Quality Measure Concepts for Inpatient Rehabilitation That Are Best Understood From the Patient's Perspective.

PURPOSE: The aim of this study was to identify inpatient rehabilitation quality-of-care concepts that are best understood from the patient perspective. DESIGN: We conducted 12 focus groups with 95 former patients, caregivers, and rehabilitation clinicians and asked them to describe high-quality inpatient rehabilitation care. METHODS: We independently reviewed the focus group transcripts and then used an iterative process to identify the quality measure concepts identified by participants. RESULTS: Based on participants' comments, we identified 18 quality measure concepts: respect and dignity, clinician communication with patient, clinician communication with family, organizational culture, clinician engagement with patient, clinician engagement with family, rehabilitation goals, staff expertise, responsiveness, patient safety, physical environment, care coordination, discharge planning, patient and family education, peer support, symptom management (pain, anxiety, fatigue, sadness), sleep, and functioning. CLINICAL RELEVANCE TO THE PRACTICE OF REHABILITATION NURSING: Rehabilitation nurses should be aware of the quality-of-care issues that are important to patients and their caregivers. CONCLUSION: Important patient-reported domains of quality of care include interpersonal relationships, patient and family engagement, care planning and delivery, access to support, and quality of life.

Inpatient Rehabilitation Quality of Care From the Patient's Perspective: Effect of Data Collection Timing and Patient Characteristics.

OBJECTIVE: To compare, by collection time and patient characteristics, inpatient rehabilitation quality measure scores calculated using patient-reported data. DESIGN: Cohort study of rehabilitation inpatients with neurologic conditions who reported their experience of care and pain status at discharge and 1month after discharge. SETTING: Two inpatient rehabilitation facilities (IRFs). PARTICIPANTS: Patients with neurologic conditions (N=391). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We calculated 18 quality measure scores using participants' responses to 55 experience of care and health status questions addressing communication, support and encouragement, care coordination, discharge information, goals, new medications, responsiveness of staff, cleanliness, quietness, pain management, care transitions, overall hospital rating, willingness to recommend, and pain. RESULTS: Of the 391 participants reporting at discharge, 277 (71%) also reported postdischarge after multiple attempts by e-mail, mail, and telephone. Discharge experience of care quality scores ranged from 25% (responsiveness of hospital staff) to 75% (willingness to recommend hospital); corresponding postdischarge scores were 32% to 87%, respectively. Five of the 16 experience of care quality scores increased significantly between discharge and postdischarge. The percentage of participants reporting high pain levels at discharge did not change across time periods. Patients with less education, older age, higher motor and cognitive function, and those who were not Hispanic or black had more favorable quality measure scores. CONCLUSION: Patients' experience of care responses tended to be more favorable after discharge compared to discharge, suggesting that survey timing is important. Responses were more favorable for patients with selected characteristics, suggesting the possible need for risk adjustment if patient-reported quality measure scores are compared across IRFs.

Feasibility of Collecting Patient-Reported Outcomes for Inpatient Rehabilitation Quality Reporting.

OBJECTIVE: To evaluate rehabilitation inpatients' willingness and ability to complete patient-reported outcomes (PROs) and the burden of completion on patients and staff. DATA SOURCES/STUDY SETTING: Two inpatient rehabilitation facilities. STUDY DESIGN: Patients with neurological disorders were assigned randomly to receive a nominal monetary incentive during or 1 month after the stay. DATA COLLECTION: Patients responded using a tablet computer or paper. PRINCIPAL FINDINGS: Of the 1,055 admissions, 74 percent were eligible, and 51 percent of eligible patients completed the survey. Most answered without assistance. A majority completed the survey 1 month after discharge; incentive timing was unrelated to postdischarge completion. Half of the 285 follow-up respondents required at least two reminder calls. CONCLUSIONS: Collection of PROs from rehabilitation patients is feasible. Results inform policy makers regarding feasibility of PRO data in evaluating rehabilitation quality.

Using the NIH Toolbox Cognition Battery (NIHTB-CB) in individuals with traumatic brain injury.

PURPOSE/OBJECTIVE: The NIH Toolbox for the Assessment of Neurological Behavior and Function Cognition Battery (NIHTB-CB) is a common data element for use in individuals with traumatic brain injury (TBI). This study evaluates its sensitivity and specificity in distinguishing individuals with complicated mild, moderate, or severe TBI, and provides support for the construct validity of the NIHTB-CB in individuals with TBI. RESEARCH METHOD: One hundred eighty-two individuals with TBI (n = 83 complicated mild/moderate; n = 99 severe) completed the NIHTB-CB and neuropsychological criterion measures. Complete data were obtained on 158 participants. A control sample of 158 individuals without known neurological impairment was extracted from the NIHTB-CB normative sample. Multivariate analyses of variance determined the sensitivity of the NIHTB-CB measures to TBI and injury severity (complicated mild/moderate TBI, severe TBI, and controls) on the demographically corrected NIHTB-CB composite scores and seven subtests. A descriptive analysis of the sensitivity of each subtest was conducted. Finally, correlations between NIHTB-CB measures and criterion tests assessed convergent and discriminant validity. RESULTS: Multivariate analyses indicated that there was a main effect for group (complicated mild/moderate vs. severe vs. controls) for fluid scores in the NIHTB-CB as opposed to only marginally significant results for the verbal scores. Moderate to strong relationships were found between the NIHTB-CB measures and their corresponding neuropsychological measures (convergent validity), whereas much smaller correlations were found between measures of different cognitive domains (discriminant validity). CONCLUSIONS: Findings provide evidence of construct validity and the clinical utility of the NIHTB-CB in individuals with TBI. (PsycINFO Database Record

Relationships between environmental factors and participation in adults with traumatic brain injury, stroke, and spinal cord injury: a cross-sectional multi-center study.

PURPOSE: To develop and evaluate a model of environmental factors-participation relationships for persons with traumatic brain injury (TBI), stroke, and spinal cord injury (SCI), and test whether this model differed across three diagnostic groups, as well as other demographic and clinical characteristics. METHODS: A cross-sectional observational study included 545 community-dwelling adults with neurological disorders (TBI = 166; stroke = 189; SCI = 190) recruited at three academic medical centers. Participants completed patient-reported measures of environmental factors and participation. RESULTS: The final structural equation model had acceptable fit to the data (CFI = 0.923; TLI = 0.898; RMSEA = 0.085; SRMR = 0.053), explaining 63% of the variance in participation in social roles and activities. Systems, services, and policies had an indirect influence on participation and this relation was mediated by social attitudes and the built and natural environment. Access to information and technology was associated with the built and natural environment which in turn influence on participation (ps < 0.001). The model was consistent across sex, diagnosis, severity/type of injury, education, race, age, marital status, years since injury, wheelchairs use, insurance coverage, personal or household income, and crystallized cognition. CONCLUSIONS: Social and physical environments appear to mediate the influence of systems, services, and policies on participation after acquired neurological disorders. These relations are stable across three diagnostic groups and many personal and clinical factors. Our findings inform health and disability policy, and provide guidance for implementing the initiatives in Healthy People 2020 in particular for people with acquired neurological disorders.

Health and Functional Literacy in Physical Rehabilitation Patients.

BACKGROUND: People with disabilities, who face multiple barriers to care, experience health disparities, yet few studies have measured health literacy in this population. OBJECTIVE: This study evaluated functional literacy, health literacy, fluid cognitive function, and self-reported health in people who live in community dwellings with spinal cord injury, stroke, or traumatic brain injury. METHODS: Participants with a traumatic spinal cord injury, stroke, or traumatic brain injury, one-year postinjury, and age 18 to 85 years, completed a battery of instruments at three medical centers in the Midwestern U.S.: functional literacy (word recognition, vocabulary knowledge), health literacy (comprehension of prose, document, and quantitative health information), fluid cognitive function (memory, executive function, and processing speed), and patient-reported outcomes (mobility, fatigue, sadness, anxiety, social function, and overall health). KEY RESULTS: There were strong correlations between functional literacy, health literacy, and fluid cognitive function. After adjustment for sociodemographic and clinical characteristics, higher health literacy was associated with better mobility, less anxiety, and better overall health; higher functional literacy was associated with less anxiety and better overall health; and higher fluid cognitive function was associated with better mobility, less sadness, better social function, and better overall health. CONCLUSIONS: To effectively address limited health literacy among people with spinal cord injury, stroke, and traumatic brain injury, and ensure that they are able to be informed partners in their health care, intervention is required at the level of patients, providers, and health care delivery systems. A special consideration is to ensure that health information is both well-targeted to people's health literacy levels and accessible for people with a range of physical, cognitive, and sensory limitations. The multimedia self-administered health literacy measure used in this study could be useful to rehabilitation providers and designers of health information and interfaces. [Health Literacy Research and Practice. 2017;1(2):e71-e85.]. PLAIN LANGUAGE SUMMARY: Health literacy represents people's abilities to obtain, understand, and use health information to make informed decisions about their health and health care. People with disabilities face physical, attitudinal, economic, and structural barriers to care. Consideration of health literacy in rehabilitation practice can enhance the effectiveness of the patient-clinician relationship and help address the needs of this population.

An Item Bank to Measure Systems, Services, and Policies: Environmental Factors Affecting People With Disabilities.

OBJECTIVES: To develop a measure of perceived systems, services, and policies facilitators (see Chapter 5 of the International Classification of Functioning, Disability and Health) for people with neurologic disabilities and to evaluate the effect of perceived systems, services, and policies facilitators on health-related quality of life. DESIGN: Qualitative approaches to develop and refine items. Confirmatory factor analysis including 1-factor confirmatory factor analysis and bifactor analysis to evaluate unidimensionality of items. Rasch analysis to identify misfitting items. Correlational and analysis of variance methods to evaluate construct validity. SETTING: Community-dwelling individuals participated in telephone interviews or traveled to the academic medical centers where this research took place. PARTICIPANTS: Participants (N=571) had a diagnosis of spinal cord injury, stroke, or traumatic brain injury. They were 18 years or older and English speaking. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: An item bank to evaluate environmental access and support levels of services, systems, and policies for people with disabilities. RESULTS: We identified a general factor defined as "access and support levels of the services, systems, and policies at the level of community living" and 3 local factors defined as "health services," "community living," and "community resources." The systems, services, and policies measure correlated moderately with participation measures: Community Participation Indicators (CPI) - Involvement, CPI - Control over Participation, Quality of Life in Neurological Disorders - Ability to Participate, Quality of Life in Neurological Disorders - Satisfaction with Role Participation, Patient-Reported Outcomes Measurement Information System (PROMIS) Ability to Participate, PROMIS Satisfaction with Role Participation, and PROMIS Isolation. CONCLUSIONS: The measure of systems, services, and policies facilitators contains items pertaining to health services, community living, and community resources. Investigators and clinicians can measure perceptions of systems, services, and policies resources reliably with the items described here. Moderate relations between systems, services, and policies facilitators and PROMIS and CPI variables provide support for the measurement and theory of environmental effects on social functioning related to participation.