Outpatient spinal cord injury rehabilitation: managing costs and funding in a changing health care environment

Purpose. To examine the literature describing the cost of outpatient rehabilitation for patients with spinal cord injury (SCI) as well as the effect of funding type on cost and outcome. A SCI rehabilitation planning and funding model is presented that calls for structured assessment of the client's economic environment, with follow through to promote full access to funding for rehabilitation plans.

Method. Literature review of specific outpatient rehabilitation intervention costs and effect of funding type, followed by development of a funding model to improve access to available funding for SCI rehabilitation.

Results. There is insufficient economic data to draw conclusions about the relationship between an individual's rehabilitation needs and access to appropriate funding for outpatient rehabilitation. Consequently, health providers and payers need to adopt an approach that will improve consistency of payment decisions and access to necessary funding for rehabilitation.

Conclusions. A model for a more formal approach to: (a) Assessment of a client's economic environment; (b) use of evidence-based SCI rehabilitation; and (c) use of available financial resources should promote better access to appropriate rehabilitation following SCI.     

Predictors of assistive technology use: the importance of personal and psychosocial factors

Objective. To validate an assistive technology (AT) baseline and outcomes measure and to quantify the measure's value in determining the best match of consumer and AT considering consumer ratings of their subjective quality of life, mood, support from others, motivation for AT use, program/therapist reliance, and self-determination/self-esteem.

Design. Prospective multi-cohort study.

Setting. Vocational rehabilitation offices and community.

Participants. Over 150 vocational rehabilitation counselors in 25 U.S. states with one consumer each receiving new AT.

Interventions. Counselor training in the Matching Person and Technology (MPT) Model and consumer completion of the MPT measure, Assistive Technology Device Predisposition Assessment (ATD PA).

Main outcome measures. Total and subscale scores on the ATD PA as well as counselor-completed questionnaires.

Results. ATD PA items differentiated consumer predispositions to AT use as well as AT and user match. There were no significant differences due to gender, physical locality, or age within this sample of working-age adult consumers. Vocational rehabilitation counselors exposed to training in the MPT Model achieved enhanced AT service delivery outcomes.

Conclusions. The ATD PA is a valid measure of predisposition to use an AT and the subsequent match of AT and user. Rehabilitation practitioners who use the ATD PA will achieve evidence-based practice and can expect to see enhanced AT service delivery outcomes.     

Rates of access to assistive equipment and medical rehabilitation services among people with disabilities

Purpose: To determine rates of access to assistive equipment and medical rehabilitation services among people with disabilities in the US, and to determine whether health plan type is associated with rates of access to these health services.

Methods: Results were derived from a nationwide US survey sample of people with cerebral palsy, multiple sclerosis or spinal cord injury. Analyses were restricted to working-age adults ( n =500). Need for, and receipt of (1) assistive equipment in the last 12 months, and (2) rehabilitative services in the last 3 months, was determined.

Results: Over half of the sample indicated a need for assistive equipment in the last 12 months. Nearly a third of those who indicated a need did not receive assistive equipment every time it was needed. Forty per cent of the sample indicated a need for rehabilitative services in the last 3 months, and over half of those indicating a need did not receive rehabilitative services every time they were needed. Access rates did not differ appreciably between respondents covered by managed care and fee-for-service health plans.

Conclusion: Emphasis in healthcare for people with disabilities should shift from traditional acute healthcare models that focus on functional restoration, to preventive services, and maintenance of function, health and independence.     

Rural access to vocational rehabilitation services: Minority farmers' perspective

Purpose. The paper documents the need for, and obstacles to effective access to rehabilitation services by minority farmers. It draws from the findings of a study * conducted in the Mississippi delta.

Method. Applying community-based participatory research approach (CBPR) the study trained farmers to conduct interviews and focus group discussions. They interviewed 1308 farmers and had 18 focus group discussions with 254 farmers. The study also interviewed 290 service providers and conducted 8 focus group discussions with 72 State Vocational Rehabilitation services (VR) counselors.

Results. The study found an unmet need for VR services in this population. Farmers were not aware of VR services or how to access them and VR was not aware of farmers' needs. Farmers felt marginalized and afraid that access to VR services would diminish their ability to earn a living on the farm.

Conclusions. Collaboration between VR and rural organizations, agencies and with rural people would help close the information and gaping service gap. One-stop service centers in rural areas could improve access to services. CBPR is an invaluable research tool especially among marginalized people.     

An introduction to the Korean Employment Promotion Agency for the Disabled

Purpose. The main aim of this article is to provide an introduction to the Korean Employment Promotion Agency for the Disabled (KEPAD), and to provide comparative thought regarding government-based vocational rehabilitation service delivery between South Korea and the USA.

Method. Relevant literature is considered, and current issues and comparative discussion in practice are highlighted.

Results. Introductory information in terms of organization, eligibility, services and programmes are presented. In addition, practical problems associated with the KEPAD system and a cross-cultural analysis is elaborated, comparing the USA and South Korean vocational rehabilitation systems.

Conclusion. KEPAD has successfully derived public support and acknowledgement of its national responsibility in ensuring vocational rehabilitation services for persons with disabilities. The KEPAD system demonstrates a unique approach in implementing vocational rehabilitation services by providing various benefits for both employers and persons with disabilities. However, considerable cautiousness in terms of cross-cultural analyses is required for international application. Furthermore, successive research of rehabilitation infrastructure is warranted.     

Medical rehabilitation in Ghana

Purpose. To explore the current system of medical rehabilitation services for persons with disabilities in a developing country (Ghana) and to identify future needs, opportunities, and barriers.

Methods. Information was obtained through a literature review and through interviews with healthcare providers, disabled people's organizations, educators, government officials, and consumers. Direct observations were made of Ghana's capital city, Accra, and of a major tertiary medical center there, Korle Bu Teaching Hospital.

Results. Ghana has virtually no medical rehabilitation and few laws to protect the disabled. There are no occupational therapists or physiatrists in the entire country, and only a handful of physical therapists, prosthetists, orthotists, and speech therapists. There are many barriers to the establishment of such services, including lack of funding, limited government support, cultural stigma of the disabled and poor utilization of existing resources.

Conclusions. A national model for sustainable medical rehabilitation is needed in Ghana and likely in other similar countries.     

How well are we doing? Families of adolescents or young adults with cerebral palsy share their perceptions of service delivery

Purpose : The satisfaction of families of adolescents and young adults with a diagnosis of cerebral palsy with the service delivery they had experienced in the areas of health, education, recreation, employment, housing and transportation was examined. Common themes across the six service areas were identified.

Method : Forty-nine adolescents (13-15 years) and 39 young adults (19-23 years) and their families rated their satisfaction with services and then participated in semi-structured interviews to discuss their experiences.

Results : Using a constant comparative method of analysis, common themes were identified from the transcribed interviews. Four themes were identified and named: caring and supportive people; fighting and fatigue; communication/information; and disability awareness.

Conclusions : Families continue to experience dissatisfaction and frustration with service delivery in the six areas examined. Both bureaucratic structure and attitudes of service providers contribute to their dissatisfaction.     

Care and compassion: Part of person-centred rehabilitation, inappropriate response or a forgotten art?

Aims of the paper. The nature of healthcare, rehabilitation and indeed even professional practice and discipline roles seems to constantly change. In particular, whilst 'care' has an accepted place in much of health service delivery, there is considerable debate about whether the concept has a place in modern rehabilitation. This paper sets out to review the concept and pose questions about the nature of caring in rehabilitation.

Key findings and implications. In order to highlight different potential understandings, this paper reviews the origins of healthcare traditions and care. We explore ethical humanistic and political aspects of caring and investigate what facilitates and obstructs adequate care. Finally we examine what the risks of caring (or not caring) are for both health professionals and their clients.

Conclusions and recommendations. Whilst the arguments presented here suggest there is value in caring, there are very limited studies that explicitly examine its nature or indeed value, particularly in rehabilitation. As a result, the potential difference in both the experience of, and outcome, from rehabilitation in relation to the nature of care is yet to be clearly established.     

Some ethical issues in community-based rehabilitation initiatives in developing countries

Purpose : This commentary provides both theoretical and practical insights into the concept of community-based rehabilitation (CBR) and its application in developing countries. In doing so it explores current practices in CBR and the debate surrounding them, namely the ethical question and how this may impact on future CBR. The main argument in this account is that disability is a development issue; with widespread poverty, inequality and violation of human rights, and should be addressed within the broader context of community development which may include strategies such as CBR.

Method : A review and analysis of recent literature on CBR has been conducted including the review of a number of empirical research documents from various CBR initiatives in developing countries.

Results : CBR has increasingly been under scrutiny in terms of the extent to which these have succeeded in delivering rehabilitation services to those in need in the community as well as the permitted level of participation and control of disabled people over the rehabilitation process. Many programmes have been unsustainable and it has been difficult to evaluate their full usefulness to disabled people. These issues raise an ethical question about CBR being an appropriate strategy for the rehabilitation of people with impairments in developing countries.

Conclusion : This background emphasizes that new directions in CBR need to be put in place in order to maximize the realization of the ultimate goal: the greatest participation for disabled people in all spheres of life. Effective rehabilitation programmes should allow people with disability to have greater control in the nature of their rehabilitation and that the role of professionals and other stakeholders is one of allies and resources in the rehabilitation process. Moreover, the participation of community members in the rehabilitation policy should be assured.     

Care and services for spinal injured people with,and without,neurological deficit

Purpose : To describe the care and service usage characteristics of the spinal injured (SI) population of New South Wales (NSW), Australia, including people without significant permanent neurological deficits.

Method : A cross-sectional mailed survey was undertaken with all persons admitted to the two spinal injury hospital units in NSW following traumatic spinal injury in the period 1977 - 1992 who were not known to be deceased ( n =2432). Response was gained from 75.8% of the 932 persons whose address was able to be confirmed ( n =706).

Results : SI persons were primarily males who incurred a motor related trauma at a young age. Over one third had minimal or no permanent neurological impairment. Over half of the respondents received assistance with everyday living (59.5%), including older persons with minimal or no motor or sensory problems, and a large number made use of professional services (40.5%). People with lower-level incomplete lesions were more likely to use paramedical services than some groups of people with quadriplegia.

Conclusions : The relatively high use of care and paramedical services by some persons with minimal physical functional limitations indicates the importance of including such persons when considering the provision of long-term care and rehabilitation services for people with spinal injury.     

Strategies for autonomy used by people with cervical spinal cord injury: a qualitative study

Purpose. To identify strategies used by people with high cervical spinal cord injury (SCI) to function autonomously. A multidimensional concept of autonomy was used, with four dimensions: independence, self-determination, participation and identification.

Methods. Qualitative methods were used, involving literature study and semi-structured interviews with eight individuals with high SCI who had been discharged from the rehabilitation centre for several years and were members of a sports club.

Results. Strategies for independence included making independent functioning a personal challenge and learning from others with SCI. Strategies for self-determination included keeping oneself informed, setting personal goals and being assertive. Strategies for participation were making challenges out of barriers, planning and organizing, asking and accepting help, and dealing with reactions from others. Strategies for identification involved taking life as it comes and focussing on positive aspects of life.

Conclusions. Different strategies are necessary for different dimensions of autonomy. Some strategies seem contradictory in terms of their effects on different dimensions of autonomy. Patients can be made aware of strategies for autonomy during the rehabilitation phase.     

What promotes physical activity after spinal cord injury? An interview study from a patient perspective

Purpose. Physical activity in people with traumatic spinal cord injury (SCI) is of importance not only for maintaining health but also for increasing the possibilities of living an independent life. Physical inactivity leads to poorer muscular and cardiovascular conditioning and sub-optimal levels of functioning. To help people with SCI to achieve optimum physical activity, it is important to understand what promotes the incorporation of regular physical activity into daily life. The aim of this study was thus to identify factors that may promote participation in physical activity among people with spinal cord injuries.

Method. Qualitative multiple case studies. Sixteen participants with SCI were interviewed.

Result. Four main themes of promoting factors could be identified. They were: using cognitive and behavioural strategies; finding supporting environmental solutions; exploring motivation post injury; and capturing new frames of reference.

Conclusion. By utilising the motivational power of role models, together with the other motivational factors identified in this study, such as identifying relevant individual motives post injury and capturing new frames of reference, the process towards physical active life may be facilitated.     

Changing philosophical perspectives on the management of children with physical disabilities--their effect on the use of powered mobility

Purpose : Over the past decade, the emergence of a new philosophical framework has influenced approaches to service delivery in paediatric rehabilitation. Traditional approaches focused on the attainment of typical movement patterns as the ultimate goal of intervention. By contrast, contemporary approaches to intervention encourage children with physical disabilities to use their most efficient movement strategies to explore their environment and participate in meaningful activities.

Methods/Results : Factors that facilitated this change in approaches to intervention are explored and include: the disability movement; the evolution of models of disablement; the shift from a medical model to a family-centred model of health care service provision; the emergence of a new theory to explain motor development and increased availability and quality of assistive technology.

Conclusion : The clinical implications of this philosophical shift for the use of powered mobility with children with physical disabilities are explored. A collaborative approach to working with families throughout the process of selecting mobility options for their children is discussed.     

The impact of Internet access for people with spinal cord injuries: a descriptive analysis of a pilot study

Purpose : A pilot study was undertaken regarding the effect of Internet access on health-related quality of life (HRQoL) and self-reported impact for people with spinal cord injuries (SCI). This study is unique in providing free Internet access and looking at benefits for people with disabilities.

Method : HRQoL was measured using indicators of global health and social isolation at baseline and after 6 to 19 months of use via telephone interviews on a convenience sample of 23 adults with SCI. Additionally, monthly telephone surveys measured usage patterns, recreation, and self-reported impact. Both quantitative and qualitative analyses were conducted. Bivariate tests for differences in proportions and paired T-tests were conducted. Qualitatively, conceptual categories of impact were created using the Constant Comparative Method.

Results : Qualitatively, the predominant benefit was quality of life, mentioned by 61% of participants 46% of months surveyed, with quantitative trends towards improved emotional health. Ease of access to information, social connection, and quality of information were also frequently reported, with modest support from quantitative data.

Conclusions : The study's persuasive qualitative results suggest the Internet has particular benefit to people with disabilities and that rehabilitation goals should include leisure. Further scientific research is strongly warranted.     

Impact of injury level and self-monitoring on free time boredom of people with spinal cord injury

Purpose: The purpose of this study was to determine whether or not level of injury and personality characteristics creates an interaction effect that impacts the free time boredom of individuals with spinal cord injury (SCI).

Method: Using a survey method, a packet containing a cover letter, a consent form, research questionnaires, and a self-addressed, stamped envelope was sent to 500 individuals with SCI who were randomly selected by computer at one of the rehabilitation centres in USA. The research questionnaires included the measures of self-monitoring (SM) and free time boredom (FTB) along with some demographic factors such as gender, ethnicity, age, injury level, and etc.

Results: This study found that a significant interaction effect between injury level and SM on FTB. That is, low self-monitors with tetraplegia reported higher levels of boredom in free time than high self-monitors with paraplegia.

Conclusion: Not all individuals with similar injury levels rate FTB in a similar degree. Individuals' personality characteristics play an important role in experiencing FTB. In particular, the significant interaction effect indicates a potential risk factor for clients with tetraplegia who are low in SM which should be an important consideration in the lives of people with tetraplegia following rehabilitation.     

Politics, policy and payment-facilitators or barriers to person-centred rehabilitation?

Aims. This paper explores the tensions between politics and payment in providing affordable services that satisfy the public demand for patient-centred care.

Key findings and implications. The two main approaches taken by the UK Government to curtail the spiralling costs of healthcare have been to focus development in priority areas and to cap spending through the introduction of a fixed-tariff episode-based funding system. The National Service Framework for Long Term Neurological Conditions embraces many laudable principles of person-centred management, but the 'one-size-fits all' approach to reimbursement potentially cuts right across these. A series of tools have been developed to determine complexity of rehabilitation needs that will support the development of banded tariffs. A practical approach is also offered to demonstrate the cost-efficiency of rehabilitation services for people with complex needs, and help to ensure that they are not excluded from treatment because of their higher treatment costs.

Conclusions. Whilst responding to public demand for person-centred care, we must recognize the current financial pressure on healthcare systems. Clinicians will have greater credibility if they routinely collect and share outcomes that demonstrate the economic benefits of intervention, as well the impact on health, function and quality of life.