Analysis of factors affecting demand for rehabilitation services in Ontario, Canada: A health-policy perspective

A qualitative description of primary health care patients' perspectives on factors influencing demand for rehabilitation in Zimbabwe

PURPOSE

Although the need for rehabilitation is increasing in Zimbabwe, rehabilitation remains undervalued. Currently, Zimbabwe struggles to provide rehabilitation services at primary health care. To justify the need for establishing rehabilitation at this level of care, the demand for these services needs to be understood. This study describes the factors influencing the demand for rehabilitation by adults attending primary healthcare in Zimbabwe.

MATERIALS AND METHODS

The study used a qualitative descriptive approach. In-depth interviews were conducted with 18 purposefully selected patients in the Shona language and audio recorded. Transcribed data were translated and back-translated. Thematic analysis was done using Atlas.ti. version 22.2®.

RESULTS

Most patients at primary health care were not actively seeking nor were they able to utilise rehabilitation services because of several factors. The factors identified from the patients' responses were categorised into (i) patient and family-, (ii) healthcare professional-, and (iii) health system-related factors. Key factors included rehabilitation awareness and availability of rehabilitation.

CONCLUSION

The identified factors may inform rehabilitation service and policy planners in improving primary health care patients' access to rehabilitation in similar low-resource settings. Future studies may determine how the identified factors may be addressed to ensure that high need translates to high demand.

Prevalence of Unmet Rehabilitation Needs Among Canadians Living With Long-term Conditions or Disabilities During the First Wave of the COVID-19 Pandemic

OBJECTIVE

We aimed to describe the prevalence of unmet rehabilitation needs among a sample of Canadians living with long-term conditions or disabilities during the first wave of the COVID-19 pandemic.

DESIGN

Cross-sectional survey.

SETTING

Individuals residing in Canada during the first wave of the COVID-19 pandemic.

PARTICIPANTS

Eligible participants were Canadians living with long-term conditions or disabilities, 15 years or older living in 1 of the 10 provinces or 3 territories (n=13,487).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

We defined unmet rehabilitation needs as those who reported needing rehabilitation (ie, physiotherapy/massage therapy/chiropractic, speech, or occupational therapy, counseling services, support groups) but did not receive it because of the COVID-19 pandemic. We calculated the national, age, gender, and province/territory-specific prevalence and 95% confidence interval of unmet rehabilitation needs.

RESULTS

During the first wave of the pandemic, the prevalence of unmet rehabilitation needs among Canadians with long-term conditions or disabilities was 49.3% (95% confidence interval [CI]; 48.3, 50.3]). The age-specific prevalence was higher among individuals 15-49 years old (55.6%; 95% CI [54.2, 57.1]) than those 50 years and older (46.0%; 95% CI [44.5, 47.4]). Females (53.7%; 95% CI [52.6, 54.9]) had higher unmet needs than males (44.1%; 95% CI [42.3, 45.9]). Unmet rehabilitation needs varied across provinces and territories.

CONCLUSIONS

In this sample, almost 50% of Canadians living with long-term conditions or disabilities had unmet rehabilitation needs during the first wave of the COVID-19 pandemic. This suggests that a significant gap between the needs for and delivery of rehabilitation care existed during the early phase of the pandemic.

How Might We Have Known? Using Administrative Data to Predict 30-Day Hospital Readmission in Clients Receiving Home Care Services from 2018 to 2021

Background

Reducing hospital readmissions can improve individual health outcomes and lower system-level costs. This study aimed to understand the characteristics of home care Personal Support clients who experienced a hospital admission (ie, hospital hold) and to identify factors that predict hospital readmission within 30 days of resuming home care Personal Support services.

Methods

We conducted a retrospective cohort study using client administrative data from a home healthcare provider organization (2018-2021). The sample included clients (⩾18 years) who received publicly funded Personal Support services and experienced a hospital hold. Descriptive statistics and a binary logistic regression model analyzed the relationship between demographics, hospital service utilization, home care service utilization, and contextual factors on the outcome of 30-day hospital readmission.

Results

Approximately 17% (n = 662) of all clients with a hospital hold (n = 3992) were readmitted to hospital within 30 days. Compared with non-readmitted clients, those with greater home care Personal Support service intensity after the index hospital hold were less likely to experience a hospital 30-day readmission. In contrast, those with greater acuity, higher assessed care needs, more hospital holds overall, more extended hospital stays (⩾2 weeks), and lower social support had a higher likelihood of 30-day hospital readmission.

Conclusion

The findings from this study provide a greater understanding of factors associated with home care clients' risk of hospital readmission within 30 days and can be used to inform targeted, evidence-based support to reduce home care clients' hospital readmissions.

Changing Directions and Expanding Horizons: Moving towards More Inclusive Healthcare for Parents of Children with Developmental Disabilities

Family-centred service (FCS) acknowledges the importance of family engagement in therapeutic processes and focuses on the needs of all family members. This way of thinking and practicing is becoming increasingly recognized as an optimal care delivery model for families of children with developmental disabilities (DDs). However, in most places, disability services are oftentimes 'child-centric', wherein family members are seen only as partners in therapy or care delivery, while their own needs are not addressed. This arises from the lack of awareness of complex and highly individual family needs by professionals with whom they interact, but also from a significant lack of service infrastructure oriented towards parent-specific needs in existing service delivery models. This concept paper highlights the known challenges associated with parenting a child with a DD and discusses the intersectionality of factors impacting parental health and well-being, with a goal of promoting more equitable, holistic, and inclusive healthcare for all family members of children with DDs.

SPINE20 recommendations 2023: One Earth, one family, one future WITHOUT spine DISABILITY

Introduction

The purpose is to report on the fourth set of recommendations developed by SPINE20 to advocate for evidence-based spine care globally under the theme of "One Earth, One Family, One Future WITHOUT Spine DISABILITY".

Research question

Not applicable.

Material and methods

Recommendations were developed and refined through two modified Delphi processes with international, multi-professional panels.

Results

Seven recommendations were delivered to the G20 countries calling them to:-establish, prioritize and implement accessible National Spine Care Programs to improve spine care and health outcomes.-eliminate structural barriers to accessing timely rehabilitation for spinal disorders to reduce poverty.-implement cost-effective, evidence-based practice for digital transformation in spine care, to deliver self-management and prevention, evaluate practice and measure outcomes.-monitor and reduce safety lapses in primary care including missed diagnoses of serious spine pathologies and risk factors for spinal disability and chronicity.-develop, implement and evaluate standardization processes for spine care delivery systems tailored to individual and population health needs.-ensure accessible and affordable quality care to persons with spine disorders, injuries and related disabilities throughout the lifespan.-promote and facilitate healthy lifestyle choices (including physical activity, nutrition, smoking cessation) to improve spine wellness and health.

Discussion and conclusion

SPINE20 proposes that focusing on the recommendations would facilitate equitable access to health systems, affordable spine care delivered by a competent healthcare workforce, and education of persons with spine disorders, which will contribute to reducing spine disability, associated poverty, and increase productivity of the G20 nations.

An ethnographic study exploring person-centred nutrition care in rehabilitation units

PURPOSE

Person-centred care (PCC) is an essential component of high-quality healthcare across professions and care settings. While research is emerging in subacute nutrition services more broadly, there is limited literature exploring the person-centredness of nutrition care in rehabilitation. This study aimed to explore person-centred nutrition care (PCNC) in rehabilitation units, as described and actioned by patients, support persons and staff. Key factors influencing PCNC were also explored.

MATERIALS AND METHODS

An ethnographic study was undertaken across three rehabilitation units. Fifty-eight hours of field work were completed with 165 unique participants to explore PCNC. Field work consisted of observations and interviews with patients, support persons and staff. Data were analysed through the approach of reflexive thematic analysis, informed by PCC theory.

RESULTS

Themes generated were: (1) tensions between patient and staff goals; (2) disconnected moments of PCNC; (3) the necessity of interprofessional communication for PCNC; and (4) the opportunity for PCNC to enable the achievement of rehabilitation goals.

CONCLUSIONS

PCNC was deemed important to different stakeholders but was at times hindered by a focus on profession-specific objectives. Opportunities exist to enhance interprofessional practice to support PCNC in rehabilitation. Future research should consider the system-level factors influencing PCNC in rehabilitation settings.

What are the perceived needs of people living with chronic pain regarding physiotherapy services? A scoping review protocol

INTRODUCTION

Chronic pain represents a major health issue, affecting the physical and mental health of approximately one in five people worldwide. It is now widely recognized that health professionals should use interventions that meet the needs of people living with chronic pain. Therefore, physiotherapists should attend to patients' perceived needs regarding physiotherapy services, i.e. the needs that are perceived by patients themselves based on their beliefs, values, preferences and expectations. However, previous reviews have mainly focused on health professionals' and experts' evaluations of patients' needs, which may result in inadequate answers to these needs. Therefore, a better understanding of patients' perceived needs could lead to more ethical and higher quality physiotherapy services.

OBJECTIVE

The aim of this scoping review is thus to explore what is known from the existing literature about the perceived needs of people living with chronic pain regarding physiotherapy services.

METHODS

This scoping review will follow Arksey and O'Malley's six-step framework. Medline, Embase, CINHAL, and APA PsycINFO will be used to search the scientific literature. The grey literature will also be searched using Google Scholar, OpenGrey and ProQuest Dissertation & Theses Global (PQDTGlobal). Studies published in English and French will only be considered. Two independent reviewers will perform the selection and extraction processes. Descriptive statistics will be performed to characterize the included studies. Quantitative, qualitative and mixed methods studies will be analyzed and synthetized using convergent qualitative meta-integration. Thereby, we will use the seven steps for convergent qualitative meta-integration proposed by Frantzen and Fetters to transform, analyze and integrate the quantitative and qualitative data.

INCLUSION CRITERIA

Included studies will describe the perceived needs of adults living with chronic pain regarding physiotherapy services. Studies focusing on the perspectives of health professionals and rehabilitation services other than physiotherapy will be excluded.

Signs of Inequitable Access: Users of Private Physiotherapy Services Do Not Reflect the Urban Population in Winnipeg, Manitoba

Purpose: Both private and public funding cover outpatient physiotherapy (PT) in Canada. Knowledge is lacking in who does and does not access PT services, which limits the ability to identify health/access inequities created by current financing structures. This study characterizes the individuals accessing private PT in Winnipeg to better understand whether inequities exist, given the very limited publicly financed PT. Methods: Patients attending PT in 32 private businesses, sampled for geographic variation, completed a survey online or on paper. We compared the sample's demographic characteristics with Winnipeg population data using chi-square goodness-of-fit tests. Results: In total, 665 adults accessing PT participated. Respondents were older and had higher levels of income and education compared to Winnipeg census data (p < 0.001). Our sample included higher proportions of female and White individuals, and lower proportions of Indigenous persons, newcomers, and people from visible minorities (p < 0.001). Conclusions: There are signs that inequities exist in access to PT in Winnipeg; the cohort who access private PT services does not reflect the wider population, which suggests that some segments of the population are not receiving care.

Study on the Measurement and Influencing Factors of Care Service Demand of Disabled Elderly in Urban and Rural China

Caregiving services are currently the weakest part of China's social security system for the elderly. It is well needed to investigate the fac-tors affecting the unmet care needs of the elderly with disabilities. Based on the Behavioral Model of Health Services Use (BMHSU), this paper explores the needs and influencing factors of care services for the disabled elderly in urban and rural areas using data from the 2018 Project of Social Policy Support System for Disadvantaged Families in China. The demand for care services of the disabled elderly in central and western areas is significantly higher than that in eastern, along with that in rural areas significantly higher than that in urban areas. The demands for care services of the disabled elderly in urban and rural areas are significantly affected by tendency factors, resource factors, and need factors. Urban and rural attributes, worried pension and LCI are the common influencing factors for the care service demand of the disabled elderly from economically disadvantaged families and ordinary families. The demands for care services of the disabled elderly were associated with tendencies, resources, and needs, increased chronic disease prevention and mental health services benefit caregivers.

Exploring the delivery of community rehabilitation services for older people in an urban Canadian setting: Perspectives of service providers, managers and health system administrators

As the global population of older people increases, policies aimed at improving health care delivery for older people often include supports for ageing in place. Living in the community not only reduces institutionalisation but also improves quality of life and reduces health care costs. For older people, community rehabilitation offers the opportunity to preserve and maximise function while maintaining the ability to live in the community. However, limited research examines the delivery, coordination and integration of community rehabilitation services in health systems. Our case study explored the perspectives of service providers, managers and health system administrators on the strengths, limitations and gaps in community rehabilitation for older people in one Canadian urban health region. Using interpretive description and thematic analysis, we analysed interview data from: 16 service providers, eight managers and five health system administrators. Three themes were identified: (a) Limited Access to Programs and Services; (b) Need to Emphasise Promoting, Maintaining and Restoring Function; and (c) Lack of Flow Across the System. Participants highlighted that restrictive eligibility criteria limited access to services. Services were organised around health conditions that did not address the needs of older people. Long waitlists meant that services were delayed. Transportation costs limited participation of individuals from lower socioeconomic status (SES). Age restrictions did not reflect differences in the ageing process and the health inequities individuals from lower SES groups experienced. There was a lack of emphasis in community rehabilitation programs on maintaining or restoring function in older people, which is the primary focus of rehabilitation. Furthermore, key stakeholders stressed the need for strengthening the integration of service delivery across the continuum of care. The findings underscore the need to develop a conceptual framework for community rehabilitation to promote greater system integration, access and availability of services and to optimise functional outcomes for older people.

Development of a minimum dataset for subacute rehabilitation: a three-round e-Delphi consensus study

OBJECTIVES

To develop a minimum dataset to be routinely collected across a heterogenous population within a subacute rehabilitation service to guide best care and outcomes for patients, and value for the health service.

DESIGN

Three-round e-Delphi exercise, followed by consensus meetings.

SETTING

Multicentre study in Brisbane, Australia.

PARTICIPANTS

Rehabilitation decision-makers, researchers and clinicians were invited to participate in the e-Delphi exercise. A multidisciplinary project steering committee (rehabilitation decision makers, researchers, clinicians and consumers) participated in consensus meetings.

METHODS

In round 1 of the e-Delphi, participants responded to an open-ended question, generating data and outcomes that should be routinely collected in rehabilitation. In rounds 2 and 3, participants rated the importance of collecting each item on a nine-point scale. Consensus was defined a priori, as items rated as 'essential' by at least 70%, and of 'limited importance' by less than 15%, of respondents. Consensus meetings were held to further refine and define the dataset for implementation.

RESULTS

In total, 38 participants completed round 1 of the e-Delphi. Qualitative content analysis of their responses generated 1072 codes, which were condensed into 39 categories and 209 subcategories. Following two rounds of rating (round 2: n=32 participants; round 3: n=28 participants), consensus was reached for 124 items. Four consensus meetings (n=14 participants) resulted in the final dataset which included 42 items across six domains: (1) patient demographics, (2) premorbid health and psychosocial information, (3) admission information, (4) service delivery and interventions, (5) outcomes and (6) caregiver information and outcomes.

CONCLUSIONS

We identified 42 items that reflect the values and experiences of rehabilitation stakeholders. Items unique to this dataset include caregiver information and outcomes, and detailed service delivery and intervention data. Future research will establish the feasibility of collection in practice.

A Systematic Review of the Effectiveness of Telerehabilitation Interventions for Therapeutic Purposes in the Elderly

BACKGROUND

Many elderly people suffer from chronic health conditions and mobility limitations. Therefore, they may benefit from traditional rehabilitation or telerehabilitation interventions as an alternative for this type of services.

OBJECTIVE

The purpose of this study was to compare the effectiveness of telerehabilitation interventions with traditional rehabilitation services for therapeutic purposes in the elderly.

METHODS

This systematic review was conducted in 2018. The searched databases were Cochrane Library, PubMed, Scopus, Web of Science, Embase, and ProQuest. The search was conducted with no time or language limitation. The selected papers included the randomized clinical trial studies in which elderly people aged 60 and over used telerehabilitation services for treatment purposes. The quality of the studies was evaluated by using the physiotherapy evidence database (PEDro) scale. Data were extracted by using a data extraction form and findings were narratively synthesized.

RESULTS

After screening the retrieved papers, eight articles were selected to be included in the study. According to the findings, telerehabilitation was used for the elderly after stroke, chronic obstructive pulmonary disease (COPD), total knee replacement, and in patients with the comorbidity of COPD and chronic heart failure. Overall, in most studies, there was no significant difference between the intervention and control groups and the level of improvements was similar for most outcomes.

CONCLUSION

Telerehabilitation services can be regarded as an alternative to traditional rehabilitation approaches to reduce outpatient resource utilization and improve quality of life. However, more rigorous studies are suggested to investigate the effectiveness of telerehabilitation services for specific diseases or health conditions.

Prioritization of patients access to outpatient augmentative and alternative communication services in Quebec: a decision tool

Purpose: A large number of people living with a chronic disability wait a long time to access publicly funded rehabilitation services such as Augmentative and Alternative Communication (AAC) services, and there is no standardized tool to prioritize these patients. We aimed to develop a prioritization tool to improve the organization and access to the care for this population.Methods: In this sequential mixed methods study, we began with a qualitative phase in which we conducted semi-structured interviews with 14 stakeholders including patients, their caregivers, and AAC service providers in Quebec City, Canada to gather their ideas about prioritization criteria. Then, during a half-day consensus group meeting with stakeholders, using a consensus-seeking technique (i.e. Technique for Research of Information by Animation of a Group of Experts), we reached consensus on the most important prioritization criteria. These criteria informed the quantitative phase in which used an electronic questionnaire to collect stakeholders' views regarding the relative weights for each of the selected criteria. We analyzed these data using a hybrid quantitative method called group based fuzzy analytical hierarchy process, to obtain the importance weights of the selected eight criteria.Results: Analyses of the interviews revealed 48 criteria. Collectively, the stakeholders reached consensus on eight criteria, and through the electronic questionnaire they defined the selected criteria's importance weights. The selected eight prioritization criteria and their importance weights are: person's safety (weight: 0.274), risks development potential (weight: 0.144), psychological well-being (weight: 0.140), physical well-being (weight: 0.124), life prognosis (weight: 0.106), possible impact on social environment (weight: 0.085), interpersonal relationships (weight: 0.073), and responsibilities and social role (weight: 0.054).Conclusion: In this study, we co-developed a prioritization decision tool with the key stakeholders for prioritization of patients who are referred to AAC services in rehabilitation settings.IMPLICATIONS FOR REHABILIATIONStudies in Canada have shown that people in Canada with a need for rehabilitation services are not receiving publicly available services in a timely manner.There is no standardized tool for the prioritization of AAC patients.In this mixed methods study, we co-developed a prioritization tool with key stakeholders for prioritization of patients who are referred to AAC services in a rehabilitation center in Quebec, Canada.

Referral patterns of stroke rehabilitation inpatients to a model system of outpatient services in Ontario, Canada: a 7-year retrospective analysis

Background

While several studies have tracked the care paths of patients in the early phases of stroke recovery, studies examining the transition from inpatient to outpatient rehabilitation are lacking. Examining this transition allows for improved understanding and refinement of the process whereby patients are referred and admitted to programs. The objective of this study was to examine the referral patterns of stroke rehabilitation inpatients to outpatient stroke therapy services, their demographics, and clinical profile.

Methods

This study examined patients who: (1) were admitted to an inpatient stroke rehabilitation unit between January 1, 2009 and March 1, 2016, (2) had a stroke diagnosis, (3) had an inpatient length of stay of > 1 day, and (4) lived within the geographical boundaries of the South West Local Health Integration Network which allowed them access to both hospital-based and home-based stroke rehabilitation outpatient programs. Patient data was collected from the National Rehabilitation Reporting System, as well as three hospital outpatient administrative databases. These databases were cross-referenced to determine each patient’s pathway. Those referred to an outpatient therapy program, and those who attended the outpatient programs, were compared to those who were not, and did not, respectively.

Results

1497 inpatients were included in the analysis. Upon discharge, 1037 (69.3%) of patients had an outpatient clinic, follow-up appointment scheduled; of those, 902 (87.0%) patients attended at least one outpatient clinic visit. 891 (59.5%) were referred to one of the interdisciplinary outpatient stroke rehabilitation programs; of those, an outpatient therapy program was attended by 80.9% of patients (n = 721). Of those receiving outpatient therapy services, the number of patients attending the in-hospital versus home-based program were equal, 360 and 361 individuals, respectively.

Conclusion

This study allows for a better understanding of the transition between inpatient and outpatient stroke care. There is a paucity of this type of information in stroke rehabilitation literature to date. This study acts as a starting point in improving rehabilitation planning across the continuum of care.

Home Care in Ontario: Perspectives on Equity

Home care is an integral aspect of the Canadian health care system. Services provided to individuals allow them to live with independence and dignity within the comfort of their own residences. This article examines the historical evolution of Ontario’s home care reform and the current challenges faced by staff members, patients, and their caregivers in reference to health equity. Political economy and feminist lenses are used to highlight the impact of market-based health care reforms on gendered experiences and access to home care services. Research and reports are used to critique the development of the home care system to date. Findings suggest that the current home care system is underfunded, understaffed, and inequitable in access to care. At this time, policies strategically remain blinded to the harsh realities of the home care sector in order to justify cost cutting, deregulation, and privatization of services.

Old principles, persisting challenges: Maternal health care market alignment in Mexico in the search for UHC

The purpose of this study is to analyze the alignment of supply and demand for antenatal care (ANC) in Mexico based on the definition of access provided by Donabedian: the "degree of adjustment" between resources and needs. Alignment was studied in the teenage and adult population of Mexico that lacked conventional social security between 2008 and 2015, a period of expanding financial resources for health and public health insurance coverage. Spatial econometric methods were used to analyze data from the Ministry of Health on the supply and demand for ANC in 2,314 municipalities (94% of all municipalities in Mexico). During this period, the relative weight of ANC demand among adolescents increased 37% while the production of antenatal consultations for adolescent and adult women remained unchanged. Bivariate spatial analyses of correlation between supply and demand for ANC services yielded a minimal spatial correlation, or lack of territorial correspondence, between supply and demand among women in both age groups. Spatial econometric analysis confirmed a non-significant association between supply and demand for ANC services. Our findings suggest the existence of misalignment between supply and demand for these services. This requires a reassessment of the management and delivery of ANC services at the local level in order to increase effective coverage and improve the overall performance of the health system.

Integrating Physiotherapists into Primary Health Care Organizations: The Physiotherapists' Perspective

Purpose: This study's purpose was to gain insight into physiotherapists' perspectives on the perceived barriers and facilitators of integrating physiotherapists into primary health care (PHC) teams. Method: A qualitative descriptive approach consisting of semi-structured face-to-face or telephone interviews was used. Interviews were audio recorded, transcribed verbatim, and checked by the interviewers to ensure trustworthiness. Data were analyzed using Braun and Clarke's six steps to thematic analysis. Results: Eight participants were interviewed, representing physiotherapists from diverse demographics and geographical regions in Ontario. Common themes discussed were the orientation process, their experiences of integrating the physiotherapist's role into the organization, programme development compared with one-to-one care, the characteristics of the physiotherapist and the interdisciplinary team, and the resources available in the organization. Our key findings of influential factors for integration were (1) the diversity and novelty of new physiotherapists' role, (2) team members' understanding of the physiotherapists' role, and (3) physiotherapists' actions and values regarding PHC. Conclusions: The integration process is affected by factors ranging from individual to system levels. The integration of physiotherapists into PHC would be enhanced by a greater understanding of the role of physiotherapy in PHC by physiotherapists, other health care professionals, and system planners.

Understanding consumer and clinician preferences and decision making for rehabilitation following arthroplasty in the private sector

Background

To understand private consumer and clinician preferences towards different rehabilitation modes following knee or hip arthroplasty, and identify factors which influence the chosen rehabilitation pathway.

Methods

Mixed methods cross-sectional study involving 95 semi-structured interviews of consumers (patients and carers) and clinicians (arthroplasty surgeons, physiotherapists and rehabilitation physicians) in Sydney, Australia, during 2014–2015. Participants were asked about the acceptability of different modes of rehabilitation provision, and factors influencing their chosen rehabilitation pathway. Interviews were in person or via the telephone. Qualitative analysis software was used to electronically manage qualitative data. An analytical approach guided data analysis.

Results

Pre-operative preferences strongly influenced the type of rehabilitation chosen by consumers. Key factors that influenced this were both intrinsic and extrinsic, including; the previous experience of self or known others, the perceived benefits of the chosen mode, a sense of entitlement, the role of orthopaedic surgeons and influence of patient preference, a patient’s clinical status post-surgery, the private hospital business model and insurance provider involvement. The acceptability of rehabilitation modes varied between clinician groups.

Conclusions

No one rehabilitation mode provided following arthroplasty is singularly preferred by stakeholders. Factors other than the belief that a particular mode was more effective than another appear to dominate the pathway followed by private arthroplasty consumers, indicating evidence-based policies around rehabilitation provision may have limited appeal in the private sector.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2379-9) contains supplementary material, which is available to authorized users.

Allocation of Rehabilitation Services for Older Adults in the Ontario Home Care System

Background: Physiotherapy and occupational therapy services can play a critical role in maintaining or improving the physical functioning, quality of life, and overall independence of older home care clients. Despite their importance, however, there is limited understanding of the factors that influence how rehabilitation services are allocated to older home care clients. The aim of this pilot study was to develop a preliminary understanding of the factors that influence decisions to allocate rehabilitation therapy services to older clients in the Ontario home care system, as perceived by three stakeholder groups. Methods: Semi-structured interviews were conducted with 10 key informants from three stakeholder groups: case managers, service providers, and health system policymakers. Results: Drivers of the allocation of occupational therapy and physiotherapy for older adults included functional needs and postoperative care. Participants identified challenges in providing home care rehabilitation to older adults, including impaired cognition and limited capacity in the home care system. Conclusions: Considering the changing demands for home care services, knowledge of current practices across the home care system can inform efforts to optimize rehabilitation services for the growing number of older adults. Further research is needed to advance the understanding of, and optimize rehabilitation service allocation to, older frail clients with multiple morbidities. Developing novel decision-support mechanisms and standardized clinical care pathways for older client populations may be beneficial.

Access to publicly funded outpatient physiotherapy services in Quebec: waiting lists and management strategies

PURPOSE

Problems with access to outpatient physiotherapy services have been reported in publicly funded healthcare systems worldwide. A few studies have reported management strategies aimed at reducing extensive waiting lists, but their association with waiting times is not fully understood. The purpose of this study was to document access to public outpatient physiotherapy services for persons with musculoskeletal disorders in hospitals and explore organizational factors associated with waiting time.

METHODS

We surveyed outpatient physiotherapy services in publicly funded hospitals in the province of Quebec (Canada).

RESULTS

A total of 97 sites responded (99%) to the survey. The median waiting time was more than six months for 41% of outpatient physiotherapy services. The waiting time management strategies most frequently used were attendance and cancelation policies (99.0%) and referral prioritization (95.9%). Based on multivariate analyses, the use of a prioritization process with an initial evaluation and intervention was associated with shorter waiting times (p = 0.008).

CONCLUSIONS

Our findings provide evidence that a large number of persons wait a long time for publicly funded physiotherapy services in Quebec. Based on our results, implementation of a prioritization process with an initial evaluation and intervention could help improve timely access to outpatient physiotherapy services. Implications for Rehabilitation Access to publicly funded outpatient physiotherapy services is limited by long waiting times in a great proportion of Quebec's hospitals. The use of a specific prioritization process that combines an evaluation and an intervention could possibly help improve timely access to services. Policy-makers, managers, and other stakeholders should work together to address the issue of limited access to publicly funded outpatient physiotherapy services.

Feasibility and safety of in-bed cycling for physical rehabilitation in the intensive care unit

PURPOSE

The purpose was to evaluate the feasibility and safety of in-bed cycle ergometry as part of routine intensive care unit (ICU) physical therapist (PT) practice.

MATERIALS AND METHODS

Between July 1, 2010, and December 31, 2011, we prospectively identified all patients admitted to a 16-bed medical ICU receiving cycling by a PT, prospectively collected data on 12 different potential safety events, and retrospectively conducted a chart review to obtain specific details of each cycling session.

RESULTS

Six hundred eighty-eight patients received PT interventions, and 181 (26%) received a total of 541 cycling sessions (median [interquartile range {IQR}] cycling sessions per patient, 2 [1-4]). Patients' mean (SD) age was 57 (17) years, and 103 (57%) were male. The median (IQR) time from medical ICU admission to first PT intervention and first cycling session was 2 (1-4) and 4 (2-6) days, respectively, with a median (IQR) cycling session duration of 25 (18-30) minutes. On cycling days, the proportion of patients receiving mechanical ventilation, vasopressor infusions, and continuous renal replacement therapy was 80%, 8%, and 7%, respectively. A single safety event occurred, yielding a 0.2% event rate (95% upper confidence limit, 1.0%).

CONCLUSIONS

Use of in-bed cycling as part of routine PT interventions in ICU patients is feasible and appears safe. Further study of the potential benefits of early in-bed cycling is needed.

Old tool, new tricks? A new adaptation of the Modified Falls Efficacy Scale

Aim:

Measuring outcomes is important in community rehabilitation programs (CRPs), both at the individual and service level. Identifying global outcome measures that can be used for all patients is challenging given the diversity of this client group.

Method:

This observational study explored measurement properties of the Modified Efficacy Scale (MES), which is an adaptation of the Modified Falls Efficacy Scale. The MES was used to assess patient confidence in performing activities without reference to falls and was trialled with 221 CRP patients. Floor and ceiling effects, responsiveness to change and minimal clinically important difference (MCID) scores were measured and compared with scores for the same sample of patients using the Lawton Instrumental Activities of Daily Living (IADL) scale.

Results:

The MES showed evidence of convergent validity and was responsive to change. Both scales showed ceiling effects on discharge, although this was more pronounced with the Lawton IADL scale (40%) than the MES (21%). Both scales had small values for MCID relative to scale width.

Conclusions:

The MES demonstrated evidence of validity and has a less pronounced ceiling effect compared with the Lawton IADL scale. The implications of a ceiling effect should be considered in the context of the assessment purpose.

Advancing research and practice in HIV and rehabilitation: a framework of research priorities in HIV, disability and rehabilitation

BACKGROUND

HIV increasingly is experienced as a complex chronic illness where individuals are living longer with a range of physical, cognitive, mental and social health-related challenges associated with HIV, comorbidities and aging, a concept that may be termed 'disability'. Rehabilitation such as physical therapy and occupational therapy can help address disability and has the potential to improve quality of life in people living with HIV. Hence, the role for rehabilitation in the context of HIV, aging and comorbidities is emerging. Our aim was to establish a framework of research priorities in HIV, disability and rehabilitation.

METHODS

We convened people living with HIV, clinicians, researchers, service providers, representatives from community-based organizations and policy and funding stakeholders to participate in the first International Forum on HIV and Rehabilitation Research. We conducted a multi-stakeholder consultation to identify current and emerging issues in HIV, disability and rehabilitation. Data were collated and analyzed using content analytical techniques.

RESULTS

Ninety-two participants attended the Forum from Canada, United Kingdom (UK), Ireland and the United States. Situated within three overarching themes (episodic health and disability across the life course; rehabilitation; and methodological advances), the Framework of Research Priorities in HIV, Disability and Rehabilitation includes six research priorities: 1) episodic health and disability; 2) aging with HIV across the life course; 3) concurrent health conditions; 4) access to rehabilitation and models of rehabilitation service provision; 5) effectiveness of rehabilitation interventions; and 6) enhancing outcome measurement in HIV and rehabilitation research. The Framework includes methodological considerations and environmental and personal contextual factors (or lenses) through which to approach research in the field. Knowledge translation should be implemented throughout the development and application of research knowledge to inform HIV clinical practice, programming and policy.

CONCLUSIONS

These priorities highlight the emerging priorities of living long-term with HIV and outline a plan for HIV and rehabilitation research in resource-rich countries such as the UK and Canada.

Telerehabilitation for older people using off-the-shelf applications: acceptability and feasibility

We investigated the feasibility of providing telerehabilitation in the home as an alternative to conventional ambulatory rehabilitation. Two groups of patients were accepted for telerehabilitation. The first group were community patients who needed rehabilitation, e.g. following a stroke, a fracture or prolonged hospital admission. The second group was from two rural nursing homes where residents were identified with a recent injury, fall or hospitalisation. Telerehabilitation employed a coaching model, with fewer therapist home visits, more feedback and “homework” for the patient. Patients had a tablet computer loaded with a videoconferencing app to connect with therapists and relevant therapeutic apps. Multidisciplinary care was provided for up to 8 weeks. The majority (86%) of eligible patients consented to receive telerehabilitation in their own home (n = 61) or in the country nursing home where they lived (n = 17). Most services were delivered using the 3G and 4G wireless networks with few technical problems. On average participants felt that they had achieved 75% of the goals set at the beginning of the programme. High levels of satisfaction were recorded. There was a 50% reduction in home visits by staff, or 10 visits per patient. Speech therapists were able to double occasions of service and direct patient contact time, whilst halving their travel time. Previous experience with technology and age were not barriers to this method of delivery but did affect recruitment. Telerehabilitation using off-the-shelf technology is feasible for post-acute treatment.

Rehabilitation therapies for older clients of the Ontario home care system: regional variation and client-level predictors of service provision

PURPOSE

To examine regional variation in service provision and identify the client characteristics associated with occupational therapy (OT) and physiotherapy (PT) services for older adults in the Ontario Home Care System.

METHODS

Secondary analyses of a provincial database containing comprehensive assessments (RAI-HC) linked with service utilization data from every older long-stay home care client in the system between 2005 and 2010 (n = 299 262). Hierarchical logistic regression models were used to model the dependent variables of OT and PT service use within 90 d of the initial assessment.

RESULTS

Regional differences accounted for 9% of the variation in PT service provision and 20% of OT service provision. After controlling for the differences across regions, the most powerful predictors of service provision were identified for both OT and PT. The most highly associated client characteristics related to PT service provision were hip fracture, impairments in activities of daily living/instrumental activities of daily living, cerebrovascular accidents, and cognitive impairment. For OT, hazards in the home environment was the most powerful predictor of future service provision.

CONCLUSIONS

Where a client lived was an important determinant of service provision in Ontario, raising the possibility of inequities in access to rehabilitation services. Health care planners and policy makers should review current practices and make adjustments to meet the increasing and changing needs for rehabilitation therapies of the aging population. Implications for Rehabilitation For older adults in home care, the goal of rehabilitation therapy services is to allow individuals to maintain or improve physical functioning, quality of life and overall independence while living within their community. Previous research has demonstrated that a large proportion of home care clients specifically identified as having rehabilitation potential do not receive it. This article used clinical assessment data to identify the predictors of and barriers to rehabilitation services for older adults in the Ontario Home Care System. Barriers of PT included dementia diagnosis and French as a first language. Barriers to OT included dementia diagnosis. Policies and practices related to service provision for older adults should be reconsidered if we are going to meet the demands of aging populations and increasing rates of functional and cognitive impairments.

Activity limitations experienced by people with stroke who receive inpatient rehabilitation: differences between 2001, 2005, and 2011

OBJECTIVE

To determine whether there were differences in characteristics and activity limitations relevant to physiotherapists among people receiving inpatient rehabilitation after stroke in 2001, 2005, and 2011.

DESIGN

A multicenter observational study of 3 periods.

SETTING

Inpatient rehabilitation units (N=15).

PARTICIPANTS

Adult stroke survivors (N=738) admitted over 3 periods (2001, 2005, 2011).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Characteristics, hospital metrics, and Motor Assessment Scale (MAS) scores were recorded on admission and discharge.

RESULTS

All 3 cohorts were similar in terms of sex, side affected by stroke, and length of time from stroke onset to rehabilitation admission. Stroke participants in the 2005 cohort were older than those in the 2011 and 2001 cohorts. Participants in the 2011 cohort had a longer inpatient rehabilitation length of stay, experienced lower average MAS gains per day (F>3.298, P<.038), and experienced more activity limitations in basic functional tasks involving bed mobility, standing up, and sitting balance on admission and discharge, and in walking and arm function at discharge only compared with earlier cohorts.

CONCLUSIONS

In 2011, on average, people admitted for rehabilitation after stroke were approximately the same age as patients in 2005 and 2001 and it took approximately 2 weeks for all of these patients to be admitted to a rehabilitation unit, but patients in 2011 had a longer inpatient rehabilitation length of stay compared with patients in 2005 and 2001. In addition, activity limitations at inpatient rehabilitation admission and discharge appear to be worse, particularly for activities such as rolling, sitting up over the edge of the bed, and balanced sitting.

The distribution of physiotherapists in ontario: understanding the market drivers

PURPOSE

To understand the factors that affect the distribution of physiotherapists in Ontario by examining three potential influences in the multi-payer physiotherapy (PT) market: population need, critical mass (related to academic health science centres [AHSCs]), and market forces.

METHODS

Physiotherapist density and distribution were calculated from 2003 and 2005 College of Physiotherapists of Ontario registration data. Physiotherapists' workplaces were classified as not-for-profit (NFP) hospitals, other NFP, or for-profit (FP), and their locations were classified by census division (CD) types (cities and counties).

RESULTS

Physiotherapist density varied significantly and distribution was neither uniformly responsive to population need, nor driven primarily by market forces. The largest factor was an AHSC in a CD; physiotherapists locate disproportionately in NFP hospitals in AHSCs rather than in the growing FP sector.

CONCLUSIONS

While some patterns can be discerned in the distribution and densities of physiotherapists across Ontario, further work needs to be done to identify why population need and market forces appear to be less influential, and why CDs with AHSCs are so attractive to physiotherapists. With this additional information, it may be possible to identify ways to influence uneven distribution in the future.

Attractiveness of employment sectors for physical therapists in Ontario, Canada (1999-2007): implication for the long term care sector

Background

Recruiting and retaining health professions remains a high priority for health system planners. Different employment sectors may vary in their appeal to providers. We used the concepts of inflow and stickiness to assess the relative attractiveness of sectors for physical therapists (PTs) in Ontario, Canada. Inflow was defined as the percentage of PTs working in a sector who were not there the previous year. Stickiness was defined as the transition probability that a physical therapist will remain in a given employment sector year-to-year.

Methods

A longitudinal dataset of registered PTs in Ontario (1999-2007) was created, and primary employment sector was categorized as ‘hospital’, ‘community’, ‘long term care’ (LTC) or ‘other.’ Inflow and stickiness values were then calculated for each sector, and trends were analyzed.

Results

There were 5003 PTs in 1999, which grew to 6064 by 2007, representing a 21.2% absolute growth. Inflow grew across all sectors, but the LTC sector had the highest inflow of 32.0%. PTs practicing in hospitals had the highest stickiness, with 87.4% of those who worked in this sector remaining year-to-year. The community and other employment sectors had stickiness values of 78.2% and 86.8% respectively, while the LTC sector had the lowest stickiness of 73.4%.

Conclusion

Among all employment sectors, LTC had highest inflow but lowest stickiness. Given expected increases in demand for services, understanding provider transitional probabilities and employment preferences may provide a useful policy and planning tool in developing a sustainable health human resource base across all employment sectors.

Strategic responses to fiscal constraints: a health policy analysis of hospital-based ambulatory physical therapy services in the Greater Toronto Area (GTA)

PURPOSE

Ambulatory physical therapy (PT) services in Canada are required to be insured under the Canada Health Act, but only if delivered within hospitals. The present study analyzed strategic responses used by hospitals in the Greater Toronto Area (GTA) to deliver PT services in an environment of fiscal constraint.

METHODS

Key informant interviews (n = 47) were conducted with participants from all hospitals located within the GTA.

RESULTS

Two primary strategic responses were identified: (1) "load shedding" through the elimination or reduction of services, and (2) "privatization" through contracting out or creating internal for-profit subsidiary clinics. All hospitals reported reductions in service delivery between 1996 and 2003, and 15.0% (7/47 hospitals) fully eliminated ambulatory services. Although only one of 47 hospitals contracted out services, another 15.0% (7/47) reported that for-profit subsidiary clinics were created within the hospital in order to access other more profitable forms of quasi-public and private funding.

CONCLUSIONS

Strategic restructuring of services, aimed primarily at cost containment, may have yielded short-term financial savings but has also created a ripple effect across the continuum of care. Moreover, the rise of for-profit subsidiary clinics operating within not-for-profit hospitals has emerged without much public debate and with little research to evaluate its impact.

Availability and structure of ambulatory rehabilitation services: a survey of hospitals with designated rehabilitation beds in ontario, Canada

PURPOSE

To determine the degree to which ambulatory physical therapy (PT), occupational therapy (OT), and speech language pathology (SLP) services are available in hospitals with designated rehabilitation beds (DRBs) in Ontario, and to explore the structure of delivery and funding among services that exist.

METHODS

Questions regarding ambulatory services were included in the System Integration and Change (SIC) survey sent to all hospitals participating in the Hospital Report 2005: Rehabilitation initiative.

RESULTS

The response rate was 75.9% (41 of 54 hospitals). All hospitals surveyed provide some degree of ambulatory rehabilitation services, but the nature of these services varies according to rehabilitation client groups (RCGs). The majority of hospitals continue to deliver services through their employees rather than by contracting out or by creating for-profit subsidiary clinics, but an increasing proportion is accessing private sources to finance ambulatory services.

CONCLUSIONS

Most hospitals with DRBs provide some degree of ambulatory rehabilitation services. Privatization of delivery is not widespread in these facilities.

The precarious balance between 'supply' and 'demand' for health care: the increasing global demand for rehabilitation service for individuals living with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is becoming a critical health concern that affects people living in high-, middle-, and low-income countries. Pulmonary rehabilitation (PR) has been demonstrated to be a clinical and cost-effective approach to minimizing the effects of COPD. Despite global predictions of an increased incidence of COPD, there continues to be an important misalignment between the demand and the supply of PR services. In other words, only a small proportion of individuals with COPD who require, or would benefit from, PR programs are receiving them on the global stage. This issue may be even more pronounced in middle- and low-income countries where the burden of disease is reported to be highest, and where access to health services and trained health professionals appears be to lowest. Given this predicament, we suggest that PR services must be viewed as an effective way in which to generate clinical efficiencies within health systems, and has the potential to relieve pressure on acute care systems. Although implementing PR programs require commitment and financial investment, we argue that such investments would yield important social and aggregated financial cost savings in the long term.