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Perceptions: In the U.S. there is a relative lack of truly integrated medical and rehabilitation care models. Attitudes towards people with disabilities and the lack of “visibility’ of rehabilitation medicine are possible barriers to the integration with medical care. Medical students had less positive attitudes towards people with disabilities than the average person and male students were more likely to hold negative attitudes. Medical Programs: Of the 126 accredited U.S. medical schools; eighty had Accredited Council for Graduate Medical Education programs in rehabilitative and physical medicine residency programs. This is compared to 117 neurology programs, 152 orthopedic surgery programs, 390 programs in internal medicine and 497 family practice programs. The complex network of “levels” of rehabilitation care, from rehabilitation hospital, to skilled nursing facilities, to home health programs, may be a barrier to integration with medical care. “Levels of care” are defined by the location of service, the types of service provided, the intensity of services, type of patients/clients served and the philosophy of the program. Finally, there may be confusion regarding the roles of individual physicians or physician specialties, in providing medical and rehabilitation care in different care settings. Economic Aspects: Many traditional primary care physicians are unwilling to manage complex care for relative low reimbursement. The recent changes for inpatient rehabilitation and skilled nursing facilities create a disincentive for medical procedures, diagnostic testing and expensive medications. CMS has a variety of payment systems, which also may be a disincentive for providers. Rehabilitation Services After Acute Hospitalization: After a person leaves the hospital, there are multiple levels of care that can be used in different ways and in different sequences. The lack of research makes it difficult to compare the effectiveness among levels of care. Question Concerning Integrating Acute, Post-Acute And Chronic Services For High Risk Populations: Who should manage health care for people with chronic disabilities? Traditional primary care physicians? Rehabilitation physicians? An integrated medical plan including both? The availability of “combined specialty” trained physicians is low. There are two demonstration projects that integrate rehabilitation with primary care for people with disabilities: Can people with disabilities use the Program of All-Inclusive Care for the Elderly model? The 1993 Rand Report: According to this report, 16% of Medicare recipients who had a stroke died in the hospital; 54.4% received no post-acute care; 10.6 received care in a SNF; 13.2% received care in a rehabilitation hospital or unit; and 26.3% received home health care. The 1996 Lee Report: According to this report, 73% of Medicare recipients who had a stroke received either post-acute institutional or ambulatory rehabilitation care during the first six months; 16.5% were admitted to inpatient rehabilitation hospital; 23.4% were admitted to a SNF one of more times; and 35.5% received home health services. Second Post-Acute Stays: Of those who used a rehabilitation facility as their first post acute provider, 47.2% had a second post-acute stay; of those who used a skilled nursing facility as their first post acute provider, 23.4% had a second post-acute stay; of those who used a long-term hospital facility as their first post acute provider, 22.6% had a second post-acute stay; and of those who used a home health agency as their first post acute provider, 0.08% had a second post-acute stay. Stroke Units: There is evidence from Europe that people improve better in stroke units, a facility the integrates medical and rehabilitative practices, than people in SNF, and costs 50-64% less. The effects of stroke units are early and long lasting. These units promote early mobilization and prevent secondary conditions. The Copenhagen Stroke Unit Study: Findings show the relative risks of initial death, poor outcome, and 1-year and 5-year mortality were reduced by 40% in patients treated in stroke units compared to general medical wards. 1996 European Helsingborg Declaration: U.S. Data: In the U.S., regulatory and payment systems have largely prevented the development of similar programs: The Glasgow Coma Scale (GCS): The most widely used scoring system used in quantifying level of consciousness following traumatic brain injury. It measures eye response, verbal response and motor response. The Disability Rating Scale (DRS): The scale is intended to measure general functional changes over the course of recovery, tracking an individual from coma to community. The first three items are very similar to GCS, eye opening and communication. The last item is employability. The maximum score a patient can obtain on the DRS is 29 (extreme vegetative state). A person without disability would score zero. The Functional Independence Measure (FIM): A nationally recognized tool for measuring outcomes of rehabilitative care. It consists of 18 items and measures a person's actual performance of basic activities of daily living. Stably employed: employed at all three follow-up intervals. Unstably unemployed: employed at 1 or 2 or 3 follow-up intervals. Unemployed: unemployed at all three follow-up intervals. Predicting Job Stability after a TBI: The objective of the study was to examine job stability moderating variables and to develop a post-injury work stability prediction model. The Numbers: There were 186 adults who had a TBI between the ages of 18 and 62. They were followed-up at intervals 1, 2, 3, or 4 years after the injury. The Results: Stably employed: Forty-four people were stably employed Unstably unemployed: Thirty-six people were employed at 1 or 2 or 3 follow-up intervals Unemployed: Fifty people were unemployed at all three follow-up intervals. The study found that unemployment levels rose from 14% pre-injury to 71% post-injury. Others report similar rates of unemployment after a TBI ranging from 55% to 78%, while some researchers documented much lower levels of unemployment, ranging from 10% to 34%. Differing definitions of employment help contribute to the widely varying return-to-work rates report by different brain injury researches. Determining or Predicting Factors of Employment: Of those who were predicted to be employed, 79% were stably employed; 19% were unstably employed and 2% were unemployed all years. Of those who were predicted to be unstably employed, 27% were stably employed; 63% were unstably employed and 10% were unemployed all years. Of those who were predicted to be unemployed, 10% were stably employed; 24% were unstably employed and 67% were unemployed all years. Driving: Of those who drove their own vehicles, 63% had stable employment; 27% had unstable employment and 10% were unemployed for all three years. Of those who relied on others for transportation, 10% had stable employment, 27% had unstable employment and 58% were unemployed all four years. Days Of Unconscious: The mean was 12.39; for people who had stable employment at was 4.67 days; for people who had unstable employment it was 8.25 days and for people who were unemployed all four years, it was 20.57. Days In Acute Care: The mean was 25.11, for people who had stable employment it was 13.95 days; for people who had unstable employment it was 20.86 days and for people who were unemployed all four years, it was 32.98. Days In Rehabilitation: The mean was 33.2 days: for people who had stable employment it was 21.62 days; for people who had unstable employment it was 33.54 days and for people who were unemployed all four years, it was 53.70. Admission GCS: The mean was 9.11; for people who had stable employment it was 8.61, for people who had unstable employment it was 7.74, and for people who were unemployed all four years, it was 7.51. DRS At Rehab Admission: The mean was 8.11; for people who had stable employment it was 10.81, for people who had unstable employment it was 13.27 and for people who were unemployed all four years, it was 16.59. DRS After One Year: For people who had stable employment it was .27, for people who had unstable employment it was 1.92 and for people who were unemployed all four years, it was 3.83. FIM At Rehab Admission: The mean was 12.39; for people who had stable employment it was 65.38, for people who had unstable employment it was 53.30 and for people who were unemployed all four years, it was 38.96. FIM After One Year: For people who had stable employment it was 123.5, for people who had unstable employment it was 121.18 and for people who were unemployed all four years, it was 111.58 Section 504 of the Rehabilitation Act of 1973: Programs or activities receiving federal assistance must provide “regular or special education and related services… that are designed to meet individual educational needs of handicapped persons as adequately as the needs of non-handicapped persons are met.” Special Education’s Related Services: “Transportation and such developmental, corrective and other services as are required to assist a child with a disability to benefit from special education.” Related services include: speech therapy, recreation therapy, early identification, parent counseling and training, transportation and mobility training. Assistive Technology Devices and Services: Any item, piece of equipment or product system, whether acquired commercially off the shelf, modified or customized, that is used to increase, maintain of improve the functional capabilities of a child with a disability. Who Is Receiving Related Services in Schools: Goals for Rehabilitation Goals for Related Services: Service Delivery Models for Rehabilitation: Services Delivery Models for Related Services: In the past, pull-out therapy was popular, but now there are increasing trends toward integrating therapy in the community and indirect therapy. Return to the top of the page.
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