Rates of attendance at a smoking cessation clinic within a cardiac rehabilitation service

Objectives: Smoking cessation has been shown to be an important intervention for preventing cardiovascular events and improving the health of patients with heart disease. However, unaided quit attempts in these patients often leads to high rates of failure and a return to smoking. Outpatient smoking cessation clinics using face-to-face counseling, ongoing behavioral support, advice on smoking pharmacotherapy and objective monitoring, have been found to be one of the most effective interventions for improving quit smoking rates. An outpatient smoking cessation clinic was trialed within a cardiac rehabilitation service in order to explore its effects on smoking rates for patients with or at risk of heart disease. Attendance rates to the clinic were also monitored. Methods: A descriptive exploratory design was used for this newly developed clinic. Patients who currently smoked tobacco and who had a history of either coronary artery disease, heart failure, atrial fibrillation or those seen under a chest pain assessment service were invited to an outpatient ‘Cardiac Patients Smokers Clinic’. Initially patients were offered up to 10 clinic visits over a 3 month period. Follow-up clinic visits were conducted at 3, 6 and 12 months. A portable carbon monoxide meter was used to objectively measure levels of smoking and validate smoking abstinence. Primary outcomes included rates of attendance. Results: Preliminary findings showed 24 per cent of participants (N = 6) completed all their clinic visits and remained smoke free as measured by their ongoing expired carbon monoxide readings. Clinic attendance rates appeared lowest for those with significant mental health issues such as schizophrenia or substance abuse. However, rates of attendance were improved by having an administration officer make reminder telephone calls prior to clinic visits. Conclusions: Early findings indicate the feasibility of providing a specialist smoking cessation clinic within a cardiac rehabilitation service. Further, that reminder telephone calls prior to appointments improved attendance rates in patients with heart disease to this type of clinic. However, future investigations are warranted.

Development, implementation, and evaluation of the Apollo model of pediatric rehabilitation service delivery

This article presents the experience of a rehabilitation program that un- dertook the challenge to reorganize its services to address accessibility issues and im- prove service quality. The context in which the reorganization process occurred, along with the relevant literature justifying the need for a new service delivery model, and an historical perspective on the planning; implementation; and evaluation phases of the process are described. In the planning phase, the constitution of the working committee, the data collected, and the information found in the literature are presented. Apollo, the new service delivery model, is then described along with each of its components (e.g., community, group, and individual interventions). Actions and lessons learnt during the implementation of each component are presented. We hope by sharing our experiences that we can help others make informed decisions about service reorganization to im- prove the quality of services provided to children with disabilities, their families, and their communities.

Occupational Therapy and Clinical Research in Mental Health Rehabilitation

Practitioners working in Australian mental health services are faced with the challenge of providing appropriate evidence-based interventions that lead to measurable improvement and good outcomes. Current government policy is committed to the development of strategic mental health research. One focus has been on under-researched practice areas, which include the development of psychosocial rehabilitation systems and models that facilitate recovery. To meet this challenge, an Australian rehabilitation service formed a collaborative partnership with a university. The purposes of the collaboration were to implement new forms of service delivery based on consumer need and evidence and to design research projects to evaluate components of the rehabilitation programme. This article examines the process of developing the collaboration and provides examples of how research projects have been used to inform practice and improve the effectiveness of service delivery. Challenges to the sustainability of this kind of collaboration are considered.

Increasing the use of group interventions in a pediatric rehabilitation program: perceptions of administrators, therapists, and parents

Objectives. To explore perceptions related to increased utilization of group interventions as a part of the service reorganization within a pediatric rehabilitation program. Methods. Individual interviews with program administrators (n=13) and focus groups with therapists (n=19) and parents of children with disabilities (n=5) were conducted. Data were analyzed using a coding grid inspired by the organized action systems theory. Results. Administrators and therapists identified several issues including the need to improve the referral process for groups and the coordination across services. Groups considerably modified practice and required substantial efforts from therapists. Administrators felt groups contributed to increased service accessibility. Although therapists had some doubts about service quality in groups, especially in regard to the reduced attention to individual needs, they reported positive benefits on children’s social participation. Generally, parents were satisfied with group interventions. Conclusion. Groups appear to be a promising method of service delivery, but organizational-related issues should be considered.

What aspects of rehabilitation provision contribute to self-reported met needs for rehabilitation one year after stroke - amount, place, operator or timing?

BACKGROUND AND OBJECTIVE: To a large extent, people who have suffered a stroke report unmet needs for rehabilitation. The purpose of this study was to explore aspects of rehabilitation provision that potentially contribute to self-reported met needs for rehabilitation 12 months after stroke with consideration also to severity of stroke. METHODS: The participants (n = 173) received care at the stroke units at the Karolinska University Hospital, Sweden. Using a questionnaire, the dependent variable, self-reported met needs for rehabilitation, was collected at 12 months after stroke. The independent variables were four aspects of rehabilitation provision based on data retrieved from registers and structured according to four aspects: amount of rehabilitation, service level (day care rehabilitation, primary care rehabilitation and home-based rehabilitation), operator level (physiotherapist, occupational therapist, speech therapist) and time after stroke onset. Multivariate logistic regression analyses regarding the aspects of rehabilitation were performed for the participants who were divided into three groups based on stroke severity at onset. RESULTS: Participants with moderate/severe stroke who had seen a physiotherapist at least once during each of the 1st, 2nd and 3rd-4th quarters of the first year (OR 8.36, CI 1.40-49.88 P = 0.020) were more likely to report met rehabilitation needs. CONCLUSION: For people with moderate/severe stroke, continuity in rehabilitation (preferably physiotherapy) during the first year after stroke seems to be associated with self-reported met needs for rehabilitation.

Predicting the grade of disability 1 year after stroke following rehabilitation

The purpose of this study was to identify predictors of grades of disability at least 1 year after stroke rehabilitation therapy. We recruited stroke patients from the inpatient rehabilitation department of a university hospital. The degree of disability was graded using the disability evaluation at least 1 year after stroke onset. Functional ability was evaluated using the Functional Independence Measure instrument on admission, on discharge from the inpatient rehabilitation program, and at the 6-month follow-up visit after discharge. Major sociodemographic, medical, and rehabilitative factors were also collected during the hospitalization period. Of the 109 patients surveyed, 64 (58.7%) had severe or very severe grades of disability. The correlates of severe or very severe disability in logistic regression analyses were bilaterally affected (odds ratio, OR, 10.8), impaired orientation (OR, 3.6), and poorer functional ability at discharge (OR, 7.6). Based on the significant predictors identified, the logistic regression model correctly classified severe or very severe disability in 68.0% of subjects. The higher frequency of severe or very severe disability in this study may have been due to the relatively more severely affected stroke patient population in the inpatient rehabilitation service and the use of unique disability evaluation criteria. These results may provide information useful in planning continuous rehabilitation care and setting relevant socio-welfare policies for stroke victims.

Grounded theory of nursing's contribution to inpatient rehabilitation

There is growing awareness of the benefits of rehabilitation both in Australia and overseas. While the provision of rehabilitation services is not new, recognition of this type of health service as an integral part of health care has been linked to changes in the provision of acute care services, advances in medical technology, improvements in the management of trauma and an ageing population. Despite this, little attention has been paid to nursing's contribution to patient rehabilitation in Australia. The aim of this grounded theory study, therefore, was to collect and analyse nurses' reports of their contributions to patient rehabilitation and to describe and analyse contextual factors influencing that contribution. Data were collected during interviews with registered and enrolled nurses working in five inpatient rehabilitation units in New South Wales and during observation of the nurses' everyday practice. A total of 53 nurses participated in the study, 35 registered nurses and 18 enrolled nurses. Grounded theory, informed by the theoretical perspective of symbolic interactionism, was used to guide data analysis, the ongoing collection of data and the generation of a substantive theory. The findings revealed six major categories. One was an everyday problem labelled incongruence between nurses' and patients' understandings and expectations of rehabilitation. Another category, labelled coaching patients to self-care, described how nurses independently negotiated the everyday problem of incongruence. The remaining four categories captured conditions in the inpatient context which influenced how nurses could contribute to patient rehabilitation. Two categories, labelled segregation: divided and dividing work practices between nursing and allied health and role ambiguity, were powerful in shaping nursing's contribution as they acted individually and synergistically to constrain nursing's contribution to patient rehabilitation. The other two categories, labelled distancing to manage systemic constraints and grasping the nettle to realise nursing's potential, represent the mutually exclusive strategies nurses used in response to segregation and role ambiguity. From exploration of the relationship between the six categories, the core category and an interactive grounded theory called opting in and opting out emerged. In turn, this grounded theory reveals nursing's contribution to inpatient rehabilitation as well as contextual conditions constraining that contribution. The significance of these findings is made manifest through their contribution to the advancement of nursing knowledge and through implications for nursing practice and education, rehabilitation service delivery and research.

Economic evaluation of adult rehabilitation: a systematic review and meta-analysis of randomized controlled trials in a variety of settings

Objectives:
To report if there is a difference in costs from a societal perspective between adults receiving rehabilitation in an inpatient rehabilitation setting versus an alternative setting. If there are cost differences, to report whether opting for the least expensive program setting adversely affects patient outcomes.

Data Sources:
Electronic databases from the earliest possible date until May 2011. All languages were included.

Study Selection
Multiple reviewers identified randomized controlled trials with a full economic evaluation that compared adult inpatient rehabilitation with an alternative. There were 29 included trials with 6746 participants.

Data Extraction
Multiple observers extracted data independently. Trial appraisal included a risk of bias assessment and a checklist to report the strength of the economic evaluation.

Data Synthesis:
Results were synthesized using standardized mean differences (SMDs) and meta-analyses for the primary outcome of cost. The Grading of Recommendations Assessment, Development, and Evaluation was applied to assess for risk of bias across studies for meta-analyses. There was high-quality evidence that cost was significantly reduced for rehabilitation in the home versus inpatient rehabilitation in a meta-analysis of 732 patients poststroke (pooled SMD [δ]=−.28; 95% confidence interval [CI], −.47 to −.09), without compromise to patient outcomes. Results of individual trials in other patient groups (orthopedic, rheumatoid arthritis, and geriatric) receiving rehabilitation in the home or community were generally consistent with the meta-analysis. There was moderate quality evidence that cost was significantly reduced for inpatient rehabilitation (stroke unit) versus general acute care in a meta-analysis of 463 patients poststroke (δ=.31; 95% CI, .15–.48), with improvement to patient outcomes. These results were not replicated in 2 individual trials with a geriatric and a mixed cohort, where costs did not differ between general acute care and inpatient rehabilitation. Three of the 4 individual trials, inclusive of a stroke or orthopedic population, reported less cost for an intensive inpatient rehabilitation program compared with usual inpatient rehabilitation. Sensitivity analysis included a health service perspective and varied inflation rates with no change to the significant findings of the meta-analyses.

Conclusions:
Based on this systematic review and meta-analyses, a single rehabilitation service may not provide health economic benefits for all patient groups and situations. For some patients, inpatient rehabilitation may be the most cost-effective method of providing rehabilitation; yet, for other patients, rehabilitation in the home or community may be the most cost-effective model of care. To achieve cost-effective outcomes, the ideal combination of rehabilitation services and patient inclusion criteria, as well as further data for nonstroke populations, warrants further research.

Taking the good life to the institution: forensic service users' perceptions of the good lives model

Previous literature has highlighted a number of concerns about forensic care and rehabilitation by those who use the services. The Good Lives Model (GLM) is a strength-based, humanistic approach to offender rehabilitation that has been largely overlooked by forensic mental health practitioners. This study explored the impact of a brief GLM program on forensic service users' perceptions of rehabilitation, both within and beyond therapeutic programs, using a thematically linked, multiple-case study research design. Pre-post comparisons of participants' perceptions of rehabilitation suggested three different outcomes: definite change, subtle change, and no change. Possible factors associated with participants' divergent experiences included level of exposure to the GLM, readiness to change, and practitioners' adherence to the GLM and experience with the model. The importance of attending to the wider system for successful implementation of this innovative approach is highlighted.

Vendor payments for medical care under public assistance, by program and type of service : fiscal years 1951-1970.

Cover title.

National social service systems; a comparative study and analysis of selected countries.

Bibliography: p. 74-78.

The Social and rehabilitation record.

Issues for Oct. 1975-Mar. 1976 not published.