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Similar to Capitalizing on the Continuum: How Post Acute Rehab & Community-based Telerehab Impact Catastrophic Care
Similar to Capitalizing on the Continuum: How Post Acute Rehab & Community-based Telerehab Impact Catastrophic Care (20)
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Capitalizing on the Continuum: How Post Acute Rehab & Community-based Telerehab Impact Catastrophic Care
- 1. QLIomaha.com @QLIrehab Capitalizing on the Continuum: How Post Acute Rehab & Community-based Telerehab Impact Catastrophic Care
- 2. Why Should You Care? Here’s what’s in it for you… Improve decision making at each level of the continuum of care Improve outcomes with all types of injures, especially complex cases Improve your ability to adapt/guide others to change, adopt new habits and learn new skills…in the workplace, at home, or on the ball field You can win some cash!
- 3. Rebuilding lives is a combination of ART and SCIENCE. Continuum of Care Delivery Model Transitions Learning Concepts
- 5. Asdl;kjasd;lfkjl;kj;lkj; lkj;lkj;lkj;lkj;lkj;lkj;lkj; lkj;lkj;lkj;lkj;lkj;lkj ICU Home or community-based, discipline specific approach. Progress, fine tune, or maintain functional abilities in all aspects of life to promote independence in the home or community. Community-Based Inpatient, interdisciplinary approach. Maximize functional abilities in all aspects of life by addressing ongoing physical, cognitive, social, emotional, and vocational deficits. Post-Acute Care Inpatient, interdisciplinary approach. Stabilize medical status and address ongoing life- threatening issues. Begin addressing physical and cognitive complications. Acute Care Inpatient, highly medical interdisciplinary approach. Constant care and supervision to maintain vital life functions to prevent further physiological decline and reduce mortality. ICU
- 6. Continuum of Care (Full Continuum – Time) ICU Acute Care Post-Acute Care Community- Based Care
- 7. Intensity is the path to excellence. As medical intensity decreases, therapeutic intensity increases. Time from injury Intensity
- 8. Continuum of Care (Outcome Predictability) ICU Acute Care Post-Acute Care Community- Based Care OUTCOME PREDICTABILITY LOW HIGH
- 9. Continuum of Care (Full Continuum – Support) ICU Acute Care Post-Acute Care Community- Based Care LEVEL OF SUPPORT HIGH LOW
- 10. Physician(s) Nursing Physical Therapy Occupational Therapy Speech Therapy Life Path Services Vocational Services Nutrition Support System Life Skills Training Injured Worker Care Coordination Psychology ICU – Post Acute Care (Therapy Team)
- 11. Community-Based (Traditional Therapy Team) Physician(s) Physical Therapy Occupational Therapy Speech Therapy Support System Injured Worker Psychology
- 12. Community-Based (Ideal Multi-disciplinary Therapy Team) Physician(s) Physical Therapy Occupational Therapy Speech Therapy Support System Injured Worker Psychology
- 13. Acute Care Post-Acute Care Community- Based Care ICU Continuum of Care (Functional Recovery Over Time)
- 14. ICU Continuum of Care (Beware of Transitions)
- 17. Navigating the Continuum Risks & Considerations Overwhelmed (Outside Comfort Zone/Interferences) Lack of purpose (Motivate w/ Meaning) Difficulty w/ skill generalization (Tie it to the Task) Social/emotional coping & adjustment Slow or prolonged recovery Greater/extended care needs & caregiver burnout
- 19. Key Concepts Grounded in behavior change theory Bridge the gap b/w clinical and health and wellness Focus on addressing all aspects of life Consider delivery approach, justification of care, & long-term cost
- 20. YES Acute Rehabilitation Setting Is the person likely to improve function w/ restorative care? Skilled Nursing Facility Health Promotion & Wellness Provider(s) Does client show signs of functional recovery? Continue Status change – sign(s) of fxnl recovery or delcine YES Post Acute Rehabilitation Intense, skilled therapy needed? Continue YES NO SIGNIFICANT Requires more frequent visits w/ skilled expertise. Community-based Rehabilitation Capable of monitoring & adapting program? Continue YES YES NO NO MINOR Requires less frequent consultative visits w/ skilled expertise. Decision Making High internal locus of control and self-efficacy? Intermittent formal therapy needs? NO NO Adequate cognitive and/or physical ability/support?
- 21. YES Acute Rehabilitation Setting Is the person likely to improve function w/ restorative care? Skilled Nursing Facility Health Promotion & Wellness Provider(s) Does client show signs of functional recovery? Continue Status change – sign(s) of fxnl recovery or delcine YES Post Acute Rehabilitation Intense, skilled therapy needed? Continue YES NO Community-based Rehabilitation Capable of monitoring & adapting program? Continue YES YES NO NO High internal locus of control and self-efficacy? Intermittent formal therapy needs? SIGNIFICANT Requires more frequent visits w/ skilled expertise. MINOR Requires less frequent consultative visits w/ skilled expertise. NO NO Adequate cognitive and/or physical ability/support? Decision Making
- 22. Health Promotion & Wellness Center Model Acute to Outpatient Continuum HPW Integration Model Skilled Maintenance Model Consultative, Proactive, “Dental” Model COMMUNITY – BASED DELIVERY MODELS Rafferty MR, Held Bradford EC, Fritz S, et al. Health Promotion and Wellness in Neurologic Physical Therapy: Strategies to Advance Practice. Journal of Neurologic Physical Therapy: JNPT. 2021.
- 23. Delivery Models Incorporating Health Promotion and Wellness Model Model 1 = Acute to Outpatient Continuum HPW Integration Model Model 2 = Consultative, Proactive, “Dental” Model Model 3 = Skilled Maintenance Model Model 4 = Health Promotion and Wellness Model Operational Definition Introduce adapted lifestyle Foster independence in community and enhance skills in OP rehab Transition to semi- supervised Provide expertly tailored therapy prescription, monitoring, and progression Restore, improve, or maintain function Use proactively or for long- term monitoring in chronic disease Improve, maintain, prevent, or slow further deterioration Limited functional gains Reasonable, necessary care delivered by skilled personnel Activities are completed with assist and progressed with clinician monitoring or supervision as needed Accessed through rehab or community center Delivery Considerations Gradually fade visit frequency & monitor transition to community Brief episode of care Follow-up episodes recommended depending on self-efficacy, independence, or risk of fxnl decline Bimonthly or monthly visits to monitor and modify program(s) Weekly visits for high-risk patients Transition OP visits to community center
- 24. Interdisciplinary Assessment Is the person likely to improve function w/ restorative care? Acute to OP Continuum HPW Integration Model Skilled Maintenance Model Consultative, Proactive, “Dental” Model Health Promotion & Wellness Model Did the client “plateau”? High internal locus of control and self- efficacy? Skilled therapy needed? Capable of monitoring & adapting program? Continue Continue Continue Degree of assist to monitor & adapt program? NO YES YES YES NO NO NO NO YES LOW - requires less frequent consultative visits w/ skilled expertise YES HIGH - requires more frequent visits w/ skilled expertise Decision Making
- 25. How to Ease the Transition(s) Gather and share information (Identify Interferences) Understand and set expectations (Motivate w/ Meaning) Build/deepen relationships (Motivate w/ Meaning)
- 26. How to Ease the Transition(s) Plan ahead and get to work quickly Ensure facility/clinic access is easy and uneventful (Support for Success) Provide adequate support upon admit/discharge (Support for Success & Tie it to the Task)
- 27. Center of Excellence v. Multi-location model Physician oversight & nursing care Clinical expertise & outcomes Therapy equipment & technology Family housing Service coordination & discharge planning Transportation services Post Acute Considerations What to look for in a program… Intensity Real-world Complexity Transitions
- 28. Telerehabilitation The Obvious Reasons Convenience Rural location – travel time Limited access to transportation Easy to schedule around other activities Access to expertise & specialty care Patient is tech savvy Compliance As a last resort
- 29. Telerehabilitation Other Considerations Contextual training environment Clinical team collaboration Caregiver involvement Level of disability & support needed Client Preference
- 30. Synchronous Telerehab Clinic-based Rehab Most Important 2nd Most Important Sum Most Important 2nd Most Important Sum Degree of Disability 23 24 47 28 24 52 Clinical Expertise 26 14 40 33 19 53 Travel Convenience 26 25 51 6 18 24 Client Preference 6 14 20 13 12 21 Speed of Tx Initiation 8 7 15 8 13 21 Cost Savings 0 5 5 1 3 4 Telerehab v. Clinic-based Rehab
- 31. Synchronous Telerehab Clinic-based Rehab Most Important 2nd Most Important Sum Most Important 2nd Most Important Sum Degree of Disability 23 24 47 28 24 52 Clinical Expertise 26 14 40 33 19 53 Travel Convenience 26 25 51 6 18 24 Client Preference 6 14 20 13 12 21 Speed of Tx Initiation 8 7 15 8 13 21 Cost Savings 0 5 5 1 3 4 Telerehab v. Clinic-based Rehab
- 32. Synchronous Telerehab Clinic-based Rehab Most Important 2nd Most Important Sum Most Important 2nd Most Important Sum Degree of Disability 23 24 47 28 24 52 Clinical Expertise 26 14 40 33 19 53 Travel Convenience 26 25 51 6 18 24 Client Preference 6 14 20 13 12 21 Speed of Tx Initiation 8 7 15 8 13 21 Cost Savings 0 5 5 1 3 4 Telerehab v. Clinic-based Rehab
- 33. Telerehab Assessment Specific to Client’s Needs A thorough assessment determines the service delivery approach. Virtual v. In-person Objective v. Functional Collaborative therapy plan of care Therapy duration/frequency Clear & measurable goals
- 34. Wrap up slide – main points
- 36. Resources Cope, et al. (2004) – Rehabilitation Comprehensive, multidisciplinary approach has value Early access to comprehensive rehabilitation is important Advantage of treatment in multiple settings beyond the hospital Braunling-McMorrow et al., (2010) – Post-Hospital Rehab Significant gains (averaging approximately 1.5 levels) demonstrated across 10 functional outcome measures Cicerone, et al. (2005) – Cognitive Rehabilitation Strategy training for mild memory impairment Strategy training for attention deficits Interventions for functionallv communication deficits
- 37. Resources Rafferty, MR, et al. (2021) - Health Promotion and Wellness Therapy delivery models Decision making for long-term management of chronic disease Kerschke, et al., (2021) – CM Perceptions of Telerehab Comparing the perceptions of telerehab v. clinic-based rehabilitation Despite anecdotal outcomes, significant incongruity between the two approaches exists
Editor's Notes
- Steve opening and giving background on the reason for the visit, conversations, and intro Custer. Ask Heddi about an intro.
- Specialized staff and how we can pick up where they leave off.
- Steve Is a combination of art and science. As we’ve already alluded to, great outcomes are dependent on program design, which takes into consideration, therapeutic intensity and complexity, the environment, and the transitions that occur throughout the continuum of care. Let’s discuss two models that I’m sure you are all familiar with when it comes to treatment of catastrophic injury: Biomedical - According to the biomedical model, health constitutes the freedom from disease, pain, or defect, making the normal human condition "healthy." The model's focus on the physical processes does not take into account the role of social factors or individual subjectivity. Biopsychosocial - The biopsychosocial model is a broad view that attributes disease outcome to the intricate, variable interaction of biological, psychological, and social factors. This is one of the first major differentiators between a traditional acute rehab and a post-hospital program. It’s also where Art and Science begin to intersect. Great programs get this…and execute it at a high level. Football team – Super Bowl Story – Bill Belichick http://theeagleswire.usatoday.com/2018/01/28/taking-a-look-at-the-eagles-super-bowl-week-schedule/ But is a model that addresses medical, physical, and cognitive recovery enough? Cue the Biomedical Model discussion. What about the emotional aspect of recovery, and also the social aspects – or maybe barriers – to recovery? What if, instead of treating a brain injury – we were treating a person who has a brain injury? And in the process of treating the person, we acknowledged as aspects of who they are and their life. In doing so, this leads us to better address the emotional and social aspects, not only as part of our clinical model, but as the most important part of our clinical model. This is hard to do in a hospital or acute setting, where medical needs are urgent and trump all other things. But at the post-acute level, when an individual is relatively medically stable, this is doable – more complicated for sure – but possible. Forgive me if this sounds fluffy, but it is usually the emotional and social factors that determine success – or failure. Hands down. (pause) We talked about your goal. Well, the goal should be to help our clients rebuild a life that they look forward to living. REBUILDING A LIFE… that’s a REALLY complex thing and the ultimate rehabilitative challenge.
- You all are now likely familiar with how things progress after an injury. But talking about the continuum is not a foregone point. Not that many years ago, individuals with a brain/spinal cord injury would (and still do) get discharged directly to a skilled facility. What we have learned over the years and what we have learned from the research is that Rehab at the Right Time is equally as important as Rehab at the Right Place.
- Steve If you type “post-acute rehabilitation” into your browser, pages and pages of provider websites pop up and after looking through several of them, I noticed there is a very wide range of services that we classify as “post-acute rehabilitation”, from inpatient facility to home health services. With no specific definition or identify for post-acute rehab, I suppose as providers, we each have a lot of leeway to decide what services we provide under this label. Now, one common thing I did notice among the definitions was that post-acute rehab is pretty clearly considered to be a step down – much less intensive – compared to acute rehabilitation. Admittedly, I’ve made the same mistake of assuming it to be less intense than rehabilitation that happens in a hospital and maybe a little more intense than the orthopedic outpatient therapy setting. I suppose my view was based on how the recovery process works for most other injuries – after an orthopedic injury for example, the acute care is relatively intense and then, once there’s no longer a need for around-the-clock medical care, an individual can start to manage their own recovery process with rapidly decreasing support from healthcare professionals. I think my view was then reinforced by the fact that post-acute rehabilitation was less expensive than hospital level of care. There’s no way something could be less expensive and more intense, right? More to come on this. We find that nearly everyone in our industry expects post-acute rehabilitation facilities to be a step down from the hospital. But the definition of acute rehab doesn’t include anything about intensity – it is short-term, immediate care. So really, it’s just the beginning of the rehab process. It is a critically important part of the recovery process – the foundation. But it’s like building a house – you wouldn’t pour the foundation and frame it then hand it over to the home owner to figure out the rest. Building the rest of the house is incredibly complex and takes coordination of sub-contractors, as an example, to come together in a particular way to make an individualized structure for the owner. And, the process beyond laying the foundation takes way more time. There’s no doubt the acute rehabilitation process is essential and is the foundation of recovery, but post-acute rehab should be the most intensive part of the rehabilitation continuum. It is a step up in the rehabilitation process. It makes sense that post-acute rehabilitation should be a step up in the rehab process because as medical intensity goes down and hospital level of care is no longer necessary, therapeutic intensity should go up. As medical stability, endurance, and strength improves, the intensity of therapy should be higher in both frequency and duration than you would expect in other settings. All to often, it is assumed that individuals, with support of their families, can navigate their own recovery once they are medically stable. That is certainly true for most other injuries. We do see individuals who are emotionally fit, have terrific family support, and have a steady positive recovery who navigate this successfully. This is not the norm. For the population we are all serving, it is more likely that things aren’t quite this simple. It is more likely that, although an individual may be medically stable and even have some of the qualities and resources listed above, they need increasing support to effectively facilitate recovery. 2017 Updates: Family housing, lake on campus, gait lab/new addition, archery range – Need a slide?
- Steve (primary) – work to transition to Kristin Reiterate equipment, specialization, etc. here, especially with the geography component.
- All about ID interferences and supporting for success
- All about ID interferences and supporting for success
- All about ID interferences and supporting for success
- Volatility Chaos Predictability Stability Proactive v. Reactive
- Billing and scheduling constraints make it easier to use our immediate surrounding – an office or therapy room – to provide rehab. But this sterile setting isn’t anything like the real world. And the generalization of skills is challenging, if not impossible, for many individuals with a BI and even those with SCI. And rehab out of the context of the real world is rarely motivating. It also doesn’t allow us to discover barriers that may interfere with someone’s success. Instead, effective therapy should be done in the context of intrinsically motivating real life tasks and provided in functional environments … not therapy rooms or institutional type settings. With a little creativity and access to technology, real world environments can provide a place where all of our rehabilitation happens so our clients are fully engaged and learning routines. This way we don’t rely on the abstract generalization of skills. No matter how persuasive our clinicians are, a sterile office can’t trump the quad rugby court.
- Introduce Ana
- Introduce Ana
- What are your biggest resources when discharging if someone needs more? Where are the gaps? Talk to us about your Pathways program. How do you utilize?