Judith A. Falconer

The Critical Path Method in Stroke Rehabilitation: Lessons from an Experiment in Cost Containment and Outcome Improvement

This study tested the effects of a project network technique called the Critical Path Method (CPM) on the costs and outcomes of inpatient team stroke rehabilitation. On admission to a large, academic, inpatient rehabilitation hospital adults who had a recent (< 120 days) stroke were randomly assigned to receive rehabilitation services from a team trained in CPM (N = 53) or from usual care teams (N = 68). Results showed no significant difference between groups in length of stay, hospital charges, or functional status at discharge. CPM may be effective in patient care services that are less influenced by specialization, professional issues, and external regulation and in settings where patient outcomes are relatively fixed and predictable, and medical care is integrated across institutions.

Team Training and Stroke Rehabilitation Outcomes: A Cluster Randomized Trial

OBJECTIVE To test whether a team training intervention in stroke rehabilitation is associated with improved patient outcomes. DESIGN A cluster randomized trial of 31 rehabilitation units comparing stroke outcomes between intervention and control groups. SETTING Thirty-one Veterans Affairs medical centers. PARTICIPANTS A total of 237 clinical staff on 16 control teams and 227 staff on 15 intervention teams. Stroke patients (N=487) treated by these teams before and after the intervention. INTERVENTION The intervention consisted of a multiphase, staff training program delivered over 6 months, including: an off-site workshop emphasizing team dynamics, problem solving, and the use of performance feedback data; and action plans for process improvement; and telephone and videoconference consultations. Control and intervention teams received site-specific team performance profiles with recommendations to use this information to modify team process. MAIN OUTCOME MEASURES Three patient outcomes: functional improvement as measured by the change in motor items of the FIM instrument, community discharge, and length of stay (LOS). RESULTS For both the primary (stroke only) and secondary analyses (all patients), there was a significant difference in improvement of functional outcome between the 2 groups, with the percentage of stroke patients gaining more than a median FIM gain of 23 points increasing significantly more in the intervention group (difference in increase, 13.6%; P=.032). There was no significant difference in LOS or rates of community discharge. CONCLUSIONS Stroke patients treated by staff who participated in a team training program were more likely to make functional gains than those treated by staff receiving information only. Team based clinicians are encouraged to examine their own team. (ClinicalTrials.gov identifier NCT00237757).

Predicting stroke inpatient rehabilitation outcome using a classification tree approach

A classification tree, a nonparametric statistical analysis, was used to develop decision rules to predict a favorable inpatient stroke rehabilitation outcome. Descriptive and functional status data collected on admission from 225 patients were the predictor variables. Favorable outcome was defined as having met three criteria: discharged to community, survival greater than 3 months postdischarge, and no more than minimal physical assistance required in functional activities on discharge. The classification tree correctly classified 88% of the sample using only four of the predictor variables (level of independence in Toilet Management, Bladder Management, and Toilet Transfer, and adequacy of Financial Resources). The cross validation error rate was 18%. The advantages of the classification tree approach over parametric methods are that it is desirable for ordinal data, it readily identifies the interactions among predictor variables, the results are easily communicated, and it provides additional insights into the factors that predict outcome.

Self Report and Performance-Based Hand Function Tests as Correlates of Dependency in the Elderly

Preventing or minimizing functional dependency in older adults rests, in part, upon the ability to predict who is at risk. The purpose of this study was to compare the ability of five tests of hand function to discriminate the degree of dependency in older adults. Seven hundred sixty four subjects were assessed for hand function on performance‐based (Williams Test of Hand Function, a test of Williams Board items only, Jebsen Test of Hand Function, grip strength), and self‐reported (Dexterity Scale of the Geriatrics‐Arthritis Impact Measurement Scale (GERI‐AIMS)) measures of hand function, and self‐reported multidimensional functional status (GERI‐AIMS). A trichotomous variable representing a continuum of dependency based upon living site (independent living, home‐bound, institutional) was used as the measure of dependency. Sixty‐two cases were dropped for incomplete data. Discriminant function analyses of the 702 subjects (age = 76.78 years, SD = 8.79) showed that basic demographic variables explain 40.8% of the variance in dependency; all hand function tests significantly correlated with dependency; the Williams Board correlated best (additional 12.5% variance explained). However, a multidimensional functional status measure explains substantially more variance in dependency (16.9%) after controlling for demographic variables and performance on the Williams Board. This comparison of methods and tests available for measuring hand function was made to provide criteria for selecting an instrument for a given setting.

Stroke Inpatient Rehabilitation: A Comparison across Age Groups

Objective: To examine and compare the inpatient stroke rehabilitation experience of older adults (≥75 years) with that of young adults (<65 years) and young‐old adults (65–74 years).

Reducing hospital costs for the geriatric patient admitted from the emergency department : a randomized trial

OBJECTIVE: To test the impact of a geriatric evaluation and management model on the costs of acute hospital management of emergently admitted older adults.

Self‐Reported Functional Status Predicts Change in Level of Care in Independent Living Residents of a Continuing Care Retirement Community

To test the hypothesis that self‐reported functional status predicts change in level of care from independent to dependent in residents of a continuing care retirement community (CCRC).

Rehabilitation Team Process

Building on a conceptual model of rehabilitation treatment effectiveness, this article presents a typology of the team process. Process emerges from the latent structure (relations) and manifest functions (actions) of the inpatient rehabilitation team. Team relations form the backbone of process and arise from characteristics of the person and the profession. Team actions reveal the manner in which the team does its work and is examined with respect to management and leadership activities. In this complex phenomenon of team process, personal and professional orientations interact with managerial and leadership activities. The successful team finds and creates a proper mix of these influences for desirable patient outcomes.

Patient-focused rehabilitation team cohesiveness in veterans administration hospitals

OBJECTIVE To quantify the relation of hospital culture, 3 levels of leadership (hospital-level administrators, discipline-specific supervisors, attending physician on the team), and physician involvement to patient-focused rehabilitation team cohesiveness. DESIGN Survey research. SETTING 48 Veterans Administration hospitals (VAHs). PARTICIPANTS Six hundred fifty members of 50 rehabilitation teams. INTERVENTIONS Not applicable. Main outcome measures Scales measuring hospital culture, administrative support, supervisor expectations, attending physician support, and physician involvement (independent variables), and patient-focused rehabilitation team cohesiveness (dependent variable). Associations between scales were examined by using a hierarchical linear regression model. RESULTS Patient-focused team rehabilitation cohesiveness was significantly (P<.05) associated with administrative support, supervisor expectations, attending physician support, and physician involvement (Wald chi(2)=1192.66, P<.0001) (R(2)=.6431). There was no statistically significant independent association with hospital culture. CONCLUSIONS Expectations of discipline-specific supervisors and hands-on team leadership and involvement by the attending physician were associated to a significant degree with the extent to which rehabilitation teams in VAHs reported functioning in a cohesive manner. Higher functioning on patient-focused team cohesion indicates that patient services were likely delivered with greater interprofessional communication and joint effort.

Measuring team process for quality improvement.

Abstract Background: Even though team care is pivotal to stroke rehabilitation, we have few tools to measure team process. Process measures of team functioning would benefit stroke rehabilitation outcomes and quality improvement (QI). Objective: To improve measures of team process and evaluate their potential for use in rehabilitation research and QI. Methods: We use item response theory (IRT) to analyze and revise selected scales from the Team Functioning Survey administrated to rehabilitation staff (n=365 at 31 VA hospitals) as part of a national clinical trial (NCT00237757). Revised scales were evaluated for reliability (Cronbach’s alpha) and validity (correlations, predictions of patient outcomes). Results: Eight scales (60 items) were selected from the TFS for analyses based on their specificity to rehabilitation and potential utility in process improvement. Factor analyses supported the dropping of 2 scales and the combining of 2 scales. As indicated by the IRT analyses of scale psychometric properties, poor performing scale items were dropped and item response categories modified needed areas for further development were identified. Cronbach’s alpha for the resultant best 5 scales was good. Intercorrelations varied among scales but were mostly in the moderate ranges. Two of the scales predicted patient outcomes of mFIM™ gain or discharge disposition. Conclusion: The analyses resulted in measures of 5 central components of team functioning: physician support, shared leadership, supervisor team support, teamness, and team effectiveness. IRT enables the scales to be refined and strengthened for use in outcome research and QI. The scales are proposed as another step toward understanding and enhancing team process.