A sustainable approach to community based rehabilitation in rural and remote Australia

This paper presents a summary of an extensive review of the health, disability and rehabilitation literature conducted for the purposes of informing the formulation of a sustainable approach to community based rehabilitation in rural and remote Australia. It begins with a review of definitions of disability and rehabilitation, which is followed by differentiating 'rehabilitation in the community' and 'community based rehabilitation'. Finally, a network of community based rehabilitation coalitions is proposed as a sustainable approach to community based rehabilitation in rural and remote Australia. Each coalition would have a community rehabilitation facilitator and community specific database of resources, as well as a register of local community rehabilitation assistants who can support the work of health professionals by providing rehabilitation interventions under the latter's direction. In this approach, rehabilitation is conceptualised as being about people's lives rather than only a series of interventions provided by health care professionals. As such, rehabilitation becomes everybody's business.

A process for the systematic review of community-based rehabilitation evaluation reports: formulating evidence for policy and practice

A methodological framework for conducting a systematic, mostly qualitative, meta-synthesis of community-based rehabilitation (CBR) project evaluation reports is described. Developed in the course of an international pilot study, the framework proposes a systematic review process in phases which are strongly collaborative, methodologically rigorous and detailed. Through this suggested process, valuable descriptive data about CBR practice, strategies and outcomes may be synthesized. It is anticipated that future application of this methodology will contribute to an improved evidence base for CBR, which will facilitate the development of more appropriate policy and practice guidelines for disability service delivery in developing countries. The methodology will also have potential applications in areas beyond CBR, which are similarly. evidence poor' (lacking empirical research) but 'data rich' (with plentiful descriptive and evaluative reports).

Classifying client goals in community-based ABI rehabilitation: a taxonomy for profiling service delivery and conceptualizing outcomes

Purpose: To develop, confirm and trial a framework for analysing the content of goals set within community-based rehabilitation. This framework (taxonomy) is proposed as a tool to assist in service evaluation and outcome exploration. Method: Qualitative thematic analysis and categorization of 1765 rehabilitation goal statements in a four phase process of synthesis, refinement, verification and application. Results: A taxonomy of goal content was developed comprising 21 categories within five domains, utilizing 125 descriptors. The taxonomy demonstrated good inter-rater consistency and was able to discriminate between similar but related data sets comprising goal statements. Conclusion: Structured analysis of the content of goal setting (particularly in community rehabilitation) utilizing a framework such as the proposed taxonomy has considerable potential as a 'window' into service delivery to broaden the parameters of existing service evaluation and to more clearly link outcome exploration to intervention.

An organizational perspective on goal setting in community-based brain injury rehabilitation

Purpose. To use a taxonomy of goal content, developed in community-based brain injury rehabilitation to examine and compare the content of goals set within two different service settings; and to further examine the potential of the taxonomy to be a reliable and comprehensive framework for classifying goals. Method. Qualitative analysis and categorization of 1492 goal statements extracted from a community-based brain injury rehabilitation service over two time periods (1996-97, 1998-99), and cross-organizational comparison of ratings of goal classifications using a random sample of 100 goal statements drawn from this data set and the original 1765 goal statements used in developing the taxonomy. Results. Application of the taxonomy beyond the original service setting in which it was developed indicated a strong inter-rater reliability, with a high test-retest agreement reported over time. For both services, a small number of categories accounted for a substantial proportion of goals set within the two time periods, while considerable change was evident in goals between the two periods for one service. Further, both placed emphasis on individually focused goals rather than relationship or family-related goals. Conclusion. The taxonomy provides a reliable means for classifying goals and is a useful tool for exploration of the multiple influences on goal setting. Further application of the taxonomy to examine the relative influence on goal setting of client factors versus a range of organizational factors would be beneficial.

A randomised controlled trial of an enhanced interdisciplinary community based group program for people with Parkinson’s disease: study rationale and protocol

Parkinson’s disease (PD) is a progressive, chronic neurodegenerative disorder for which there is no known cure. Physical exercise programs may be used to assist with the physical management of PD. Several studies have demonstrated that community based physical therapy programs are effective in reducing physical aspects of disability among people with PD. While multidisciplinary therapy interventions may have the potential to reduce disability and improve the quality of life of people with PD, there is very limited clinical trial evidence to support or refute the use of a community based multidisciplinary or interdisciplinary programs for people with PD. A two group randomized trial is being undertaken within a community rehabilitation service in Brisbane, Australia. Community dwelling adults with a diagnosis of Idiopathic Parkinson’s disease are being recruited. Eligible participants are randomly allocated to a standard exercise rehabilitation group program or an intervention group which incorporates physical, cognitive and speech activities in a multi-tasking framework. Outcomes will be measured at 6-week intervals for a period of six months. Primary outcome measures are the Montreal Cognitive Assessment (MoCA) and the Timed Up and Go (TUG) cognitive test. Secondary outcomes include changes in health related quality of life, communication, social participation, mobility, strength and balance, and carer burden measures. This study will determine the immediate and long-term effectiveness of a unique multifocal, interdisciplinary, dual-tasking approach to the management of PD as compared to an exercise only program. We anticipate that the results of this study will have implications for the development of cost effective evidence based best practice for the treatment of people with PD living in the community.

HOME-BASED REHABILITATION AND ITS IMPACT ON HOSPITAL UTILIZATION

There is compelling evidence for the effectiveness of home-based occupational therapy and physiotherapy rehabilitation for community dwelling elderly who may struggle with basic activities and the functions of daily living and mobility. Nonetheless, an estimated 2% of home care’s elderly clients receive these therapies. Ontario’s home care data indicates that 78% of clients that could benefit from these specific therapies are not receiving them. The study examined a subset of elderly clients receiving home care following a hospital discharge during 2009-2010. The aim of this study was to: understand the difference between those home care clients who received occupational therapy or physiotherapy and those who did not; and determine if receiving these therapies impacted the utilization of hospital emergency departments and inpatient admissions. A retrospective cohort design and multivariate and survival analysis of hospital and home care administrative data structured the study. Results suggest that home-based rehabilitation is offered to a minority of the home care population. Distinct client characteristics and process variables significantly associated with the increased likelihood of receiving home-based occupational and physical therapies included: clients who were older, females, admitted to home care from hospital inpatient units, assessed as non-acute for clinical and service needs and required more home making support and assistance with activities of daily living. Almost one quarter of the total sample returned to hospital. Visits to emergency departments accounted for the greater part of hospital utilization and primarily for sub-acute general symptoms and signs, post-procedural complications, infections or acute episodes from chronic obstructive pulmonary disease and renal failure. Slightly over half of the clients returning to hospital did not receive home-based rehabilitation. Clients who received occupational therapy returned to the hospital sooner following their home care admission whereas clients receiving physiotherapy spent the longest time before rehospitalizing. The majority of the clients receiving occupational therapy were admitted to home care having just resolved sub-acute conditions or symptoms, many of which are known to influence functional and physical decline. Moreover, analysis of process variables indicated that the wait time for a referral to occupational therapy was two times longer compared to physiotherapy. These same clients also waited, on average, over one month before an occupational therapist’s first visit. The need to discriminate who receives home-based rehabilitation is essential to understanding how specific therapies contribute to improving systems outcomes. This study is the first examination that focuses specifically on home-based occupational therapy and physiotherapy rehabilitation and the client characteristics and process variables associated with receiving/not receiving these therapies and the impact these factors have on the time-to-rehospitalization.

Managing Risk in a Culture of Rights: Providing Support and Treatment in Community-Based Settings for Persons with Intellectual Disabilities who Sexually Offend

People with intellectual disability who sexually offend commonly live in community-based settings since the closing of all institutions across the province of Ontario. Nine (n=9) front line staff who provide support to these individuals in three different settings (treatment setting, transitional setting, residential setting) were interviewed. Participants responded to 47 questions to explore how sex offenders with intellectual disability can be supported in the community to prevent re-offenses. Questions encompassed variables that included staff attitudes, various factors impacting support, structural components of the setting, quality of life and the good life, staff training, staff perspectives on treatment, and understanding of risk management. Three overlapping models that have been supported in the literature were used collectively for the basis of this research: The Good Lives Model (Ward & Gannon, 2006; Ward et al., 2007), the quality of life model (Felce & Perry, 1995), and variables associated with risk management. Results of this research showed how this population is being supported in the community with an emphasis on the following elements: positive and objective staff attitude, teamwork, clear rules and protocols, ongoing supervision, consistency, highly trained staff, and environments that promote quality of life. New concepts arose which suggested that all settings display an unequal balance of upholding human rights and managing risks when supporting this high-risk population. This highlights the need for comprehensive assessments in order to match the offender to the proper setting and supports, using an integration of a Risk, Need, Responsivity model and the Good Lives model for offender rehabilitation and to reduce the likelihood of re-offenses.

DUI program as OEF/OIF Veterans Outreach: Descriptive Data from Two Community-Based Outpatient Clinics

Although initially conceived as providing simply the preventive portion of an extended continuum of care for veterans, the Driving Under the Influence (DUI) program has turned out to be an important outreach service for active duty or recently discharged OEF/OIF (Operation Enduring Freedom/Operation Iraqi Freedom) veterans. Veterans receive empirically-based, state-mandated education and therapy under the only Department of Veterans Affairs (VA) - sponsored DUI program in the State of Colorado, with the advantage of having providers who are sensitive to symptoms of Post-Traumatic Stress Disorder (PTSD) and other relevant diagnoses specific to this population, including Traumatic Brain Injury (TBI). In this paper, the rapid growth of this program is described, as well as summary data regarding the completion, discontinuation, and augmentation of services from the original referral concern. Key results indicated that for nearly one third (31.9%) of the OEF/OIF veterans who were enrolled in the DUI program, this was their initial contact with the VA health care system. Furthermore, following their enrollment in the DUI program, more than one fourth (27.6%) were later referred to and attended other VA programs including PTSD rehabilitation and group therapy, anger management, and intensive inpatient or outpatient dual diagnosis programs. These and other findings from this study suggest that the DUI program may be an effective additional pathway for providing treatment that is particularly salient to the distinctive OEF/OIF population; one that may also result in earlier intervention for problem drinking and other problems related to combat. Relevant conclusions discussed herein primarily aim to improve providers' understanding of effective outreach, and to enhance the appropriate linkages between OEF/OIF veterans and existing VA services.