily enables MOC principles? Workforce Education & training Information & communication technology Infrastructure Relationships Emerging themes in the research What therapy intensity and frequency is optimal for best outcome? What is the optimal timing for commencing a rehabilitation model of care What setting is rehabilitation best provided and for who, including telemedicine
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