A qualitative study of healthcare provider perspectives on measuring functional outcomes in geriatric rehabilitation.

OBJECTIVES: To explore, from the perspective of healthcare providers, the barriers to and facilitators of using standardized outcome measures of physical function in geriatric rehabilitation settings. METHODS: In-depth semi-structured interviews with medical doctors, nurses, physiotherapists and occupational therapists were conducted from three geriatric rehabilitation hospitals in Ontario. Qualitative content analysis through an inductive approach was used to identify barriers to and facilitators of outcome measurement in geriatric rehabilitation settings. RESULTS: A total of 20 healthcare providers from different disciplines were interviewed. Barriers are standardized outcome measures that (1) cannot be used in isolation to inform clinical decision-making for older patients, (2) are difficult to complete and interpret in older complex patients, (3) may not be useful for all members of the clinical team and (4) are used for reasons unrelated to patient care. Facilitators are to (1) divide the standardized outcome measure into components that are useful for each team member's practice, (2) encourage standardized outcome measures as tools for improving daily communication and (3) provide adequate education and support for their daily use. CONCLUSION: This study revealed important barriers to using standardized outcome measures in geriatric rehabilitation from the perspective of healthcare providers. However, it also identified multiple factors that may help facilitate their use.

Opinion versus practice regarding the use of rehabilitation services in home care: an investigation using machine learning algorithms.

BACKGROUND: Resources for home care rehabilitation are limited, and many home care clients who could benefit do not receive rehabilitation therapy. The interRAI Contact Assessment (CA) is a new screening instrument comprised of a subset of interRAI Home Care (HC) items, designed to be used as a preliminary assessment to identify which potential home care clients should be referred for a full assessment, or for services such as rehabilitation. We investigated which client characteristics are most relevant in predicting rehabilitation use in the full interRAI HC assessment. METHODS: We applied two algorithms from machine learning and data mining - the LASSO and the random forest - to frequency matched interRAI HC and service utilization data for home care clients in Ontario, Canada. RESULTS: Analyses confirmed the importance of functional decline and mobility variables in targeting rehabilitation services, but suggested that other items in use as potential predictors may be less relevant. Six of the most highly ranked items related to ambulation. Diagnosis of cancer was highly associated with decreased rehabilitation use; however, cognitive status was not. CONCLUSIONS: Inconsistencies between variables considered important for classifying clients who need rehabilitation and those identified in this study based on use may indicate a discrepancy in the client characteristics considered relevant in theory versus actual practice.

Communicating during care transitions for older hip fracture patients: family caregiver and health care provider's perspectives.

INTRODUCTION: Older hip fracture patients frequently require care across a variety of settings, from multiple individuals, including their family caregivers. We explored issues related to information sharing during transitional care for older hip fracture patients through the perspectives of both health care providers and family caregivers. METHODS: Thirty-five semi-structured interviews were conducted with family caregivers (n = 9) and health care providers (n = 26) of six hip fracture patients to gather perspectives on information sharing at each care transition, beginning with post-surgical discharge from acute care. Data were analysed using conventional qualitative content analysis methods using NVivo8 software. RESULTS: Both family caregivers and health care providers recognise that family caregivers' involvement has important benefits for patients, but this involvement is frequently limited by poor information sharing. Barriers include limited staff time, patient privacy regulations and lack of a clear structure to guide information sharing. Receiving, not offering, information was the focus of information sharing by both family caregivers and health care providers. CONCLUSIONS: Specific barriers that lead to poor information sharing between family caregivers and health care providers have been identified in this study. Possible interventions to improve information sharing include encouraging communication with family caregivers as standard care practice, educational strategies and more effective use of health information systems and technologies.

Underestimating physical function gains: comparing FIM motor subscale and interRAI post acute care activities of daily living scale.

OBJECTIVE: To investigate the construct validity of the activities of daily living (ADLs) sections of 2 major systems developed to measure functional ability in rehabilitation settings. Health assessment systems can inform care planning as well as policy decision-making on service effectiveness. Frailty, comorbidity, and heterogeneity make it difficult to accurately measure health outcomes for older adults. Objective investigation of the value of geriatric rehabilitation services requires assessment systems that are comprehensive, reliable, valid, and sensitive to clinically relevant changes in older patients. DESIGN: Trained health care workers assessed patients with both tools at admission and discharge. We used Rasch analysis to compare the instruments' dimensionality, item difficulty, item fit, differential item function, and number of response options. SETTING: Musculoskeletal and geriatric rehabilitation units in 2 Ontario hospitals. PARTICIPANTS: Older adults receiving rehabilitation (N=209; mean age ± SD, 78.5±9.3; 67% women). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FIM and the interRAI Post Acute Care Assessment (interRAI PAC). RESULTS: For both the FIM motor and the interRAI PAC ADLs items, the difficulty level of the items was much lower than the participant's level of ability, resulting in a large ceiling effect. Also, on both scales, less actual change in functional ability was required to move between the midlevel response options. CONCLUSIONS: Both scales have limited ability to discriminate between subjects with higher functional ability, which indicates that they may underestimate the effectiveness of inpatient rehabilitation for this group of patients when used alone.

A multi-site study of the feasibility and clinical utility of Goal Attainment Scaling in geriatric day hospitals.

BACKGROUND: Goal Attainment Scaling (GAS) is an individualized goal-setting and measurement approach that is useful for patients with multiple, individualized health problems, such as those served by geriatric day hospitals (GDHs) and other specialized geriatric programmes. PURPOSE: To assess the feasibility and utility of GAS in a multi-site study of six GDH affiliated with the Regional Geriatric Programmes of Ontario. METHOD: Individualized GAS guides were developed for 15 consecutively admitted patients at each site [total n = 90; mean age: 76.2 SD 8.3; 58.9% female; mean attendances: 24.0 SD 10.3]. Staff members (n = 39) were surveyed on their experience with GAS. RESULTS: Mean goals/patient ranged across sites from 2.1 to 4.3. Mean GAS discharge score was 52.3 SD 8.7, close to the theoretically expected values of 50 SD 10. Common goals included mobility, community reintegration, basic and instrumental activities of daily living, medical issues, cognition/communication, and home safety. Estimated mean time to develop a GAS guide ranged across sites from 15.3 to 43.8 min. CONCLUSION: Clients were often involved in goal setting; family involvement was less frequent. The staff survey identified challenges and benefits regarding the use of GAS. Study results are being used to inform a more consistent approach to the clinical and research use of GAS in GDH.

Inpatient versus home-based rehabilitation for older adults with musculoskeletal disorders: a systematic review.

OBJECTIVE: To review and summarize available evidence to compare the outcomes of home-based rehabilitation to inpatient rehabilitation for older patients with musculoskeletal conditions. DATA SOURCES: Relevant articles published prior to August 2011 were identified using MEDLINE, CINAHL and the Cochrane Central Register of Controlled Trials databases. REVIEW METHODS: English-language articles that compared patient outcomes of home-based and inpatient rehabilitation for older adults were included. Outpatient care was not included as home-based or inpatient rehabilitation. Methodological quality of included studies was evaluated by two reviewers using the PEDro scale. RESULTS: A systematic search yielded eight randomized controlled trials and four cohort studies. Older adults who received rehabilitation in the home had equal or higher gains than the inpatient group in function, cognition, and quality of life; they also reported higher satisfaction. CONCLUSION: Home-based rehabilitation may be an effective alternative for treating older patients with musculoskeletal conditions.

Transitional care programs: who is left behind? A systematic review.

OBJECTIVE: Older adults are at risk of rehospitalization if their care transitions from hospital-to-home are not properly managed. The objective of this review was to determine if older patient populations recruited for randomized controlled trials of transitional care interventions represented those at greatest risk of rehospitalization following discharge. Relevant risk factors examined were cognitive impairment, depression, polypharmacy, comorbidity, length of stay, advanced non-malignant diseases, and available social support. DESIGN: Systematic review. SETTING: Hospital to home. PARTICIPANTS: Older hospitalized adults. MEASUREMENTS: For inclusion, articles were required to focus on hospital-to-home transitions with a self-care component, have components occurring both before and after discharge, and a randomized controlled trial design. Articles were excluded if participants had a mean age under 55 years, or if interventions focused on developmental disabilities, youth, addictions, or case management, or were solely primary-care based. RESULTS: Following title, abstract, and full review by two authors, 17 articles met inclusion criteria. Risk factors for rehospitalization were often listed either as exclusion criteria or were not reported at baseline by the studies. One study included patients with all identified risk factors for rehospitalization. CONCLUSIONS: These data suggest that published studies of transitional care interventions do not often include older adults at highest risk of rehospitalization, raising concerns about the generalizability of their results. Studies are needed that evaluate interventions that explicitly address the needs and characteristics of these patients.

Health information use in home care: brainstorming barriers, facilitators, and recommendations.

There is growing recognition of the importance of sharing health information in home care; however, limited research exists to identify appropriate strategies, especially with home care providers. We engaged home care stakeholders from three locations in Ontario to determine facilitators, barriers, and recommendations for using health information in home care. The results suggest that health professionals recognize the potential of these systems to enhance communication through several emergent themes; however, there was a lack of agreement on the current facilitators, barriers, and recommendations for future interventions. More research is needed to achieve consensus before strategies for improvement can be initiated.

Comparison of the responsiveness of the FIM and the interRAI post acute care assessment instrument in rehabilitation of older adults.

OBJECTIVE: To compare the responsiveness of 2 major systems developed for rehabilitation settings--the FIM and the interRAI Post Acute Care (PAC) assessment--in older patients. DESIGN: Trained raters assessed patients with both tools at admission and discharge. SETTING: Musculoskeletal (MSK) and geriatric rehabilitation units (GRUs) in 2 rehabilitation hospitals. PARTICIPANTS: Older adults receiving rehabilitation (N=208; mean age +/- SD, 78.5+/-9.3; 67% women). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Responsiveness was evaluated using effect size (ES) and standardized response mean (SRM). RESULTS: ES and SRM were somewhat higher for the FIM motor (GRU ES=1.68, SRM=1.31; MSK ES=2.12, SRM=2.25) than the PAC (GRU ES=1.64, SRM=1.29; MSK ES=1.57, SRM=1.89) in both patient groups. Both tools were more responsive in MSKs than GRUs. This may reflect the greater frailty and clinical complexity of GRU patients. CONCLUSIONS: Both the FIM motor and the PAC were able to detect clinically relevant improvement in functional ability in older rehabilitation inpatients.

The use of electronic health information systems in home care: facilitators and barriers.

Electronic health information systems (EHIS) containing standardized assessment data (e.g., RAI-Home Care, Outcome and Assessment Information Set [OASIS]) hold considerable promise, but their potential has yet to be fully realized. Literature was searched for strategies on implementing and using EHIS, including barriers and facilitators of their use in home care. Results of this review will be discussed in terms of their implications for the future development and use of EHIS in home care, and for future research.

Comparing the functional independence measure and the interRAI/MDS for use in the functional assessment of older adults: a review of the literature.

BACKGROUND: The rehabilitation of older persons is often complicated by increased frailty and medical complexity - these in turn present challenges for the development of health information systems. Objective investigation and comparison of the effectiveness of geriatric rehabilitation services requires information systems that are comprehensive, reliable, valid, and sensitive to clinically relevant changes in older persons. The Functional Independence Measure is widely used in rehabilitation settings - in Canada this is used as the central component of the National Rehabilitation Reporting System of the Canadian Institute of Health Information. An alternative system has been developed by the interRAI consortium. We conducted a literature review to compare the development and measurement properties of these two systems. METHODS: English language literature published between 1983 (initial development of the FIM) and 2008 was searched using Medline and CINAHL databases, and the reference lists of retrieved articles. Relevant articles were summarized and charted using the criteria proposed by Streiner. Additionally, attention was paid to the ability of the two systems to address issues particularly relevant to older rehabilitation clients, such as medical complexity, comorbidity, and responsiveness to small but clinically meaningful improvements. RESULTS: In total, 66 articles were found that met the inclusion criteria. The majority of FIM articles studied inpatient rehabilitation settings; while the majority of interRAI/MDS articles focused on nursing home settings. There is evidence supporting the reliability of both instruments. There were few articles that investigated the construct validity of the interRAI/MDS. CONCLUSION: Additional psychometric research is needed on both the FIM and MDS, especially with regard to their use in different settings and with different client groups.