Post-acute Settings Research Articles

ICF Core Set for patients with musculoskeletal conditions in early post-acute rehabilitation facilities

Purpose: The aim of this consensus process was to decide on a first version of the ICF Core Set for patients with musculoskeletal conditions in early post-acute rehabilitation facilities.Methods: The ICF Core Set development involved a formal decision-making and consensus process integrating evidence gathered from preliminary studies including focus groups of health professionals, a systematic review of the literature and empiric data collection from patients.Results: Fifteen experts selected a total of 70 second-level categories. The largest number of categories was selected from the ICF component Body Functions (23 categories or 33%). Seven (10%) of the categories were selected from the component Body Structures, 22 (31%) from the component Activities and Participation, and 18 (26%) from the component Environmental Factors.Conclusion: The Post-acute ICF Core Set for patients with musculoskeletal conditions is a clinical framework to comprehensively assess patients in early post-acute rehabilitation facilities, particularly in an interdisciplinary setting. This first ICF Core Set will be further tested through empiric studies in German-speaking countries and internationally.

Validation of a new measure for post-acute rehabilitation

This study aimed to develop and validate a brain injury outcome measure with sufficient discriminatory power for use in a post-acute rehabilitation setting. A 56-item questionnaire – the Postacute Rehabilitation Measure (PARM) – covering disability and participation restriction was validated against the Functional Independence Measure and Functional Assessment Measure (FIM+FAM) using both carers and the rehabilitation team as respondents. Participants were 67 patients with acquired brain injury from 12 post-acute rehabilitation facilities. PARM showed a lower mean score than FIM+FAM on all sections except emotions. Correlations between sections of PARM and FIM+FAM ranged 0.63–0.89. Test–retest reliability ranged 0.84–0.97. Inter-rater reliability (carer vs team) was more variable. PARM is therefore a reliable and valid measure for post-acute outpatient rehabilitation that has the advantage of being completed by either the carer or the team. It shows fewer ceiling effects than FIM+FAM in this population.

Development of an applied cognition scale to measure rehabilitation outcomes

Coster WJ, Haley SM, Ludlow LH, Andres PL, Ni PS. Development of an applied cognition scale to measure rehabilitation outcomes. Objective To examine the structure and content coverage of an item pool of new items based on the Activity categories from the International Classification of Functioning, Disability and Health and items from existing instruments to measure the applied cognition dimension of function. Design Prospective study. Setting Four postacute care rehabilitation settings (inpatient, transitional care, home care, outpatient) in an urban-suburban area of northeast United States. Participants Convenience sample of 477 patients (mean age, 62.7y) receiving rehabilitation services for neurologic, orthopedic, or complex medical conditions. Interventions Not applicable. Main outcome measures Participants were administered applied cognition items from the new Activity Measure for Post-Acute Care, the Medical Outcomes Study 8-Item Short-Form Health Survey, and an additional setting-specific measure: the FIM instrument (inpatient rehabilitation); the Minimum Data Set (skilled nursing facility); the Minimum Data Set–Post Acute Care (postacute settings); or the Outcome Assessment and Information Set (home care). Rasch (partial-credit model) analyses were conducted to examine item fit, item coverage, scale unidimensionality, and category difficulty estimates. Results The majority of items (46/59) could be located along a single continuum. Relatively few people were performing at the lower end of the difficulty scale, and about 25% were at ceiling. Conclusions The proposed definition of applied cognition dimension provides a useful guide for item development to measure this dimension. Further work is needed to determine how best to measure function in this domain for people at the upper and lower ends of the continuum.

Characteristics associated with delirium persistence among newly admitted post-acute facility patients.

Delirium is costly, common, and may persist for weeks or months. Therefore, the adverse impact of delirium on loss of independence may occur in the post-acute setting rather than in the hospital. The purpose of this study is to describe the rate of delirium persistence and identify baseline patient characteristics that are associated with delirium persistence at 1 month among newly admitted post-acute facility patients who were admitted with delirium. Patients were recruited from 4 Boston area skilled nursing facilities specializing in post-acute care (PAC). Assessment instruments included the Confusion Assessment Method Diagnostic Algorithm, the modified Delirium Symptom Interview, the Memorial Delirium Assessment Scale (MDAS), and the Blessed Dementia Rating Scale (BDRS). Multiple logistic regression analyses were used to identify patient characteristics associated with delirium persistence (at 1 month). Nearly 51% of the 85 delirious patients enrolled in this study had delirium at their 1-month follow-up assessment. Four patient factors associated with delirium persistence were identified: older age (> or =85 years), severe delirium at PAC admission (MDAS score >15), prehospital cognitive impairment based on proxy report [BDRS], and the presence of all 8 modified Delirium Symptom Interview symptoms at PAC admission. Our model has very good predictive power (area under the receiver operating characteristic = 0.85). Delirium is persistent in the post-acute setting. If verified in further research, the risk factors found in this study could be used to identify patients who are likely to have delirium after 1 month, and may prove useful in developing and targeting interventions of care.

Refining the conceptual basis for rehabilitation outcome measurement: personal care and instrumental activities domain.

Rehabilitation outcome measures routinely include content on performance of daily activities; however, the conceptual basis for item selection is rarely specified. These instruments differ significantly in format, number, and specificity of daily activity items and in the measurement dimensions and type of scale used to specify levels of performance. We propose that a requirement for upper limb and hand skills underlies many activities of daily living (ADL) and instrumental activities of daily living (IADL) items in current instruments, and that items selected based on this definition can be placed along a single functional continuum. To examine the dimensional structure and content coverage of a Personal Care and Instrumental Activities item set and to examine the comparability of items from existing instruments and a set of new items as measures of this domain. Participants (N = 477) from 3 different disability groups and 4 settings representing the continuum of postacute rehabilitation care were administered the newly developed Activity Measure for Post-Acute Care (AM-PAC), the SF-8, and an additional setting-specific measure: FIM (in-patient rehabilitation); MDS (skilled nursing facility); MDS-PAC (postacute settings); OASIS (home care); or PF-10 (outpatient clinic). Rasch (partial-credit model) analyses were conducted on a set of 62 items covering the Personal Care and Instrumental domain to examine item fit, item functioning, and category difficulty estimates and unidimensionality. After removing 6 misfitting items, the remaining 56 items fit acceptably along the hypothesized continuum. Analyses yielded different difficulty estimates for the maximum score (eg, "Independent performance") for items with comparable content from different instruments. Items showed little differential item functioning across age, diagnosis, or severity groups, and 92% of the participants fit the model. ADL and IADL items from existing rehabilitation outcomes instruments that depend on skilled upper limb and hand use can be located along a single continuum, along with the new personal care and instrumental items of the AM-PAC addressing gaps in content. Results support the validity of the proposed definition of the Personal Care and Instrumental Activities dimension of function as a guide for future development of rehabilitation outcome instruments, such as linked, setting-specific short forms and computerized adaptive testing approaches.

Delirium among newly admitted postacute facility patients: prevalence, symptoms, and severity.

Delirium may persist for weeks or months, and discharging elderly patients quickly from acute care facilities is not uncommon. Therefore, the adverse impact of delirium on loss of independence may occur in the postacute setting rather than in the hospital. The purpose of this study is to describe the prevalence of delirium, delirium symptoms, and severity assessed at admission to postacute facilities. Subjects were recruited from seven Boston-area skilled nursing facilities specializing in postacute care. Assessment instruments included the Mini-Mental Status Exam, Delirium Symptom Interview, Memorial Delirium Assessment Scale, and Confusion Assessment Method (CAM) Diagnostic Algorithm. Delirium status was categorized into four groups: full, two or more symptoms, one symptom, and no delirium. Descriptive statistics were calculated and chi-square analyses and an analysis-of-variance were used to examine delirium characteristics by delirium group. Among 2158 subjects, approximately 16% had full CAM-defined delirium at admission to the postacute facility. In addition, nearly 13% of the subjects had two or more symptoms of delirium, approximately 40% had one delirium symptom, and 32% had no symptoms of delirium. In a comparison of the group with no symptoms of delirium with that with CAM-defined delirium, there was a significant trend toward (a) older age, (b) lower scores on the Mini-Mental Status Exam, (c) more Delirium Symptom Interview symptoms, and (d) higher Memorial Delirium Assessment Scale Scores. Results indicate that 16% of admissions to postacute facilities have CAM-defined delirium, and over two thirds had at least one delirium symptom. It is not known whether or not postacute staff have the training necessary to detect or manage delirium. Managing delirium may require different strategies and techniques in a postacute setting, thereby requiring further research.

Relationship Between Acute Care Hospital-Based Factors and Discharge Destination for Rehabilitation Following a Hip Fracture

ABSTRACTHospitals may transfer seniors with a hip fracture to various rehabilitation settings. Knowing the relationship between hospital teaching status and post-acute rehabilitation setting may help evaluations of the transfer from acute care. The purpose of this study was to determine the relationship between hospital teaching status and rehabilitation destination following acute care in seniors with a hip fracture. Hospital separations were linked with home care records to identify hip fractures and hospital-based or home care rehabilitation (n = 806). Two logistic regression models determined the likelihood of transfer to any rehabilitation destination and to hospital-based versus home care rehabilitation. Teaching hospitals were no more likely than non-teaching hospitals to discharge patients to any rehabilitation (OR 1.20, 95% CI 0.88,1.65). However, among those referred to rehabilitation, the odds of discharge to hospital-based versus home care rehabilitation were almost four times greater for patients in teaching hospitals (OR 3.76, 95% CI 2.23, 6.37). The results are consistent with the availability of post-acute rehabilitation in the planning area. Future study of post-acute rehabilitation outcomes should consider hospital teaching status as an indicator of how hospital-based factors may affect the utilization of post-acute rehabilitation.

Variability of viral load in plasma of rhesus monkeys inoculated with simian immunodeficiency virus or simian-human immunodeficiency virus: implications for using nonhuman primate AIDS models to test vaccines and therapeutics.

Viral RNA level in plasma is a sensitive experimental endpoint for evaluating the efficacy of AIDS vaccines or therapies in nonhuman primates. By quantifying viral RNA in the plasma of 77 rhesus monkeys for 10 weeks after inoculation with simian-human immunodeficiency virus 89.6P (SHIV-89.6P) or simian immunodeficiency virus mac 251 (SIVmac 251), we estimated variability in three viral load (VL) measures: peak VL, the postacute set point VL, and VL decline from peak. Such estimates of biological variability are essential for determining the number of animals needed per group and may be helpful for selecting the most appropriate measure to use as the experimental endpoint. Peak VL was positively correlated with set point VL for both viruses. Variability (standard deviation) was substantially higher in monkeys infected with SIVmac 251 than in those infected with SHIV-89.6P for set point VL and VL decline. The variability of peak VL was less than one-half that of set point VL variability and only about two-thirds of that of VL decline, implying that the same treatment-related difference in peak VL could be detected with fewer animals than set point VL or VL decline. Thus, differences in VL variability over the course of infection and between viruses need to be considered when designing studies using the nonhuman primate AIDS models.

Noninvasive Mechanical Ventilation for Post Acute Care

The increasing use of NPPV in both acute and chronic settings has added to ventilator options in the post acute setting. Some patients start NPPV during their acute presentation and continue use during their post acute stay. Others are difficult to wean from invasive mechanical ventilation, and, if selected carefully, can be extubated and weaned using NPPV. Still others may initiate NPPV in the post acute setting with the anticipation of long-term use. In any care settings, principles of patient selection and management in monitoring practices overlap considerably. Noninvasive ventilation has been shown to reduce morbidity, mortality, and hospital stay in the acute setting for selected patients, and almost certainly prolongs survival for patients with restrictive thoracic disorders in the chronic setting. Although efficacy studies have not been performed in the post acute setting, it is reasonable to anticipate that appropriate use of NPPV will yield similar benefits. Accordingly, clinicians working in the post acute setting must acquire skill and experience in the proper application of NPPV to optimally manage the increasing number of patients treated with NPPV in this expanding arena.

Stroke care: a method for measuring compliance with AHCPR guidelines.

The purpose of this article is to describe a method for converting practice guidelines to measurement criteria. To evaluate the processes of care received by patients with stroke at 11 Veteran's Administration hospital sites, we developed a measurement system based on Agency for Health Care Policy and Research (AHCPR) Post-Stroke Rehabilitation Clinical Practice Guidelines. Guideline recommendations were used as the framework for identifying important dimensions of care, and for developing chart abstraction instruments for both the acute and postacute settings. Using a modified Delphi technique to solicit opinions from an expert panel, a method was developed for aggregation of item-level chart abstraction components to overall guideline compliance scores. The measurement system was shown to have good-to-excellent intrarater and interrater reliability at the item, dimension, and overall compliance score levels. Abstraction of a sample of 100 medical records demonstrated the ability of the instruments to detect variability in processes of post-stroke care. This study provides the foundation for future research, which will evaluate associations between processes of post-stroke care, as measured by this medical chart abstraction system, and patient outcomes. (All abstraction instruments, criteria, and scoring algorithms described in this article are available for download at http://www2.kumc.edu/coa.)

Patterns of rehabilitation utilization after hip fracture in acute hospitals and skilled nursing facilities.

Hospitalized hip fracture patients may receive physical therapy (PT) in acute and/or postacute settings. Patterns of PT use may vary by patient, clinical, and hospital characteristics. These patterns can be analyzed if the acute and postacute stays are linked. We classified the following patterns of PT use: acute PT only, skilled nursing facility (SNF) PT only, acute and SNF PT, and no PT. For each pattern, we compared (1) characteristics of hip fracture patients, (2) length of stay (LOS), and (3) discharge outcomes. The study included 187,990 hospitalized hip fracture patients derived from Medicare administrative data. Dependent variables were PT use patterns, acute hospital and SNF LOS, total episode days of care, and discharge destination. Independent variables were demographic, clinical, and facility characteristics. PT use patterns were also used as independent variables in the LOS and discharge destination models. Patterns of PT use were influenced by demographic and clinical characteristics such as age, race, and surgery type. Similarly, different LOS measures and discharge destinations varied by the PT use patterns. Patients receiving acute PT had longer acute LOSs; however, those patients who were subsequently transferred to SNFs had shorter SNF LOSs and total episode days of care. Patients utilizing PT were more likely to be discharged to home after the acute or SNF stay. Disparities in PT use exist for subgroups of patients such as the elderly and blacks. Providers should determine the most appropriate setting for initiation of PT to achieve better discharge outcomes with efficient use of resources.

Treatment of maladaptive behavior in acquired brain injury: Remedial approaches in postacute settings

This article describes remedial behavior therapy approaches for the treatment of maladaptive behavioral sequelae to an acquired brain injury (ABI). Remedial approaches are sophisticated and nonintrusive treatment strategies that involve teaching the individual skills or capacities to manage difficult life circumstances. Functional equivalence is one major category of remedial intervention and involves the determination of the behavioral function of the problem behavior and the teaching of an adaptive alternative response or skill cluster that provides the individual with efficient access to that function. Errorless remediation is a second category and entails teaching the individual to tolerate situations associated with problem behavior through hierarchical exposure to increasingly difficult conditions and reinforcement for successful management of those conditions.

Predictive validity of the Neurobehavioural Cognitive Status Examination (NCSE) in a post-acute rehabilitation setting

Within the context of a post-acute rehabilitation setting, association and agreement between results from the Neurobehavioural Cognitive Status Examination (NCSE) and from the neuropsychological (NP) evaluation are examined. All participants (n = 48) had sustained a severe traumatic brain injury and NCSE testing preceded NP testing by an average of 1 month. A significant relationship and fair classification agreement (i.e. presence or absence of cognitive impairment) was found between the overall results from NCSE and NP evaluation. Significant relationships were also observed between most NCSE subtests and paired NP tests thought to be assessing the same cognitive domains. However, the classification agreement (i.e. the presence or absence of deficient performance) between most NCSE subtests and paired NP tests was poor. The findings are discussed from the standpoint of individual treatment planning.

Self-awareness of traumatically brain injured patients in the acute inpatient rehabilitation setting

The self-awareness of brain injured patients in an acute inpatient rehabilitation programme was measured using the Functional Self-Appraisal Scale (FSAS), which compares patient and staff ratings of patient performance on tasks relevant for acute rehabilitation and in a format that is easy to administer. There was a significant difference between patients' and staff's ratings near admission, consistent with previous findings in post-acute settings that brain injured patients tend to overestimate their abilities relative to other raters. Patient and staff ratings tended to converge at time of discharge, likely reflecting patients' improvements on rehabilitation tasks rather than increased self-awareness. The average difference between patients' and staff's ratings did not correlate with neuropsychological functioning on admission, supporting evidence that self-awareness early in the recovery process is a unique construct. Future research is outlined, including investigating the relationship of early levels of self-awareness following TBI to functional outcome.

Outcome Measures for Use with Home Care Clients

RÉSUMÉAvant les années 1990, la plupart des recherches portant sur l'évaluation des résultats des programmes de soins à domicile, notamment sur les efforts pour retarder le placement, maintenir le fonctionnement et assurer l'autonomie des aîné(e)s, ne reposaient pas sur des fondements théoriques. Les résultats attendus des programmes étaient rarement mentionnés. L'élaboration de nouvelles politiques exige maintenant une évaluation complète des besoins et une agrégation des données recueillies. Depuis qu'un nombre croissant de patients quittent l'hôpital avec des problèmes cliniques complexes et que les objectifs de réhabilitation deviennent plus étendus, on assiste à une explosion des services de soins à domicile. Les modèles de soins sociaux, bien que toujours en cours, ne constituent désormais qu'une mince part du marché des soins offerts à domicile. Dans cet environnement en mutation, la pertinence des programmes de soins dans les établissements ou des autres soins dispensés suite à une maladie grave soulève de nouvelles interrogations. On s'interroge également sur les déplacements des clients entre les diverses installations de soins suite à des maladies graves. Cet article décrit un ensemble de mesures fonctionnelles, comportementales et sociales proposées en lien avec l'évaluation des effets des programmes de soins faisant suite à une longue maladie. L'instrument normalisé de collecte de données utilisé est le Resident Assessment Instrument for Home Care (RAI-HC). L'article présente un résumé des mesures proposées et témoigne de la validité de groupes identifiés à partir d'un échantillon national des clients de soins à domicile. Les données soulignent les différentes caractéristiques des clients entre les organismes et attestent que le RAI-HC permet de recueillir des données fiables et valides pour décrire les populations et évaluer l'efficacité des programmes.

Group psychotherapy for persons with traumatic brain injury: management of frustration and substance abuse.

Residual emotional and behavioral difficulties in individuals who have sustained a traumatic brain injury (TBI) have been well documented in the literature. The issues are complex, interdependent, and often include substance abuse, depression, anxiety, chronic suicidal or homicidal ideation, poor impulse control, and significant degrees of frustration and anger. Often, preexisting psychological conditions and poor coping strategies are exacerbated by the trauma. Emotional and behavioral difficulties can interfere with the neurorehabilitation process at all levels. In acute rehabilitation, these issues have traditionally been addressed on an individual basis. However, in postacute settings, an interpersonal group format can be effectively implemented. The majority of individuals with TBI have minimal funding for long-term cognitive and behavioral remediation; often the only avenue available is support groups. This article will describe group psychotherapy models used with individuals with acute or postacute TBI within a comprehensive rehabilitation center. Interdisciplinary treatment of frustration and substance abuse and a continuum of care will be emphasized. Education, social support, skills development, interpersonal process, and cognitive-behavioral approaches will also be discussed. The psychotherapy groups focus on treatment of substance abuse and frustration management through education, social support, and development of interpersonal skills. Practical considerations of running such groups are presented.

The PPVT‐R: Validity as a quick screen of intelligence in a postacute rehabilitation setting for brain‐injured adults

The PPVT‐R: Validity as a quick screen of intelligence in a postacute rehabilitation setting for brain‐injured adults

The extent of early viral replication is a critical determinant of the natural history of simian immunodeficiency virus infection.

Different patterns of viral replication correlate with the natural history of disease progression in humans and macaques infected with human immunodeficiency virus type 1 (HIV-1) and simian immunodeficiency virus (SIV), respectively. However, the viral and host factors influencing these patterns of viral replication in vivo are poorly understood. We intensively studied viral replication in macaques receiving identical inocula of SIV. Marked differences in viral replication patterns were apparent within the first week following inoculation, a time prior to the development of measurable specific immune effector responses to viral antigens. Plasma viral RNA levels measured on day 7 postinoculation correlated with levels measured in the postacute phase of infection. Differences in the susceptibility of host cells from different animals to in vitro SIV infection correlated with the permissiveness of the animals for early in vivo viral replication and hence with the postacute set point level of plasma viremia. These results suggest that host factors that exert their effects prior to full development of specific immune responses are critical in establishing the in vivo viral replication pattern and associated clinical course in subjects infected with SIV and, by extension, with HIV-1.