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Keywords:

  • Rehabilitation;
  • rehabilitation nursing;
  • disability;
  • functional outcomes;
  • FIM (Functional Independence Measure);
  • evidence-based practice;
  • prospective payment system (PPS)

Abstract

  1. Top of page
  2. Abstract
  3. Purpose
  4. Research Questions
  5. Literature Review
  6. Methodology
  7. Analysis
  8. Limitations
  9. Implications
  10. Future research
  11. Summary
  12. Acknowledgments
  13. References

Purpose

This study provides evidence of the outcome trends following inpatient rehabilitation services.

Methods

The methodology of this study design uses descriptive statistical analysis, paired t-tests, and analysis of variance (ANOVA) to examine multiple variables. This quantitative, non-experimental study describes the research population and the data collection instrument, the inpatient rehabilitation facility patient assessment instrument (IRF PAI), including the Functional Independence Measure (FIM).

Findings

Identified trends provide evidence that functional gains of the disabled population were maintained post discharge from an inpatient rehabilitation facility. Demographics, medical information, and discharge information were studied to describe relationships between the discharge information (discharge living setting, discharge with home health services, discharge to the person living with) and maintained functional performance.

Conclusions

This evidence provides essential information for healthcare providers, including nurses, policy makers, and governments regarding functional gains following inpatient rehabilitation, and community discharge trends of people receiving inpatient rehabilitation services.

Clinical Relevance

The evidence in this study supports that inpatient rehabilitation services should be provided to all persons with disabilities to increase functioning to the greatest level of independence possible. Further evidence-based knowledge regarding the proposed 75% Rule of the Prospective Payment System (PPS) is needed and required, affecting the access and delivery of rehabilitation services. All patients have a right to quality, cost-effective care without restrictions to certain populations to encourage return to community dwelling.


Purpose

  1. Top of page
  2. Abstract
  3. Purpose
  4. Research Questions
  5. Literature Review
  6. Methodology
  7. Analysis
  8. Limitations
  9. Implications
  10. Future research
  11. Summary
  12. Acknowledgments
  13. References

The purpose of this research study was to document trends resulting from inpatient rehabilitation post discharge outcomes. This includes all populations receiving inpatient rehabilitation, even those excluded from the 75% Rule, but exhibiting functional decline with potential for improvement on admission. Although not required by the Centers for Medicare and Medicaid Services (CMS), post discharge assessments help to create accreditation standards and to measure the post rehabilitation progress of a discharged patient. Follow-up assessments provide evidence of rehabilitation program effectiveness, whether patients maintain or continue to make functional gains following inpatient rehabilitation services. Furthermore, this study suggests that inpatient rehabilitation services decreases the burden on the healthcare system by facilitating independence, or the optimum level of functioning, supporting this population's return to the community to live within the society.

Evidence of functional gains following inpatient rehabilitation services is required for payment as described by policy. Section 4421 of the Balanced Budget Act of 1997 (Public Law 105-33), as amended by section 125 of the Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP) Balanced Budget Refinement Act of 1999 (Public Law 106-113), and by section 305 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (Public Law 106-554), authorizes the implementation of a per discharge prospective payment system (PPS), through section 1886(j) of the Social Security Act, for inpatient rehabilitation hospitals and rehabilitation units, referred to as inpatient rehabilitation facilities (IRFs). The IRF PPS will utilize information from a patient assessment instrument (IRF PAI) to classify patients into distinct groups based on clinical characteristics and expected resource needs. Separate payments are calculated for each group, including the application of case and facility level adjustments (CMS, 2011).

Research Questions

  1. Top of page
  2. Abstract
  3. Purpose
  4. Research Questions
  5. Literature Review
  6. Methodology
  7. Analysis
  8. Limitations
  9. Implications
  10. Future research
  11. Summary
  12. Acknowledgments
  13. References

(a) Do inpatient rehabilitation patients maintain functional gains achieved post discharge to the community setting? (b) What is the relationship between discharge information (discharge living setting, discharge with home health services, discharge to the person living with) and maintained functional performance?

Literature Review

  1. Top of page
  2. Abstract
  3. Purpose
  4. Research Questions
  5. Literature Review
  6. Methodology
  7. Analysis
  8. Limitations
  9. Implications
  10. Future research
  11. Summary
  12. Acknowledgments
  13. References

This literature review provides a theoretical perspective of the evidence that guides rehabilitation and outcome trends post rehabilitation. This study population includes all diagnostic or impairment groups meeting rehabilitation criteria for services. Furthermore, studies of follow-up assessments are examined, measuring functional gains following rehabilitation services. Inpatient rehabilitation outcomes are the focus, while other post discharge information is included. In addition, implications of PPSs or financial funding on outcomes and alternative models of rehabilitation delivery are investigated as significant to the rehabilitation patient having successful access to needed services post discharge and in the community.

Scope of the Literature Review

Rehabilitation nursing practice is based philosophically and theoretically on the rehabilitation model of disability and the conceptual models and theories of nursing (Derstine & Hargrove, 2001; Lutz & Bowers, 2003). The rehabilitation model is based on the functionalist perspective of illness and conceptualizes disability as a problem of individual functioning. The social model, however, conceptualizes disability as a problem of the social and physical environments constructed by our society (Lutz & Bowers, 2003). In the evolution of these concepts, theories, and models, the WHO's attempts to integrate the models have carried the assumption of the functionalist model. In addition, the enabling–disabling framework for rehabilitation practice, developed by the Institute of Medicine in 1997, is applied. Conceptual models and theories of nursing practice, specifically that proposed by Orem (Orem, 1991), help define how to care for people with disabilities, with similarities to the functionalist perspective in relation to health deviation self-care. Also grounded in nursing theory, Orem's Self Care Deficit Theory provides an understanding of individual function and varying degrees of dependence or independence of people with disabilities within the society (Orem, 1980, 1985, 1991). Thus, the functionalist perspective guides the definitions of disability and approach to care of people with disabilities in this research study. Disability is often conceptualized from a provider defined, functionalist perspective within rehabilitation practice environments, and should rather include a comprehensive perspective including community outcomes. Therefore, the review of the literature examines studies of discharge trends and outcome measures, post rehabilitation of people with disabilities, based on the evidence-based practice framework.

Evidence-Based Practice

Rehabilitation studies are conducted to generate evidence to guide the practice of rehabilitation and rehabilitation nursing. Healthcare providers should base their treatment decisions or practice, on evidence from well-designed studies, as opposed to decisions based on opinion or tradition. Care delivery outcomes are defined as the observable or measurable efforts of some intervention or action (Melnyk & Fineout-Overholt, 2005, p. 307). These outcomes are focused on the recipient of the rehabilitation service and are measured at the individual, group, organization, and community level. Outcomes research measures the effect of an intervention, directed toward populations, such as those receiving rehabilitation services as people with disabilities.

Melnyk and Fineout-Overholt (2005, p. 301) identifies evidence-based contributors to outcomes. These contributors are grouped by illness severity, patient characteristics, location of services, and provider characteristics. The patient characteristic contributors resemble the descriptive demographics or patient identification data on the IRF PAI (UDS for CMS, 2005). The data grouped and labeled as Discharge Information are not unlike the location of services described in the studies of evidence-based practice. For this study, similar contributors that are included as discharge information are as follows: the community setting the patient is discharged to, whether the patient will be receiving home health services or not, and the person the patient is being discharged with. Therefore, this described data are grouped, labeled, and reported, as identified in the evidence-based practice studies, as contributors to outcomes.

Discharge Trends

In an 8-year empirical study by Ottenbacher et al. (2004), admission, discharge, and follow-up data were reviewed from 226,147 patients, receiving inpatient medical rehabilitation from 744 hospitals in 48 different states in the USA. Trends were documented post discharge, including functional status, length of stay (LOS), discharge setting, and mortality from 1984 to 2001, before implementation of the inpatient rehabilitation PPS of 2002. IRFs increased efficiency as measured by patient functional gain and decreased LOS by 8 days while maintaining stable gains in functional improvement at 3-month follow-up (Ottenbacher et al., 2004). In addition, evidence that earlier admission to rehabilitation produces improved functional outcomes for some impairment or diagnostic groups was supported.

Evidence exists in the literature, supporting the functional performance of patients post discharge from rehabilitation hospitalization. In the studies by O'Connor, Cano, Thompson, and Playford (2005); Poon, Zhu, Ng, and Wong (2005); and Yu, Evans, and Sullivan-Marx (2005), physical functioning improved from admissions to discharge and was maintained at follow-up assessment. The Functional Independence Measure (FIM) was found to be an independent predictor for 1-year outcomes in the studied populations (Poon et al., 2005) and at 3-month follow-up (O'Connor et al., 2005). Poon et al. (2005) found that FIM was statistically significant (0.86) at 12- and 16-week follow-up of this disabled population. Furthermore, the telephone administration of the FIM at 12 and 16 weeks was found to be a useful and cost-effective method for community follow-up of disabled patients, also significant to this study.

In a contrary study by Giaguinto (2006), 176 highly dependent patients with FIM scores of 18–39, discharged within 60 days, were studied. At 1-year follow-up, 89 subjects survived, 72 died, and 14 were not found, with a significantly negative correlation existing between age and FIM score at follow-up (Giaguinto, 2006). However, this study proposed that unexpected improvement of these subjects cannot be ruled out.

An increasing FIM score implied functional improvement when both FIM scores and their changes over time were used to measure changes in functional abilities in a study by Bottemiller, Bieber, Basford, and Harris (2006). Scores at the extremes of the scale correlated with discharge disposition. Lower scores were more likely to discharge to facilities while higher scores (88%) returned home (Bottemiller et al., 2006). Therefore, FIM scores and FIM efficiencies were associated with discharge disposition. These results were also supported by Lutz (2004), who identified the variables of age, gender, and prior living status as having a relationship with discharge.

Contrary to these studies was a 5-year study by Valach, Selz, and Signer (2004). Utilizing the FIM as a predictive tool for LOS and decisions to discharge was examined in their study of 1,047 subjects. Criteria identified included aiming for optimal improvement and different rates of improvement as indicated by FIM (Valach et al., 2004). Authors concluded that further research needs to exist examining these criteria for statistically significant data, but at this time, could not support FIM as a predictor of LOS as it is associated with discharge disposition.

Outcome Measures

In a study by Aitken and Bohannon (2001), reliability and validity of FIM were well established. Results showed that discharge FIM scores were significantly higher than admission FIM scores (p < .001) following inpatient rehabilitation. Adding support to the validity of FIM scores was the consistency of the significant predictors of outcome. Findings recommended the FIM as an effective outcome measure (Aitken & Bohannon, 2001).

Several studies supported the FIM gain as an indicator of discharged subjects functioning at a greater level of independence. Subjects discharged home were more independent in bowel and bladder function, transfer ability, and locomotion as measured by the FIM (Sandstrom & Mokler, 1998). In a study by Lutz (2004), subjects with higher FIM scores were more likely to be discharged to the community associated with a higher level of function (Lutz, 2004). Furthermore, evidence of the potential for discharge to home resulting in longtime economic savings over alternative placements of long-term care was provided by Schmidt, Drew-Cates, and Dombovy (1999). In this study, 63% of subjects studied were discharged home with a FIM score mean of 61.24 and admission FIM score mean of 34.12. The severely disabled in this population also benefited from rehabilitation, even though longer LOS and increased costs were identified (Schmidt et al., 1999). Finally, FIM increased during rehabilitation hospitalization from admission to discharge, with the functional change weakly predicting significantly by therapy units (hours/day) received (Bohannon, Ahlquist, Lee, & Malijanian, 2003).

Research has shown that patients in countries where rehabilitation is offered have more optimal outcomes and achieve a higher level of function than patients in countries where rehabilitation is not available (Health Canada, 2006). In a Dutch rehabilitation setting, a longitudinal study, to determine if FIM assessed progress during rehabilitation, found that FIM was not suitable to assess progress in Dutch rehabilitation (Steppel, 2002). The mean FIM difference between admission and discharge of the subjects was 19.3 (16.9), with only 55% exceeding a difference score (gain) of 13 points, indicating progress and therefore, did not support the FIM as an outcome measurement in this Dutch population.

An Australian national strategy to improve consumer outcomes identified measures of functioning as relevant in monitoring consumer outcomes, as well as quality of life and satisfaction with services. The strategy concluded that the lived experience and the interaction of people with their environment are needed to guide the development of functional outcome measures (Fossey & Harvey, 2001). In the Australian rehabilitation setting, authors stated that further exploration is required for a conceptual framework integrating the disabled's living experience and the interaction with their environment at discharge (Fossey & Harvey, 2001).

Methodology

  1. Top of page
  2. Abstract
  3. Purpose
  4. Research Questions
  5. Literature Review
  6. Methodology
  7. Analysis
  8. Limitations
  9. Implications
  10. Future research
  11. Summary
  12. Acknowledgments
  13. References

Method

The methodology of this quantitative, nonexperimental study identifies and describes the research population and their selection, and the data collection instrument, the IRF PAI (UDS for CMS, 2005). An IRF is a term referred to by the CMS (formerly known as Health Care Finance Administration or HCFA) as inpatient rehabilitation hospitals and rehabilitation units. The PAI is a document that contains clinical, demographic, and other information on a patient, utilized by the Uniform Data System (UDS) by CMS for their insurance payer program. The measurement of the data collection tool, including the FIM, has proven to be consistent and accurate as a measure of disability (UDS for CMS, 2005; Ottenbacher et al., 2004; Ottenbacher, 2005; Poon et al., 2005; Stinemann, 2001; Granger, Hamilton, Linacre, Heinemann, & Wright, 1993). High reliability using intraclass correlation coefficients was found to be greater than 0.85. FIM is the functional assessment instrument included in the Uniform Data System for Medical Rehabilitation (UDSMR) required by CMS (UDS for CMS, 2005). It is composed of 18 items rated on a seven-level scale that represents graduations in function from independence (7) to complete dependence (1). Institutional Review Board approval was obtained from both the academic university and the rehabilitation organization, including tools used.

The study design described, using descriptive statistical analysis, paired t-tests, and analysis of variance (ANOVA), were the research methods selected to examine multiple variables statistically. Statistical analysis determines if rehabilitation patients maintain functional gains post discharge to the community setting. In addition, ANOVA tests the mean differences among the groups by comparing variability within the groups and between the groups (demographics, medical information, discharge information, and follow-up FIM). This analysis determines the relationships of the selected variables and maintained functional performance post discharge. Therefore, this study identifies relationships of discharge information among discharge living setting, discharge with home health services, discharge to person living with, and maintained functional performance.

Sample Group

This study examines the outcome trends of patients discharged from an inpatient rehabilitation setting in an urban rehabilitation hospital in the central southern region of the USA, to the community or home environment. Community or home environment is identified by discharge to home, board and care, transitional living or assisted living (UDS for CMS, 2005). Approximately, 244 patients were expected to be studied that were discharged to these community or home settings. No patients were excluded from participating in the study by the researcher. Of these 244 subjects signing informed consents, 74 subjects declined participation, while 170 subjects agreed to informed consent. A resulting 108 patients actually completed the study (16 deceased; 3 readmitted to acute care; 14 discharged to skilled care; 11 unanswered phone after 3 attempts; 18 phones disconnected or wrong numbers).

Telephone Follow-up

Self-report methods required by telephone follow-up to obtain FIM scores at 80–180 days are dependent on respondents or their proxy, such as family members/relatives, friends, caregivers, or attendants, willingness to verbally share the accurate information of physical performance (Polit & Beck, 2008, p. 369 & 468). Any participating proxy had some participation in the care of the subject (people with disabilities) and was knowledgeable about the functional tasks performed in the inpatient setting before discharge. Arrangements were made before discharge from the inpatient rehabilitation setting for follow-up, informing the people receiving inpatient rehabilitation care and/or their proxy about the expectation for the follow-up phone call. The UDSMR states that follow-up assessments administered 80–180 days after discharge can provide insight into program effectiveness, such as whether patients make functional gains or experience setbacks (UDS for CMS, 2005, p. 2.1).

During the telephone interviews, every effort was made to put the respondents at ease, to encourage openness and honesty, by the use of open- and close-ended questions, without any approval or disapproval by the investigator. The same investigator for the study was responsible for all telephone interviews and for assigning FIM scores for consistency, post training and certification in FIM determination. Informed consent allowed withdrawal from the study at any time if the subject or their proxy did not choose to verbally provide the information. In addition, a decision tree recommended for telephone follow-up and script provided by UDS for CMS (2005) required structure and training to lessen ambiguity, to facilitate obtaining accurate FIM data post discharge. Although, the possible limitation of inaccurate, self-reported data exists, recommendations for this method of post discharge follow-up are made by the CMS (UDS for CMS, 2005). The FIM Decision Tree as recommended by the UDS and script utilized for the telephone interview can be found in the UDS-PRO System Clinical Guide (Uniform Data System for the Centers for Medicare & Medicaid Services of the U.S. Government, 2005, III-8).

Description of the Sample by Impairment Group

The final sample consisted of 108 subjects who received inpatient rehabilitation and were discharged into the community. Community included discharge to the home, board and care, transitional care, and assisted living, as indicated by UDS for CMS (2005) of the IRF PAI. This descriptive information was grouped into impairment groups for all subjects according to UDS coding guidelines (UDS for CMS, 2005). Of the 17 impairment groups, no subjects occurred in pain syndrome, pulmonary disorders, burns, congenital deformities, or developmental disabilities. The largest impairment group of orthopedic disorders was 53% for the total sample. The subjects are identified by impairment group and are included in Table 1.

Table 1. Description of the Impairment Groups of the Sample
Code GroupImpairment GroupTotal nCode n Description
01Stroke1701.13Lt Body Involvement/Rt Brain
01.27Rt Body Involvement//Lt Brain
01.47No Paresis
02Brain Dysfunction 502.13Nontraumatic
02.222Traumatic, Closed Injury
03Neurologic Conditions 703.11Multiple Sclerosis
03.22Parkinsonism
03.31Polyneuropathy
03.41Guillain-Barre Syndrome
03.82Neuromuscular Disorders
04Spinal Cord Dysfunction 104.131Other Nontraumatic Spinal Cord Dysfunction
05Amputation 405.43Unilateral Lower Limb Below Knee (BK)
05.91Other Amputation
06Arthritis 306.23Osteoarthritis
08Orthopedic Disorders5708.1120Status Post Unilateral Hip Fx
08.22Status Post Femur (Shaft) Fx
08.33Status Post Pelvic Fracture
08.41Status Post Major Multiple Fx
08.513Status Post Unilateral Hip Replacement
08.6122Status Post Unilateral Knee Replacement
08.622Status Post Bilateral Knee Replacement
08.94Other Orthopedic
09Cardiac 5095Cardiac
13Other Disabling Impairments 1131Other Disabling Impairments
14Major Multiple Trauma 414.94Other Multiple Trauma
16Debility 2162Debility—Noncardiac/Non-Pul
17Medically Complex 217.71Skin Disorders
17.91Other Medically Complex Conditions

Demographics by impairment group are included in Table 2. Significant in the demographics is the mean age of the sample at 76.57 with a female population (77%) three times greater than males. A predominately white population (79%) by race was indicated, although 21% of the black population was represented with no subjects occurring in other categories.

Table 2. Demographics of the Population by Impairment Group
Demo CharaStroke (01)Brain (02)Neuro (03)Spin Cor (04)Amp (05)Arth (06)Ortho (08)Card (09)Other (13)Multi Trauma (14)Debil (16)Medi Com (17)
N n = 17n = 5n = 7n = 1n = 4n = 3n = 57n = 5n = 1n = 4n = 2n = 2
Age (M)67.0858.475.148382.2585.3375.37699078.7573.581
Gender
Female12 4 3 1 3 249 1 1 4 1 2
Male 5 1 4 0 1 1 8 4 0 0 1 0
Race
Black 2 4 0 0 2 014 0 0 1 0 0
White15 1 7 1 2 343 5 1 3 2 2
Never Married 4 2 0 0 0 0 6 0 0 0 0 0
Married 9 2 7 1 1 120 4 0 0 1 0
Widowed 3 1 0 0 2 225 0 1 4 1 2
Separated 0 0 0 0 0 0 0 0 0 0 0 0
Divorced 1 0 0 0 1 0 6 1 0 0 0 0

Medical information was grouped by impairment groups, indicating discharge and follow-up FIM scores, as well as admission FIM, necessary for LOS efficiency calculation. Comorbidities were grouped in two categories for analysis, 1–3 comorbidities and more than three comorbidities, with no subjects in the sample having zero comorbidities. The FIM efficiency for all impairment groups was greater than 1. The greatest FIM gains from discharge to follow-up were identified in the impairment groups of major multiple trauma, neurologic conditions, and brain dysfunctions, totaling 16 patients. This information is reflected in Table 3.

Table 3. FIM Scores, Comorbidities, and LOS Efficiency by Impairment Groups
VariablesStrokeBrainNeuroSCIAmpArthOrthoCardOtherMTDebMed Comp
FIM (Means)
Admission56.6550.4050.573848.7564.3358.1658.67 64 60.2550.5 64.5
Discharge82.4788.8909381.594.6793.0490107 95.7597106
Follow-up87.9496.898.1499879299.0595.6711111098107
LOS Efficiency 3.19 2.93 2.27 1.9 2.26 1.94 4.24 3.13 3.58 1.63 2.39 5.02
Comorbidities
1–3 4 3 1 0 1 022 1 0 2 2 2
>313 2 6 1 3 335 4 1 2 0 0

Description of the Discharge Information of the Sample

The variables described are those of discharge settings, identified by UDS for CMS (2005) as community settings. Those community settings identified include: home, board and care, transitional care, and assisted living. The majority of these subjects were actually discharged to the home environment, representing 92% (n = 99) of the total subjects (n = 108), with 8% (n = 9) discharged to the other options. Another variable, those receiving home health services, including outpatient therapy, is slightly more than half of the population studied (51%, n = 55). The person or people that the subject was discharged with are represented as: alone, family, friend, attendant, or other. Almost all subjects (n = 90, 83%) were discharged home with another person. The majority of these person(s) were family members, identified by 74% (n = 80) of the subjects. Of the remaining subjects (n = 18, 17%) discharged alone, more than half (10 of 18 subjects) occurred in the orthopedic disorders impairment group. The discharge information included in this study is included in Table 4.

Table 4. Discharge Information by Impairment Group
VariablesStrokeBrainNeuroSCAmpArthOrthoCardOtherMaj TrauDebMed Comp
DC Setting
Home17561415251322
Room & Board001001 200000
Transitional Care000000 100100
Assisted Living000001 200000
HH Services
Yes5341313221120
No12230122530302
Living With
Alone2000111010201
Family14561314041221
Friend000000 100000
Attendant100001 300000
Other001000 300000

Analysis

  1. Top of page
  2. Abstract
  3. Purpose
  4. Research Questions
  5. Literature Review
  6. Methodology
  7. Analysis
  8. Limitations
  9. Implications
  10. Future research
  11. Summary
  12. Acknowledgments
  13. References

Do Inpatient Rehabilitation Patients Maintain Functional Gains Post Discharge to the Community?

To investigate whether inpatient rehabilitation patients maintain functional gains post discharge to the community setting, a paired t-test was employed. The sample results for the 108 patients in the study show an average gain in FIM from discharge to follow-up of 5.778. The standard deviation of the gains in FIM from discharge to follow-up is 9.488. It is notable that over 90% of the 108 study patients experienced maintained or improved functional performance post discharge into the community. Only 10 of the 108 study patients have a follow-up FIM score that is less than the discharge FIM score indicated by a negative score for FIM gain. A graphical summary for the gains in FIM from discharge to follow-up is provided in Figure 1.

image

Figure 1. Summary of FIM gains from discharge to follow-up.

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The p value for the paired t-test in this study is less than .001 (t = 6.33), and therefore the sample results provide very strong evidence that the average change in FIM from discharge to follow-up is positive. A 95% confidence interval for the average gain in FIM from discharge to follow-up is given (3.968, 7.588). In other words, the sample results provide very strong evidence that inpatient rehabilitation patients have a higher FIM score at follow-up than at discharge, on average, and therefore are maintaining, or actually improving, functional performance post discharge to the community. Therefore, rehabilitation patients do maintain functional gains post discharge from inpatient rehabilitation into the community.

The Relationships Between PostDischarge Function and the Independent Variables

Using analysis of variance, the means of the independent variables were compared among three or more groups, identified in this study as demographics, medical information, and discharge information, with the dependent variable of follow-up FIM. The analysis of discharge information was the focus. Discharge information indicated that the majority of subjects were discharged in the community to their home with another person, primarily family members. Furthermore, more than half of the sample received post discharge services, such as home health or outpatient therapy.

A four-way analysis of variance (ANOVA) was performed employing a model that allows the effects of the factors or variables to be studied simultaneously, and to allow interaction effects between the variables. ANOVA results indicated no significant differences in average FIM gains from discharge to follow-up for different demographic information (age, gender, race, marital status, Table 5).

Table 5. ANOVA for FIM Gain and Demographic Information Without Outliers Analysis of Variance for FIM Gain, No Outliers, Using Adjusted SS for Tests
SourceDFSeq SSAdj SSAdj MS F p
Age255.061.800.900.030.970
Gender199.401.421.420.050.826
Race19.920.870.870.030.863
Marital Status3152.51105.6935.231.210.311
Age Category*Gender2145.9094.5947.291.630.204
Age Category*Race294.9135.1217.560.600.549
Age Category*MarSt6209.41279.3046.551.600.159
Gender*Race189.460.180.180.010.937
Gender*Mar St341.9226.758.920.310.820
Race*Mar St3114.71114.7138.241.320.276
Error732121.772121.7729.07  
Total973134.98    

In addition to ANOVA analysis with and without outliers, a Mann–Whitney test provided strong evidence that the gain in FIM is higher for those with fewer comorbidities (2 to 3), as compared with those with more than three comorbidities. The ANOVA with and without outliers did not show any significant effects due to impairment groups nor LOS efficiency. The three-way ANOVA and Levene's test for equal variances of treatment groups determined that there were no significant effects due to access to home services (including outpatient services) nor to the person living with (Table 6).

Table 6. ANOVA for FIM Gain of Discharge Information Without Outliers Analysis of Variance for FIM Gain With No Outliers for Discharge Information Using Adjusted SS for Tests
SourceDFSeq SSAdj SSAdj MS F P
Home Services126.3318.6318.630.510.478
Discharge With492.8885.9921.500.590.674
Living Setting3277.04277.0492.352.520.063
Error903304.083304.0836.7 l  
Total983700.32    

However, the living setting discharge was found to have a relationship with maintained functional gain. Although the living setting was further examined, making statistical comparisons between the small groups was difficult. The distribution with the residuals has four low outliers and five high outliers, combined with the previous subsets. A graphical summary of the residuals from the ANOVA is provided in Figure 2.

image

Figure 2. ANOVA for discharge information with residuals.

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Limitations

  1. Top of page
  2. Abstract
  3. Purpose
  4. Research Questions
  5. Literature Review
  6. Methodology
  7. Analysis
  8. Limitations
  9. Implications
  10. Future research
  11. Summary
  12. Acknowledgments
  13. References

Limitations of the study identified include impairment groups or diagnoses, ethnic considerations, attrition, and mortality. The limitation that conclusions cannot be generalized from this study's results to individual impairment groups or diagnosis is acknowledged. Some impairment groups, such as spinal cord dysfunction, other disabling conditions, debility, and medically complex groups had only one to two subjects in each impairment group in the sample. On the contrary, orthopedic disorders and stroke impairment groups comprised 69% of the sample. Therefore, the results should not be generalized to specific impairment groups due to limited numbers available in the sample. In addition, the results of this study should not be generalized to the population of inpatient rehabilitation patients receiving rehabilitation services and discharged to the community, noting that results occurred in one geographic area.

The limitation of the lack of diversity of the demographics of the population studied was identified. The predominately white population (79%) with representation of the black population (21%) eliminated any other variances of ethnicity. However, 90% of the population growth in the USA by 2050 is expected to be attributed to minorities (U.S. Census Bureau, 1999). Therefore, the lack of minorities and diversity in the studied population is identified as a limitation.

The attrition of the subjects in the final sample size indicated a greater population than anticipated. The deceased subjects (>9%) at follow-up contributed to this attrition. The mean age of the sample occurred at 76.57 years old in a population with a life expectancy of 79.8 years in females and 72.4 years in males (Stanhope & Lancaster, 2008, p. 665; CDC, 1999). In addition, the existence of comorbidities in all subjects was documented, with 65% having more than three comorbidities. The multiple comorbidities and advanced age of the population studied were thought to have contributed to attrition.

The primary threat of reliability to this study is the threat of self-report. However, the assignment of function by an ordinal measurement scale (FIM) reduces the threat. In addition, the same investigator obtaining all data and utilizing the FIM Decision Tree and script (UDS for CMS, 2005), certified and trained in FIM assignment and interview techniques, reduces the threat. Compounded with the threat of attrition, the limitation was acknowledged by obtaining telephone numbers of at least two people, with whom the subject or family identified as a close relative or next of kin, as well as the contact telephone number of the subject and/or caregiver, providing any needed post discharge care in the home.

Key Practice Points

  • Patients maintain functional gains post discharge to the community following inpatient rehabilitation.
  • Inpatient rehabilitation supports discharge to the community of people receiving inpatient rehabilitation.
  • Inpatient rehabilitation services should be provided equally to people with disability for optimal levels of functioning.
  • Evidence-based knowledge regarding the current prospective payment system is needed and required for policy development.
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Implications

  1. Top of page
  2. Abstract
  3. Purpose
  4. Research Questions
  5. Literature Review
  6. Methodology
  7. Analysis
  8. Limitations
  9. Implications
  10. Future research
  11. Summary
  12. Acknowledgments
  13. References

This study provides evidence of the discharge outcomes of patients receiving inpatient rehabilitation care. The sample studied, maintained, or exceeded their functional gains post discharge from inpatient rehabilitation into the community. This functional independence in this population of people with disabilities allows and encourages return to the community. Therefore, the burden of care or the loss of healthy life resulting from disability on the healthcare system is lessened by the intervention of rehabilitation services. People with disability returning to the community, with improved and/or maintained function, lessen the need for this population to be cared for by society. In addition, the burden of care on the healthcare system of people with disabilities is lessened by the intervention of rehabilitation services. The global burden of disease (Institute of Medicine, 2001) combines losses from premature death and losses of healthy life style from disability (Stanhope & Lancaster, 2008, p. 82). This global burden of disease does not contribute to the economic growth of the community and recognizes that people with disabilities may need to be cared for. Functional independence, or the optimum level of function achieved, in this population of people with disabilities supports the intervention of rehabilitation services.

The implication from these findings for nursing practice is the need for effective rehabilitation programming. This study of evidence of the improved function of people with disabilities results in discharge to the community. As a result of the rehabilitation intervention, return to the community is possible as opposed to institutionalization. Therefore, appropriate discharge decisions into the community could be best determined after inpatient rehabilitation services are received and functional gains are determined and accomplished as indicated by this study. Community living of people with disabilities promotes independence and is encouraged as the optimal goal of rehabilitation services. The need for clearly defined and measureable outcomes across the continuum of care, including discharge, is needed to assist in effective discharge planning and successful community living.

The evidence needed for policy makers, healthcare providers, and funding sources to determine effective payment systems has been described. The subjects for this study represented a population that did not all qualify for rehabilitation services, according to the 75% Rule. However, the subjects met admission criteria for inpatient rehabilitation. The 75% Rule is a criterion used by the CMS to determine if a facility may be classified as an IRF. The PPS is a system of payments to a healthcare facility (IRF) at a predetermined rate for treatment regardless of the cost of care for a specific patient (UDS for CMS, 2005). The implication is that the current PPS is not inclusive of all people with disabilities that might benefit from inpatient rehabilitation services, as evidenced by the documented FIM gains post discharge from inpatient rehabilitation and discharged into the community. Rehabilitation nurses and all rehabilitation providers have a vital role as patient advocates for rehabilitation care and must be responsible in influencing policies that direct that care. All healthcare providers must take an active role in understanding the regulations and requirements that direct rehabilitation and provide reimbursement in a cost-driven healthcare system (Black, 2009).

Future research

  1. Top of page
  2. Abstract
  3. Purpose
  4. Research Questions
  5. Literature Review
  6. Methodology
  7. Analysis
  8. Limitations
  9. Implications
  10. Future research
  11. Summary
  12. Acknowledgments
  13. References

Recommendations for future study include the need for evidence-based practice studies in rehabilitation and rehabilitation nursing. Replication of this study with a larger sample size influencing outcomes of each impairment group, with a more diverse population is needed. In addition, determining the causes of the trends or relationships identified following inpatient rehabilitation, as they relate to rehabilitation efficiency, is a recommendation for further study. Rehabilitation has failed to document clearly the effects of needed, rehabilitation services. The Rehabilitation Research Agenda is consistent with these findings, with a high priority research issue including “the effectiveness of rehabilitation programs with respect to individual and/or family outcomes across the continuum of care” (Jacelon, 2007, p. 29). The need for studies of effective rehabilitation programming including access is paramount to provide cost-effective, quality rehabilitation programs that meet the needs of people with disabilities. This investigation is critical in the development of an evidence-based practice of rehabilitation, including rehabilitation nursing intervention.

Summary

  1. Top of page
  2. Abstract
  3. Purpose
  4. Research Questions
  5. Literature Review
  6. Methodology
  7. Analysis
  8. Limitations
  9. Implications
  10. Future research
  11. Summary
  12. Acknowledgments
  13. References

The need for evidence-based practice in rehabilitation is identified. The need for effective policy development is reviewed, including the outcome instrument (FIM), the effect and relationship of discharge variables, and the population studied. The findings of this study indicate that inpatient rehabilitation patients maintain functional gains achieved post discharge to the community. It can be concluded from the findings of this study that age, race, gender, marital status, impairment group, LOS efficiency, discharge with home service and person living with had no significant relationships with the follow-up function post discharge to the community in the subjects studied. However, there was a relationship identified with fewer comorbidities and greater functional gains. The discharge living setting was also found to have a relationship with maintained functional gain, but statistical comparisons were difficult due to the few numbers in the diagnostic categories. Therefore, trends or relationships of the selected variables of demographics, medical information, and discharge information are described. The limitations of the study were identified, including impairment groups or diagnoses, ethnic considerations, attrition, mortality, and proxy versus self-report.

Based on the outcomes of this study, needed evidence is available to the government, policy makers, and healthcare providers for the population of people with disabilities. Evidence-based knowledge regarding the proposed 75% Rule of the PPS is needed and required for policy development, affecting the access and delivery of rehabilitation services. This study provides knowledge needed relevant to people with disabilities receiving quality, cost-effective care without restrictions to certain populations of people with disability as measured by functional outcomes. Therefore, inpatient rehabilitation services should be provided equally to people with disability to increase functioning to the greatest level of independence possible. This opportunity for rehabilitation could result in discharge from inpatient rehabilitation services into the community as opposed to institutional living. Recommendations for future studies are proposed, identifying the need for evidence-based practice studies in rehabilitation and rehabilitation nursing.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Purpose
  4. Research Questions
  5. Literature Review
  6. Methodology
  7. Analysis
  8. Limitations
  9. Implications
  10. Future research
  11. Summary
  12. Acknowledgments
  13. References

Acknowledgments and appreciation for the completion of this research study include: University of South Africa, Pretoria, Health Studies, Professor Makhubela Nkondo, Supporter; HealthSouth Rehabilitation Corporation, HealthSouth North of Memphis, Facility #030164, Institutional Approval #03043 awarded, Research Permission Received; Arkansas State University, College of Nursing and Health Professions, Dr. Susan Hanrahan, Dean; Office of Organized Research Transfer and Technology, Funding Awarded, IRB approval including request for continuation (includes Informed Consent); Dr. Debra Ingram, Department Chair of Statistics, Arkansas State University.

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  2. Abstract
  3. Purpose
  4. Research Questions
  5. Literature Review
  6. Methodology
  7. Analysis
  8. Limitations
  9. Implications
  10. Future research
  11. Summary
  12. Acknowledgments
  13. References
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