Effect of robotic-assisted three-dimensional repetitive motion to improve hand motor function and control in children with handwriting deficits: a nonrandomized phase 2 device trial.

OBJECTIVE: We explored the efficacy of robotic technology in improving handwriting in children with impaired motor skills. METHOD: Eighteen participants had impairments arising from cerebral palsy (CP), autism spectrum disorder (ASD), attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), or other disorders. The intervention was robotic-guided three-dimensional repetitive motion in 15-20 daily sessions of 25-30 min each over 4-8 wk. RESULTS: Fine motor control improved for the children with learning disabilities and those ages 9 or older but not for those with CP or under age 9. All children with ASD or ADHD referred for slow writing speed were able to increase speed while maintaining legibility. CONCLUSION: Three-dimensional, robot-assisted, repetitive motion training improved handwriting fluidity in children with mild to moderate fine motor deficits associated with ASD or ADHD within 10 hr of training. This dosage may not be sufficient for children with CP.

Enabling a survey of primary care to measure the health care experiences of adults with disabilities.

PURPOSE: To enable an existing survey on primary care so that it can be used to assess the healthcare experiences reported by adults living with disabilities, and to evaluate its properties. METHODS: Mixed-methods study. We first identified content areas for measurement as compared to the items in the existing instrument and then developed new candidate items. Cognitive testing was conducted in English and Spanish. After revisions to the primary care instrument based on the cognitive testing results, the draft-enabled instrument was field-tested by mail with telephone follow-up, in English and Spanish. RESULTS: Consumer focus groups and a technical expert panel identified eight content areas in primary care that are particularly important to maximise function and well-being of people of with disabilities. Cognitive testing also revealed serious problems with several items in the existing survey when answered by or about people with disabilities. Field testing yielded 1086 surveys, of which 40% were completed by a proxy respondent. Learning disabilities were reported by 38% of respondents. Item non-response for revised and new questions was less than 4%. CONCLUSIONS: It is feasible to enable a survey of primary care and its administration. Survey administration instructions should be modified to accommodate proxy respondents. The screener item to identify people with mobility impairments on walking a distance should be replaced with walking for 6 min. Adding questions from the American Community Survey about functional ability will allow survey sponsors to identify respondents with various limitations, and to compare their experiences to those of people with no limitations. Careful development and testing of the items with input from interested parties throughout the design and testing stages yielded a survey with good psychometric properties and content validity in multiple languages. Health delivery systems can use the survey data to identify clinical processes needing improvement to provide high quality care for people with disabilities.

Towards a modified consumer haptic device for robotic-assisted fine-motor repetitive motion training.

PURPOSE: To develop, test and evaluate affordable haptic technology to provide robotic-assisted repetitive motion fine-motor training. METHODS: A haptic computer/user interface was modified by adding a pantograph to hold a pen and to increase the haptic workspace. Custom software moves a pen attached to the device through prescribed three-dimensional (3D) stroke sequences to create two-dimensional glyphs. The pen's position is recorded in 3D coordinates at 1 kHz. Twenty-one healthy child volunteers were taught a standard handwriting curriculum in a group setting, two times per week for 45-60 min each session over 8 wks. The curriculum was supplemented by the device under the supervision of occupational therapy students. Outcomes were measured using the Evaluation Tool of Children's Handwriting (ETCH), and the Beery-Buktenica Developmental Test of visual-motor integration. RESULTS: Word legibility made significant gains on near point copying task (p=0.04; effect size=0.95). Letter legibility made no significant improvement. One healthy volunteer with illegible handwriting improved significantly on 8 of 14 ETCH measures. The children found the device engaging, but made several recommendations to redesign the pantograph and scribing movements. CONCLUSIONS: A consumer haptic device can be modified for robotic-assisted repetitive motion training for children. The device is affordable, portable, and engaging. It is safe for healthy volunteers. Objective time-stamped data offer the potential for telerehabilitation between a remote therapist and the school or home.

Case-mix adjustment and enabled reporting of the health care experiences of adults with disabilities.

OBJECTIVES: To develop activity limitation clusters for case-mix adjustment of health care ratings and as a population profiler, and to develop a cognitively accessible report of statistically reliable quality and access measures comparing the health care experiences of adults with and without disabilities, within and across health delivery organizations. DESIGN: Observational study. SETTING: Three California Medicaid health care organizations. PARTICIPANTS: Adults (N = 1086) of working age enrolled for at least 1 year in Medicaid because of disability. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Principal components analysis created 4 clusters of activity limitations that we used to characterize case mix. We identified and calculated 28 quality measures using responses from a proposed enabled version of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. We calculated scores for overall care as the weighted mean of the case-mix adjusted ratings. RESULTS: Disability caused a greater bias on health plan ratings and specialist ratings than did demographic factors. Proxy respondents rated care the same as self-respondents. Telephone and mail administration were equivalent for service reports, but telephone respondents tended to offer more positive global ratings. Plan-level reliability estimates for new composites on shared decision making and advice on healthy living are .79 and .87, respectively. Plan-level reliability estimates for a new composite measure on family planning did not discriminate between health plans because respondents rated all health plans poorly. Approximately 125 respondents per site are necessary to detect group differences. CONCLUSIONS: Self-reported activity limitations incorporating standard questions from the American Community Survey can be used to create a disability case-mix index and to construct profiles of a population's activity limitations. The enabled comparative report, which we call the Assessment of Health Plans and Providers by People with Activity Limitations, is more cognitively accessible than typical CAHPS report templates for state Medicaid plans. The CAHPS Medicaid reporting tools may provide misleading ratings of health plan and physician quality by people with disabilities because the mean ratings do not account for systematic biases associated with disability. More testing on larger populations would help to quantify the strength of various reporting biases.

The business case for adult disability care coordination.

DESIGN: The study used a retrospective pretest, posttest design of 245 beneficiaries. Physical impairment ranged from slight to severe. SETTING: Minnesota Disability Health Options (MnDHO), a capitated Medicaid program. PARTICIPANTS: Medicaid beneficiaries ages 18 to 64 with physical disabilities arising from multiple sclerosis, cerebral palsy, spinal cord injury, or brain injury. INTERVENTIONS: Not applicable. MAIN OUTCOMES MEASURES: Change in expenditures, rate of return, and utilization. RESULTS: Mean MnDHO monthly expenditures including care coordination increased by a factor of 1.75 (P<.001) over the previous expenditures. Increasing age has a multiplier effect on increased expenditures. Hospitalization rates were unchanged, but the average cost per admission and average length of stay dropped significantly (P=.017, P=.032, respectively). For people enrolled at least 3 years, annual reductions in medical costs more than paid for the added cost of care coordination, but the savings in Year 3 were about 20% of the savings in the first 2 years. CONCLUSIONS: Care coordination leads to higher program expenditures for enrollees with moderate physical impairments who encounter access problems, but has little impact on enrollees who are already getting 24-hour care. There is some evidence of adverse selection bias. MnDHO's disability care coordination may not be financially sustainable over the long term.

Identifying and classifying people with disabilities using claims data: further development of the Access Risk Classification System (ARCS) algorithm.

BACKGROUND: The goal was to develop an inexpensive and rapid method for health systems to classify people by their ability to access routine care. We sought to refine and revalidate a software algorithm, the Access Risk Classification System (ARCS), using automated claims data to classify people into one of four categories based on the probable need for care coordination or health system accommodations. METHODS: Through simple linkages of longitudinal claims data, the algorithm assigned individuals into one of four categories. We evaluated the algorithm's sensitivity and specificity by comparing the predicted classification against self-report. The validation results were used to refine the algorithm. RESULTS: When we classified people into two groups of any degree of functional limitation or no limitation, the sensitivity was 91% and the specificity was 26%. When classified into two groups of those needing proactive care coordination and all others, sensitivity was 83% and specificity was 30%. Thus, overall correct classification ranges from good to fair. CONCLUSIONS: The algorithm utilizes claims databases readily available to many health claims payers. Adding Healthcare Common Procedural Coding System claims and number of prescriptions improves correct classification rates. Even when the claims data are incomplete and imprecise, ARCSv2 (ARCS version 2) can be used as an initial screen to identify people who should be included in the calculation of quality measures and who should be surveyed for consumer reported quality measurement. When using four classification categories, 69% of the people with the greatest risk and need for care coordination are correctly identified. ARCS can increase the correct identification of people with disabilities by 400% over random digit dialing of a general population. However, the ARCS should be further refined and validated in a larger population that includes more men with disabilities, children, and people without disabilities before it is used to compute quality measures using administrative data. Correct classification might be improved by incorporating information on comorbidities and specific medication categories.

Consumer evaluation of a disability care coordination organization.

Disability care coordination organizations (DCCOs) arrange comprehensive, disability-competent social and medical services for people with disabilities. This study used consumer ratings of access and quality to measure outcomes in one of the first operational DCCOs over a three-year period. Working-age Medicaid adults with physical disabilities reported statistically significant improvements in service coordination, patient education, system-wide disability competency, comprehensive assessment, health visit support, and self-direction of care. Global quality ratings showed statistically significant and sustained improvement over two years, with the percentage of people rating the health system as excellent rising from 7% before enrollment to 44% in the DCCO. The percentage of people rating primary care physicians as excellent rose from 18% before enrollment to 38% in the DCCO. Over time, enrollees became more knowledgeable about the need for preventive health care services, were more likely to receive needed care and medical equipment, and reduced their need for rehabilitation therapies. Disability care coordination organizations can reduce disparities and improve access to care for this vulnerable population.

Televideo assessment using Functional Reach Test and European Stroke Scale.

This study explored the equivalence of physical function assessment by physical therapists (PTs) during face-to-face and remote administration of the European Stroke Scale (ESS) and the Functional Reach Test (FRT) to 26 subjects with a history of stroke. Patients were randomized to remote or face-to-face administration groups. Each patient was simultaneously rated by both the face-to-face and remote PTs. The PTs were blinded to each other's results. Equivalence was set at the 95% limits of agreement. When the face-to-face PT directed the patient, the two PTs reported equivalent values in more than 90% of the patients for the FRT and for all ESS components, with the exception of gait (83%) and maintaining leg position (85%). When the remote PT directed the patient, the two PTs reported equivalent values in more than 90% of the patients for the FRT and more than 83% for all ESS components. Televideo assessment of function by PTs is substantially equivalent to a face-to-face encounter.

Meeting information needs to facilitate decision making: report cards for people with disabilities.

BACKGROUND: Several states within the United States offer low-income adults with disabilities a choice of health plans. No states issue comparative 'report cards' specifically for adults with disabilities. OBJECTIVE: To explore conceptualizations of quality, information needs, and report card preferences from the perspective of people with disabilities. RESEARCH DESIGN: Eight focus group interviews were conducted in 2003. Existing report cards for California, Maryland, Michigan and Texas were shared for feedback. SUBJECTS: 34 women and 15 men with various behavioural, physical or sensory disabilities in Oregon, California, Virginia, Maryland and the District of Columbia. RESULTS: Quality was mostly defined in terms of choice and disability sensitivity of service providers. Respondents identified various obstacles to receiving appropriate health plan and service information. All beneficiaries were keenly interested in the comparative health plan report cards, but did not think the report cards provided enough pertinent information, especially with regard to provider ratings, accessibility, disability competence and reasons for participating in the Medicaid program. CONCLUSIONS: Existing comparative report cards omit several major content domains important to people with disabilities. Organizations providing decision support to people with disabilities should cultivate novel avenues for distribution, such as food banks, libraries and places of worship.

Equivalence of functional communication assessment in speech pathology using videoconferencing.

We examined the equivalence of videoconferencing assessment of communication by speech-language pathologists (SLPs). Using a randomized, double-crossover agreement study, 24 post-stroke patients were randomized to a remote or face-to-face administration of a subset of the Boston Diagnostic Aphasia Examination and to remote or face-to-face assessment of speech comprehension, speech expression and motor speech. The videoconferencing equipment was operated at a transmission speed of 384 kbit/s. Each patient was simultaneously scored by both the face-to-face and the remote SLPs. SLPs were blind to each other's results. Percentage agreement within the 95% limits of agreement ranged from 92% to 100% for each functional communication measure, regardless of assessment site and administration of the aphasia examination. The results suggest that assessment of a patient's functional communication using videoconferencing is equivalent to a face-to-face encounter.

Disability care coordination organizations: improving health and function in people with disabilities.

Disability care coordination organizations (DCCOs) combine attributes of the medical home model and community nursing. Teams of nurses and social workers collaborate with the client to arrange disability-competent medical and social services. This article synthesizes observational findings from site visits to approximately half of the DCCOs operating in 2004. DCCOs have 6 core clinical activities: comprehensive assessment; self-directed, person-centered planning; health visit support; centralized medical-social record; community resource engagement; and constant communication. We also identified 3 core business competencies: service coordination, patient education/behavioral modification, and continuous enhancement of disability competency. Each DCCO started as a new company rather than as a product line of an existing business, and each included the target population in the design stage. Most DCCOs contract with state Medicaid agencies under a prepaid capitation arrangement, and some also enroll Medicare beneficiaries. Capitated DCCOs retain cost savings and may be financially stronger than fee-for-service DCCOs. Although studies suggest that DCCOs improve coordination and clinical outcomes while reducing costs, the current evidence has not been peer reviewed.

Making the business case for telemedicine: an interactive spreadsheet.

The objective of this study was to demonstrate the business case for telemedicine in nonrural areas. We developed an interactive spreadsheet to conduct multiple financial analyses under different capital investment, revenue, and expense scenarios. We applied the spreadsheet to the specific case of poststroke rehabilitation in urban settings. The setting involved outpatient clinics associated with a freestanding rehabilitation hospital in Oklahoma. Our baseline scenario used historical financial data from face-to-face encounters as the baseline for payer and volume mix. We assumed a cost of capital of 10% to finance the project. The outcome measures were financial breakeven points and internal rate of return. A total of 340 telemedicine visits will generate a positive net cash flow each year. The project is expected to recoup the initial investment by the fourth year, produce a positive present value dollar return of more than $2,000, and earn rate of return of 20%, which exceeds the hospital's cost of capital. The business case is demonstrated for this scenario. Urban telemedicine programs can be financially self-sustaining without accounting for reductions in travel time by providers or patients. Urban telemedicine programs can be a sound business investment and not depend on grants or subsidies for start-up funding. There are several key decision points that affect breakeven points and return on investment. The best business strategy is to approach the decision as whether or not to build a new clinic.

Medicaid payment for telerehabilitation.

OBJECTIVE: To assess current payment practice for telerehabilitation in state Medicaid programs. DESIGN: Telephone survey. SETTING: State Medicaid programs. PARTICIPANTS: State Medicaid directors. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Descriptive. RESULTS: Half of the 35 state Medicaid programs contacted reimbursed at least some telemedicine services other than radiology in 2002. The primary reason for reimbursing for telemedicine is to make services available when there is no local practitioner. Consultation and evaluation and management services were most likely to be reimbursed (12 states). Seven state programs reimbursed telepsychology, and 4 states reported reimbursing for telespeech and language pathology, physical therapy, or occupational therapy. CONCLUSIONS: Telemedicine helps Medicaid programs deliver specialized care to locations with provider shortages. Telerehabilitation is not yet widespread, despite its potential benefit to people with disabilities who cannot travel to a clinic for rehabilitation therapy. Most Medicaid programs calculate the financial costs and patient benefits when considering payment policies, and about half of states require a state law to allow payment for telerehabilitation. Minnesota, Hawaii, and Nebraska, among the responding states, currently reimburse for telerehabilitation. Research is needed to evaluate the appropriateness of telerehabilitation for Medicaid beneficiaries.

Financial risk reduction for people with disabilities in Medicaid programs.

A growing number of states are enrolling Medicaid beneficiaries with disabilities into prepaid health plans. This shift from fee-for-service insurance to pre-paid insurance typically transfers the risk from the state to the health plans. However, health plans want the state Medicaid program to minimize their financial risk. Interviews with Medicaid officials in six states provided insights into how each state selected its financial risk reduction method. Officials also offered advice for other states. Widespread recommendations included allowing ample time for discussions with disability advocacy groups and health plans, allowing two years for financial modeling and start up, and selecting a method that is politically acceptable, financially feasible, and actuarially sound. The primary impediment to diagnostic-based payments is lack of data.

Health plan selection criteria by people with impaired mobility.

BACKGROUND: Many decision-support tools for consumers selecting a health plan include a module measuring peer-group satisfaction with service and quality of care. The most widely used tools are sufficient for most people, but fail to report measures that are important to many individuals with disabilities. OBJECTIVES: To elicit health plan selection and assessment criteria by groups of people with one type of functional impairment arising from different origins. RESEARCH DESIGN: Observational study and qualitative analysis of structured focus groups. Content analysis of CAHPS survey instruments. SUBJECTS: Each participant had a mobility impairment arising from spinal cord injury, cerebral palsy, rheumatoid arthritis, or multiple sclerosis. Each participant had a choice of health plans. Focus groups were conducted in Phoenix, Philadelphia, and Washington DC. RESULTS: People with mobility impairments arising from the studied conditions desire comparative health plan information on the reliability of transportation to medical appointments, the ability to use an experienced and knowledgeable specialist as a primary provider, and accessible buildings and examination equipment. This study population also seeks information about the experience of their peers in each health plan, especially about benefits administration. CONCLUSIONS: People with mobility impairments arising from spinal cord injury, cerebral palsy, multiple sclerosis, or rheumatoid arthritis currently have little information and little bona fide choice of health plans and physicians. This group of people seeks specific information within the areas of benefit coverage, benefits interpretation and administration, provider panels, accessibility to clinics and equipment, and how to navigate the health plan's grievance and appeals process.

The organization and financing of health services for persons with disabilities.

Americans with disabilities are rarely considered a distinct group of health care users in the same way as are older Americans, children, racial and ethnic minorities, and others who are perceived to have different needs and access issues. Indeed, to some extent individuals with disabilities overlap with all these groups. But they also have distinct needs with material implications for the organization, delivery, and financing of health care services. Despite the disproportionate health care needs and expenditures of many--though not all--individuals with disabilities, the mainstream health services research community has largely neglected them. This article outlines the most pressing health service research issues in addressing the health care needs of individuals with disabilities.