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.     

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.     

Lucy Montoro Rehabilitation Network mobile unit: an alternative public healthcare policy

Purpose: The aim is to analyze rehabilitation services provided by a mobile rehabilitation clinic (MU) in nine regions of the State of São Paulo, demonstrating the distribution of orthoses, prostheses and other mobility aids for persons with physical disabilities according to age groups and impairments, as well as the number of persons with physical disabilities as estimated by Brazilian official data sources. Method: The number of persons with disabilities in each region was obtained through estimations from the 2010 Brazilian IBGE Census. The number of assistive technologies suppliers and technicians were provided by the Brazilian Technical Orthopedics Association (ABOTEC). Patients were referred to the MU by Regional Health Departments. After examination of a multidisciplinary team, assistive devices are prescribed and delivered according to patients' needs. Data on patients were also assessed according to questionnaires on their age, diagnosis, gender, marital status and education level. Results: From 2009 to 2011, the MU went through 15?000 km providing rehabilitation services through the Public Health System to 1801 patients. Additionally, 3328 devices were delivered in this period. Different age, diagnosis, gender, marital status and schooling profiles are highlighted in each of the analyzed regions. Conclusion: Data on patients' profiles were made available through services provided by the MU – including the average index of 1.85 devices delivered to each patient and demand projections – which can be used in the planning of public policies. The MU made rehabilitation services more accessible, trained professionals, raised awareness on the correct delivery and use of assistive devices, and identified and organized people's demand in each region.

• Implications for Rehabilitation

• Delivering prostheses, orthoses and other mobility aids fulfills the rights of persons with disabilities to personal mobility with the greatest possible independence, as foreseen by the Convention on the Rights of Persons with Disabilities, increasing their participation in society on an equal basis with others.

• The direct impact of actively reaching out into the community to provide quality rehabilitation services and assistive devices increases the level of access of persons with disabilities to health services and equalizes opportunities.

• Outreach initiatives to deliver rehabilitation services in the community must include a capacity-building component. Building the capacities of local practitioners and health personnel will further empower both these professionals and persons with disabilities, diminishing attitudinal barriers.

• Reaching out into the community allows gathering data on the prevalence of health conditions, local need and demand for assistive devices and rehabilitation services, and informs decision-making.

     

A research study into the requirements of disabled residents for rehabilitation services in Beijing

Purpose.?Rehabilitation services need strengthening further. This study explores a sample of the population in Beijing in order to establish the extent of medical impairments and disabilities. It describes the present utilization of rehabilitation by different economic groups of the population and also explores the attitudes of these same groups to the concepts inherent in rehabilitation. The conclusions are that a considerable information program is needed to help people with disabilities to access and utilize services appropriately. Finally, it concludes that the present Rehabilitation Services need to be professionally improved and expanded.

Background.?In China, the spectrum of disease is changing, along with the development of society, and progress in science and technology. The requirements of people for medical rehabilitation following major accidents, and acute or chronic disease, leading to disability and handicap, increase year by year. This is especially so now, with the added geriatric problems of an aging population. At present, rehabilitation services and resources within this country are limited. It is difficult to meet the immediate or long-term needs of disabled persons. Recently, there have been many national publications describing the requirements and discussing those factors which influence Rehabilitation Service provision, but much of this discussion has been theoretically based, rather than facing practical issues. We can find no studies describing the nature and extent of disabling disorders in the Beijing population and, in particular, few formal studies relating the provision of rehabilitation services to that population in need of this essential management process. We have therefore carried out a survey-based study to demonstrate the present rehabilitation service requirements for disabled residents in some typical Beijing urban districts. We have also looked at those factors which influence clients to accept the various services which are available to them at present. This will, we suggest, provide an epidemiological and demographic analysis with data on which to base future policies for government services to best meet these requirements.

Method.?A series of comprehensive questionnaires were designed, in order to investigate the demographic characters, health conditions, knowledge of rehabilitation services, and social status of the interviewees. Some 460 disabled residents from three districts in the city of Beijing were selected. They were randomized, with multi-stage cluster sampling for in-house survey.

Results.?Some 74.78% of interviewees expressed a need for rehabilitation, at different levels, but only 26.73% received any services. Factors influencing requests for community rehabilitation services for disabled residents in Beijing included income, nature of disability, awareness of rehabilitation services and the nature of services supplied. The expressed needs for rehabilitation services by disabled residents in communities in Beijing urban districts are real, and are largely unmet. Only a few of the disabled received any services. Factors influencing disabled residents' abilities to access rehabilitation service, included the nature and degree of disability, the economic status of the residents, the quality and nature of the rehabilitation programs and treatment available, and the knowledge by clients of the existence and availability of these services.

Conclusion.?More effective measures need to be taken to make the appropriate Rehabilitation Services more available to community residents with medical disabilities.     

Value for money – recasting the problem in terms of dynamic access prioritisation

Purpose.?To develop an approach for achieving value for money in rehabilitation based on dynamic prioritisation of access to services according to individual capacity to benefit.

Method.?A critical review of economic evaluation and adaptation of a prioritisation method used in determining access to elective surgical services in New Zealand to a rehabilitation context.

Results.?The cost-effectiveness frontier is not straight but curved, suggesting that some people benefit more from a given intervention than others. An approach that identifies those most likely to benefit from inpatient rehabilitation following stroke (as an example) and enables access in order of capacity to benefit is presented in the context of a quality improvement programme. The approach is operationalised as a prioritisation tool that is dynamic in the sense that is can be reapplied subject to changes in the patient's clinical status. The steps proposed to develop such a tool include qualitative research with expert clinicians, pair-wise comparison of alternative scenarios (1000Minds® survey), construction of an economic model of the tool's operation and an observational cohort study to help populate the model and calibrate the tool.

Conclusion.?A dynamic prioritisation approach to guide access to scarce health-care resources (such as inpatient rehabilitation following stroke) offers a transparent and equitable way of achieving value for money in the delivery of rehabilitation services.     

Examining the role of vocational rehabilitation on access to care and public health outcomes for people living with HIV/AIDS

Abstract

Purpose: The purpose of this study is to examine the role of vocational rehabilitation services in contributing to the goals of the National HIV/AIDS strategy. Three key research questions are addressed: (a) What is the relationship among factors associated with the use of vocational rehabilitation services for people living with HIV/AIDS? (b) Are the factors associated with use of vocational rehabilitation also associated with access to health care, supplemental employment services and reduced risk of HIV transmission? and (c) What unique role does use of vocational rehabilitation services play in access to health care and HIV prevention? Method: Survey research methods were used to collect data from a broad sample of volunteer respondents who represented diverse racial (37% Black, 37% White, 18% Latino, 7% other), gender (65% male, 34% female, 1% transgender) and sexual orientation (48% heterosexual, 44% gay, 8% bisexual) backgrounds. Results: The fit of the final structural equation model was good (root mean square error of approximation?=?0.055), with 90% upper bound of 0.058, Comparative Fit Index?=?0.953, TLI?=?0.945). Standardized effects with bootstrap confidence intervals are reported. Conclusions: Overall, the findings support the hypothesis that vocational rehabilitation services can play an important role in health and prevention strategies outlined in the National HIV/AIDS strategy.

• Implications for Rehabilitation

• Vocational rehabilitation services can play a unique role in contributing to the goals of the National HIV/AIDS strategy by increasing access to care, increasing use of job support services and reducing health-risk behaviors.

• Increased job confidence and more positive health perception reduced HIV stigma, which is a key mediator to use of vocational rehabilitation services.

• The Behavioral Model of Vulnerable Populations is a useful framework to evaluate the impact of vocational rehabilitation services on access to health care and health-risk behaviors.

     

Disability and access to health care – a community based descriptive study

Abstract

Purpose: The World Disability Report highlighted the need for adequate access to health and medical rehabilitation services for those with disability. Participants in a large community based survey in a low-income area were asked questions relating to their use of health related services. Method: Using random, cluster sampling a representative sample of 1083 households in a deprived area of Cape Town were approached and 152 people with disability were interviewed. Results: Those with disability were more likely to be male (χ²?=?4.24, p?=?0.03) and unemployed (χ²?=?66.89, p?>?0.001) compared to those without disability. The percentages reporting unmet needs were respectively: 54% for home-based care; 34.5% for assistive devices, 28.9% for medical rehabilitation services; and 2.5% for health services. Those over 65 years of age were less likely to have had the medical rehabilitation that they required (χ²?=?8.00, p?=?0.018). There were fewer respondents with sensory and language disorders but these groups reported proportionately more unmet needs. The main problems with accessing services included inadequate finances (71%) and transport problems (72%). Conclusion: It is recommended that all efforts be expended to extend appropriate rehabilitation services, including home based-care and appliances to those identified as having disability, particularly to those older than 65 years. In addition, the services need to be affordable and accessible in terms of suitable transport, particularly in the light of the high unemployment rate and the large number of respondents with mobility problems.

• Implications for Rehabilitation

• People with disability may be the most in need of additional health related care and the least able to access it.

• Transport and financial considerations were found to limit the ability to access appropriate care.

• Rehabilitation and health services need to reach out through home-based care and appropriate forms of rehabilitation delivery to ensure that those who are most in need of care, such as the elderly and those with more neglected forms of disability, are provided with the services that they require.

     

A population approach to understanding children's access to assistive technology

Purpose.?To determine whether service delivery system factors, including having a quality medical home, access to therapeutic services, or enrolment in early intervention/special education services, are associated with meeting children's needs for assistive technology (AT).

Method.?Data were analysed for children 0–17 years of age participating in the 2001 US National Survey of Children with Special Health Care Needs who required AT services (N = 18,372) and a subgroup of children needing assistive devices typically provided by rehabilitation professionals (N = 4429). AT needs included vision or hearing aids or care, communication or mobility devices, or other medical equipment. Unmet need was defined as not receiving all needed services. Estimates were generated of the per cent of children needing and having unmet needs for services. Associations between the medical home, therapy and education variables and having an unmet need for AT were assessed using logistic regression.

Results.?An estimated 49% of children with special health care needs require AT services. Twelve per cent require AT services typically provided by rehabilitation professionals. Of the latter group, 14% had unmet needs. The likelihood of having unmet AT needs was greater for children lacking a quality medical home (a.O.R. = 3.27 [95% C.I. = 2.29–4.66]) and/or those not receiving needed therapy services (a.O.R. = 3.52 [95% C.I. = 2.25–5.48]) than for children whose medical home and therapy service expectations were met. Enrolment in early intervention/special education was not associated with having unmet needs for AT.

Conclusions.?Promoting quality care within a complex service delivery system is critical to meeting the AT needs of children and their families. Changes in the structure and processes of care, including facilitating access to a quality medical home and needed therapy services would likely increase access to needed AT.     

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.     

Access and perceived need for physical and occupational therapy in chronic arthritis

Purpose.?Physical and occupational therapy are beneficial for persons with chronic arthritis; however, access is problematic. The goal was to examine issues related to access to these services for patients with chronic arthritis.

Methods.?We used two data sources: 1) questionnaires sent to a random sample of 600 family physicians and to all 85 rheumatologists in the province of Quebec; and 2) interviews of 211 patients with physician-confirmed chronic arthritis recruited from 34 primary care settings in Quebec.

Results.?Only 11.5% of family physicians and 31.7% of rheumatologists referred patients with rheumatoid arthritis (RA) to rehabilitation, whereas 60.4% of family doctors referred patients with osteoarthritis. Only 26.1% of patients felt that they required rehabilitation and this was associated with lower self-efficacy (OR: 0.84, 95% CI: 0.72, 0.99) and higher educational level (OR: 2.10, 95% CI: 1.01, 4.36).

Conclusion.?Family physicians are less likely to refer patients with RA to therapy. Only about a quarter of patients with chronic arthritis treated in primary care perceived the need for these services. Efforts to improve arthritis care should address education of physicians and patients regarding the benefits of rehabilitation and there should be efforts to increase therapy resources in order to enhance access.     

Job functions of Swedish public and private sector vocational rehabilitation workers

Purpose. This study has had two main aims, the first to investigate and gather knowledge of the major job functions of Swedish rehabilitation workers, the second to study the frequency of use of these functions in the VR process.

Method. Structured questionnaires were sent to Swedish rehabilitation workers from public and private sectors. To identify the major dimensions of Swedish rehabilitation workers' job in the vocational rehabilitation (VR) process, a principal component factor analysis was performed.

Results. Results revealed that there are four main factors (dimensions) that comprised the VR process in Sweden. The four factors (dimensions) are job development and career counselling; assessment and counselling interventions; workplace adjustment and employer consultation and client support, personnel development and public relations.

Conclusions. The VR process in Sweden is limited in both its scope and depth. This when one compares with the results of studies carried out in the USA, who found seven and six dimensions, respectively. It is argued that it cannot be excluded that the negative trend of extensive sick leave and early pensions are attributable to the limitations in the VR process that have been found. Suggested is the urgent need to put resources in place that would support the further advancement of the knowledge and competencies of the VR services in Sweden.     

Continuity,transition and participation: Preparing clients for life in the community post-stroke

Aims. To examine issues of continuity and transition facing clients as they return to life in the community following stroke and the role of rehabilitation in this process.

Key findings and implications. The sudden onset of disability following a stroke represents a major disruption to the continuity of a person's life experience. Rehabilitation has an important role in the transition from the non-disabled to the disabled state however current rehabilitation services and outcomes post-stroke focus on functional recovery rather than on a return to meaningful roles and activities and pay little attention to the transition from the non-disabled to the disabled self. Although some current rehabilitation models address the importance of involvement in a life situation, they do not adequately address issues of the role of the environment, the nature of community, the importance of meaning and choice when thinking about life situations, and change in abilities across the life course.

Conclusions. Models of rehabilitation service delivery need to move to a chronic disease management model that incorporates outcomes that are meaningful to clients, and not the assumed needs or outcomes as defined by rehabilitation professionals.     

Validation of the Dutch Giving Youth a Voice Questionnaire (GYV-20): A measure of the client-centredness of rehabilitation services from an adolescent perspective

Purpose. The objective was to validate the Dutch translation of the Canadian Giving Youth a Voice Questionnaire (GYV-20) for use in paediatric rehabilitation settings in The Netherlands. The GYV-20 consists of 20 items (assessing four domains) and was designed to evaluate the client-centredness of rehabilitation services from an adolescent perspective.

Method. The construct validity, concurrent validity, and reliability of the Dutch GYV-20 were determined. Participants were 116 youngsters aged 11 – 21 years (Mean = 15.9; SD = 2.1) recruited through six paediatric rehabilitation settings in The Netherlands.

Results. Correlations between the GYV-20 scale scores were positive (r = 0.69 – 0.78). The GYV-20 showed adequate internal consistency, with Cronbach's α ranging from 0.76 – 0.81. The ICCs of test-retest reliability ranged from 0.82 – 0.92, which demonstrated good stability of the GYV-20. Dutch adolescents judged the GYV-20 as a valuable and useful tool to evaluate rehabilitation services in The Netherlands.

Conclusions. The Dutch GYV-20 showed sufficient evidence of construct validity and good reliabilities. The Dutch GYV-20 offers users a useful measurement option for various research and clinical purposes.     

Gender difference in access and intervention outcomes: the case for women with disabilities

Purpose. This study replicated the one that was conducted 30 years ago to determine systematic gender differences in access and outcomes of vocational rehabilitation services (VRS).

Methods. Unlike the original study that was confined to Region V, this study examined case management data from 653,206 cases that were closed by State VRS in 2004 in all states. It used a t-test to analyse gender differences in access to VRS and intervention outcomes in education, employment, earnings and dependence on public support. The study also conducted multivariate analysis to determine the effects of gender on VRS intervention outcomes.

Results. The study found differences similar to those found 30 years ago. Although women had better educational outcomes, they had lower employment and earnings and greater dependence on needs-based public support than did men. A disturbing finding is that the gender employment and earnings gaps were wider after VRS interventions than before. After controlling for other factors, the study found that gender is a significant predictor of earnings and employment outcomes.

Conclusion. These findings suggest that men with disabilities stand a better chance of escaping poverty than do women. There is a need for changes in VRS service provision that ensures equity in quality of services which might translate into more equitable employment and earnings outcomes.     

In home telerehabilitation for older adults after discharge from an acute hospital or rehabilitation unit: A proof-of-concept study and costs estimation

Purpose.The purpose of this study is to investigate rehabilitation through teletreatment as an alternative to a physical home-care visit to deliver services to individuals at home following discharge from an acute hospital or rehabilitation unit.

Method.Four community-living elderly people were recruited for telerehabilitation services prior being discharged from an acute-care hospital and a geriatric rehabilitation unit. Once the patient returned home, an appointment was made for the assessing therapist to take the clinical measurements (T1) in a face-to-face session. Four clinical variables were used (functional autonomy, balance, locomotor performance in walking and lower-body strength). Telerehabilitation sessions with the participants were conducted with trained personnel in the individual's home. The system used to support telerehabilitation services for this proof of concept was built around network-attached remotely-controlled pan/tilt/zoom cameras with MJPEG compression, media displays and hands-free phones. Before the patient was discharged from the physiotherapy program, the same assessing therapist visited the subject again to take the T2 measurements in a face-to-face session. The satisfaction of the health-care professional was determined for each session with the homemade questionnaire. Costs related to telerehabilitation were compared to theoretically home visits.

Results.All four subjects improved on the four clinical variables. Mean costs for the telerehabilitation program, comprising 12 sessions over 4 weeks was $487.

Conclusion.Telerehabilitation seems to be a practical alternative for dispensing rehabilitation services after patients are discharged from an acute hospital or rehabilitation unit.     

The demand for rehabilitation therapists in Beijing health organizations over the next five years

Purpose. To estimate the demand for rehabilitation therapists in Beijing health organizations over the next 5 years.

Methods. A literature search was carried out to confirm the distribution of rehabilitation therapists in Beijing health organizations in the past and to predict the demand for rehabilitation therapists in Beijing hospitals over the next 5 years by linear regression and logistic curve fitting.

Results. The total demand for rehabilitation therapists in Beijing in 2007 and 2010 will be 1480 – 1620 and 2240 – 2530, respectively.

Conclusions. The allocation and training of manpower specialized in rehabilitation therapeutics for the rehabilitation departments of polyclinics in Beijing should be improved.     

Contemporary vocational rehabilitation in Australia

Abstract

Purpose: There is a strong connection between disability and decreased participation rates in the Australian labour market. Australian government policy recognises vocational rehabilitation as a key strategy to increase employment rates of people with disabilities. Methods: This paper examines current Australian disability employment policies and practices. It also reviews vocational rehabilitation competency research to identify knowledge and skill domains central to quality service provision, and explores the delivery of tertiary level vocational rehabilitation education. Results: Policy changes in Australia over the last decade have been aimed at addressing the unsustainable increase in disability benefits. In this context vocational rehabilitation services continue to be viewed as crucial in assisting people with disabilities to maintain employment and reduce disengagement. Competencies research has consistently identified vocational counselling, personal counselling, professional practice and case management as central to quality vocational rehabilitation service provision. Two competencies identified in recent research, workplace disability case management and workplace interventions and program management, reflect the centrality of vocational rehabilitation to disability management. Conclusions: Changes in the policy environment to reduce the number of disability pension recipients will inevitably lead to an increased demand for trained vocational rehabilitation personnel. Given the development of strong accreditation standards for vocational rehabilitation education and practice that underpin the provision of tertiary level rehabilitation counselling training programs, professionally qualified rehabilitation counsellors are ideally placed to address the complex employment needs of people with a disability.

• Implications for Rehabilitation

• It is important to understand changes that may occur in policy environments in terms of their impact on vocational rehabilitation service delivery for people with disabilities.

• Variable levels of training in the vocational rehabilitation sector result in people with complex needs not consistently receiving the services they need to access and maintain employment.

• Practitioners need to focus increasingly on individualized service delivery where the client has significant control over decisions about their rehabilitation program.

     

Revisiting therapy assumptions in children's rehabilitation: clinical and research implications

Purpose. This commentary draws on a recent workshop hosted by the Canadian Children's Rehabilitation Research Network that brought together stakeholders to critically examine assumptions embedded in children's rehabilitation in order to advance current debates and suggest areas for further inquiry.

Method. Six issues are discussed: (1) the wisdom of dichotomising ‘fix’ versus ‘function’; (2) the ethics of ‘it might help and it won't hurt’ therapy approaches; (3) the emphasis on early intervention rather than a lifespan approach; (4) the challenges of providing care for new rehabilitation populations; (5) discrepancies between performance outcomes and patient satisfaction; and (6) innovative partnerships to support care transitions of adolescents and their families.

Results. Issues identified include: finding the right balance between therapies that focus on ‘fixing’ children versus enhancing function, judicious design of therapy programs as to not overburden children and families, adopting lifespan approaches to meet the needs of multiple ‘paediatric’ populations, cautious interpretation of measures and approaches that link well-being with physical performance, and the benefits of including parent and youth facilitators on children's rehabilitation teams.

Conclusions. Ongoing debate, discussion and research are needed in each of these areas to ensure that rehabilitation services are enhancing the well-being of children and families.     

Adjusting expectations after spinal cord injury across global settings: A commentary

Purpose. The objective of this paper is to stimulate thought and discussion as to how best to set rehabilitation goals to maximize activities and participation of persons with spinal cord injury, across global settings where circumstances and environments may be widely different.

Method. A review of literature and commentary are presented. Three points are articulated: (1) rehabilitation professionals need to understand factors that impact upon activities and participation, and need measurement tools that report these factors, in order to better appreciate outcomes in different settings, (2) rehabilitation professionals generally set goals with patients, but current measures of activities and participation do not indicate when or why maximal achievable function is sometimes not chosen, and (3) we need to develop realistic expectations for activities and participation after SCI in settings where current standard outcome chart targets are not feasible, due to socio-economic circumstances.

Conclusions. A standardized approach to reporting measures of activities and participation, along with factors that influence these scores, is required for purposes of comparing rehabilitation outcomes in settings of differing socio-economic environments. In regards to spinal cord injury rehabilitation, an accepted standard of setting achievable rehabilitation goals is required for each level of complete spinal cord injury that could apply in various global settings.