Roadmap for Connecting Cancer Rehabilitation With Survivorship to Improve Patient Outcomes and Clinical Efficiency.

ABSTRACT: An evolved model of comprehensive cancer care is needed that begins at cancer diagnosis to proactively manage cancer treatment toxicities and optimize patient health, function, and well-being. Building new care models requires connecting oncology, primary care, and specialized clinicians from many disciplines including cancer rehabilitation. Having a vision for an evolved standard of comprehensive cancer care is a requirement, but it is not enough to bring an innovative clinical program to life and sustain it over the long term. To inform the development of new clinical programs, two example programs are presented that successfully integrate cancer rehabilitation services along with details of a three-step process these programs used to facilitate their success and build robust business models that ensure their sustainability. Following the roadmap for growth presented here, gaining input from stakeholders and ensuring their buy-in, leveraging existing programmatic priorities, as well as developing a strategic growth plan can help clinical innovators ensure that new programs anticipate and continually meet the needs of oncology, primary care, subspecialty care, and programs, while addressing the business needs of administrators and improving the experience for patients.

A Comprehensive Strategy to Pain Management for Cancer Patients in an Inpatient Rehabilitation Facility.

Cancer pain has been shown to have a significant negative impact on health-related quality of life (HRQoL) for people experiencing it. This is also true for patients admitted to inpatient rehabilitation facilities (IRFs). An interdisciplinary approach is often needed to fully address a person's pain to help them attain maximum functional independence and to ensure a safe discharge home. Improving a patient's performance status in an IRF may also be a crucial determinant in their ability to continue receiving treatment for their cancer. However, if a person is determined to no longer be a candidate for aggressive, disease modulating treatment, IRFs can also be utilized to help patients and family's transition to comfort directed care with palliative or hospice services. This article will discuss the interventions of the multidisciplinary inpatient rehabilitation team to address a person's pain.

The Who, What, Why, When, Where, and How of Team-Based Interdisciplinary Cancer Rehabilitation.

OBJECTIVE: To review the key components necessary for successful application of rehabilitation principles to oncology survivors. DATA SOURCES: Validated databases, including PubMed, MEDLINE, and Scopus. CONCLUSION: Rehabilitation is an essential component of cancer care that addresses functional needs for oncology survivors and is best accomplished via an interdisciplinary team. Interdisciplinary care, provided by nursing, physiatry, rehabilitation therapy, and exercise physiology, are critical components for comprehensive intervention. Challenges exist in implementing services, but opportunity also exists within the post-acute care sector. IMPLICATIONS FOR NURSING PRACTICE: Nurses play an important role in the screening, assessment, and treatment of cancer-related functional impairments.

Depression Characterization and Race Among Stroke Survivors Receiving Inpatient Rehabilitation.

Race and ethnicity play a significant role in poststroke outcomes. This brief report describes the presence of depression among stroke survivors who received inpatient rehabilitation and whether depression differs by race. Data from eRehabData and electronic medical records were analyzed for patients who received rehabilitation after an acute ischemic or hemorrhagic stroke. Of 1501 stroke patients, 61.3% were white, 33.9% were African American, and 4.8% were of other race/ethnic backgrounds. By retrospective clinical review, depression was documented for 29.7% of stroke patients. Premorbid versus new onset of poststroke depression was documented for 13.4% and 21.6% of whites, 7.5% and 11.5% of African American, and 0% and 16.7% of patients of other race/ethnic groups. Compared with whites, African American and people of other races had a lower odds of poststroke depression (African American adjusted odds ratio = 0.52, 95% confidence interval = 0.41-0.68; other races odds ratio = 0.37, 95% confidence interval = 0.19-0.71), after adjusting for all other significant risk factors identified in the bivariate analysis (sex, hyperlipidemia, cognitive deficit, neglect). Depression was documented for one in three stroke survivors who received inpatient rehabilitation and highest among whites especially for prestroke depression. Addressing depression in rehabilitation care needs to consider individual patient characteristics and prestroke health status.

Intractable Central Pain in a Patient With Diffuse Glioma.

Central neuropathic pain can be difficult to treat and, subsequently, cause a great amount of disability and distress to patients, which limits quality of life. Common etiologies include the following: stroke, spinal cord injury, multiple sclerosis, infection, vasculitis, and malignancy. This case is a description of an 18-yr-old male patient diagnosed with a grade IV diffuse glioma who experienced severe neuropathic pain refractory to first-line treatment options including the following: gabapentinoids, tricyclic antidepressants, and selective serotonin and norepinephrine reuptake inhibitors. The patient remained on high-dose oral gabapentin as well as methadone and high-dose oxycodone for pain control at the time of submission. The aims of this case report were to review the nociceptive pathways and to explore the role of opioids in central neuropathic pain secondary to neoplasm because a better understanding of these topics can aid physiatrists in better taking care of these patients and improving function and quality of life.

Inpatient Care for the Cancer Survivor: Opportunities to Develop and Deliver Standards for Care.

Cancer continues to evolve from a terminal diagnosis to a chronic medical condition. With improved survivorship rates, opportunities exist to deliver rehabilitation care throughout the oncology continuum. By definition, inpatient rehabilitation is generally considered postacute care and is provided either in inpatient rehabilitation facilities, in skilled nursing facilities, or in long-term care hospitals. Each institution is subject to specific regulations and legislation that help define appropriateness for admission based on diagnosis, medical necessity, and functional need. However, these criteria may present barriers to access care for the oncology survivor. As the healthcare landscape changes, and reimbursement structures shift from fee-for-service to those that emphasize effectiveness and efficiency in care, inpatient rehabilitation has a unique opportunity to improve value in terms of outcomes and cost. With the implementation of the Improving Medicare Post-Acute Care Transformation Act, standardization of measures throughout postacute care may allow for a more consistent approach to delivery of inpatient rehabilitation care. Further work will be necessary to define the parameters by which oncology survivors should be gauged in this framework.

Turning Data Into Information: Opportunities to Advance Rehabilitation Quality, Research, and Policy.

Attention to health care quality and safety has increased dramatically. The internal focus of an organization is not without influence from external policy and research findings. Compared with other specialties, efforts to align and advance rehabilitation research, practice, and policy using electronic health record data are in the early stages. This special communication defines quality, applies the dimensions of quality to rehabilitation, and illustrates the feasibility and utility of electronic health record data for research on rehabilitation care quality and outcomes. Using data generated at the point of care provides the greatest opportunity for improving the quality of health care, producing generalizable evidence to inform policy and practice, and ultimately benefiting the health of the populations served.

A Rare Intramedullary Spinal Cord Metastasis from a Retroperitoneal Leiomyosarcoma Presenting as a Non-Traumatic Spinal Cord Injury.

Leiomyosarcoma (LMS) is a rare but well-recognized malignant soft tissue sarcoma of smooth muscle origin. Metastases commonly occur in the lungs, liver, kidney, brain, and bone. Cases of metastatic osseous lesions or other extradural space-occupying masses secondary to LMS leading to neurologic compromise are relatively commonplace in the literature. Conversely, cases of intramedullary spinal cord metastasis (ISCM), an unusual entity as a sequela of any cancer, are exceedingly rare as a consequence of LMS. Only 2 cases of an ISCM from LMS are currently documented in the literature, and to the best of our knowledge, no case is described in the rehabilitation literature. This case report presents a patient with a history of longstanding metastatic LMS presenting with incomplete paraplegia, neurogenic bowel and bladder, and neuropathic pain. The patient was found to have an ISCM of the thoracic spinal cord. She made functional gains with concurrent inpatient rehabilitation and radiation but was unable to perform her own intermittent catheterization program, bowel program, or transfers and was unable to discharge home independently. Intramedullary spinal cord metastasis is a rare and potentially devastating consequence of LMS or any primary cancer, but can be amenable to common interventions in the acute inpatient rehabilitation setting.

Palliative Care and Physiatry in the Oncology Care Spectrum: An Opportunity for Distinct and Collaborative Approaches.

As cancer evolves from a terminal illness to a chronic medical condition, so too does the view of clinical services. Palliative care and physical medicine and rehabilitation (PM&R) will increase in acceptance because they provide a valuable resource. The overarching theme is improving cancer-related symptoms or treatment-related side effects, improving patient health-related quality of life, lessening caregiver burden, and valuing patient-centered care and shared decision making. Managing symptom burden may improve therapy participation/performance. PM&R and palliative care departments are well-equipped to develop patient-centered care protocols, and could play an important role in developing a universal measure of performance status.

Depression and Functional Status Among African American Stroke Survivors in Inpatient Rehabilitation.

PURPOSE: To examine the prevalence of poststroke depression (PSD) among African American stroke survivors and the association of depression with functional status at inpatient rehabilitation facility (IRF) discharge. METHODS: Secondary data analysis was conducted of a patient cohort who received care at 3 IRFs in the United States from 2009 to 2011. Functional status was measured by the Functional Independence Measure (FIM). Multiple linear regression models were used to examine associations of PSD and FIM motor and cognitive scores. RESULTS: Of 458 African American stroke survivors, 48.5% were female, 84% had an ischemic stroke, and the mean age was 60.8 ± 13.6 years. Only 15.4% (n = 71) had documentation of PSD. Bivariate analyses to identify factors associated with depression identified a higher percentage of patients with depression than without who were retired due to disability (17.1% versus 11.6%) or employed (31.4% versus 19.6%) prestroke (P = .041). Dysphagia, cognitive deficits, and a lower admission motor FIM score were also significantly more common among those with depression. There was no significant relationship between depression and functional status after adjusting for patient characteristics. CONCLUSIONS: In this study, 15% of the African Americans who received rehabilitation after a stroke had documentation of PSD but this was not associated with functional status at discharge.

Factors associated with discharge to home versus discharge to institutional care after inpatient stroke rehabilitation.

OBJECTIVE: To examine sociodemographic and clinical characteristics independently associated with discharge home compared with discharge to a skilled nursing facility (SNF) after acute inpatient rehabilitation. DESIGN: Retrospective cohort study. SETTING: Three tertiary accredited acute care rehabilitation facilities. PARTICIPANTS: Adult patients with stroke (N=2085). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Not applicable. RESULTS: Of 2085 patients with stroke treated at 3 centers over a 4-year period, 78.2% (n=1631) were discharged home and 21.8% (n=454) discharged to an SNF. Findings from a multivariable logistic regression analysis indicated that patients were less likely to be discharged home if they were older (odds ratio [OR], .98; 95% confidence interval [CI], .96-.99), separated or divorced (compared with married; OR, .61; 95% CI, .48-.79), or with Medicare health insurance (compared with private insurance; OR, .69; 95% CI, .55-.88), or had dysphagia (OR, .83; 95% CI, .71-.98) or cognitive deficits (OR, .79; 95% CI, .77-.81). The odds of being discharged home were higher for those admitted with a higher motor FIM score (OR, 1.10; 95% CI, 1.09-1.11). The following were not associated with discharge disposition: sex, race, prestroke vocational status, availability of secondary health insurance, number of days from stroke onset to rehabilitation facility admission, stroke type, impairment group, cognitive FIM on admission, other stroke deficits (aphasia, ataxia, neglect, or speech disturbance), stroke complications of hyponatremia or urinary tract infection, or comorbid conditions. CONCLUSIONS: One in 5 patients with stroke were discharged to an SNF after inpatient rehabilitation. On admission, several sociodemographic and clinical characteristics were identified that could be considered as important factors in early discussions for discharge planning.