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.
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.
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.
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).