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503 Midterm

Disablement process The health impact of disease/illness: Organ level: impairment Individual level: disability Social group/community level: handicap
Cultural Issues in conceptualization of disability 1. Disability is viewed differently in various cultures and societies 2. Disabled may be included or excluded depending on these views 3. Changes within cultural/societal areas impact directly on how the disabled are cared for and treated
Med. Model Focus: 1.Emphasis is on pathology; cause of the disability lies within the individual 2.Has objective and standardized measurements to define and characterize the condition 3.Goal of treatment is to eliminate illness/ disease/ disability
Med. model Implications: ignores the indiv's role and fx within the broader context of society and the env disability not only the result of condition itself, but of limitations, barriers PWD encounter in their social and physical env. client has little/no say in their own tx
ICF Model International standard for describing and measuring health and disability Universal classification of functional status related to numerous health conditions Tool for measuring efficiency and effectiveness of rehabilitation services
ICF model focus: Focus is on health not on the conseq. of illness Uses the health continuum dealing with PWD and Pw/o D's Promotes the concept of the disability as a result of assets or barriers found within the social or physical environment instead of as a “problem”
ICF Structure and parts: Function and Disability: 1.Body function: physiological funct. (mental, sensory, funct. of immune system)/ body structure:anatomical components; structure of nervous system, or cardiovasc. system.)
ICF Structure and parts: 2.activity:tasks of actions that individ's carry out in daily life(reading, writing, daily routeine, dressing, bathing) /participation: involvement in activities of daily life or society (social activities, going to school, having a job, engaging in rec.
ICF Part II of structure Contextual factors: 1. environmental: more than just the phys env. (building accessibility, accessible transportation) but products and technology(phones and comps), climate, and social environment(attitudes, norms, services)
ICF part II of structure 2. Personal factors: gender, race, education, occupation, human factors( past experience, temperament, and other intrinsic characteristics; state of mind)
ICF "Experience" of disability focuses on the individual and his or her personal resources, health condition, and individual environment.
Health: Health- components of health and components of well being
Function Function – all body functions, activities, and participation in society
Disability Disability – any impairment, activity limitation, or participation restrictions resulting from a health condition or personal societal, or environmental factors
Inpairment Impairment – deviation from certain generally accepted population standards of function (WHO,2001)
Functional capacity Degree of disability depends on the individual’s goals as well as the barriers or facilitators that may be present in their physical and social environment
TR and reconceptualizing disability Re-conceptualization of chronic illness and disability into the continuum of health and function helps to remove the stigma and isolation seen in the past Focus on funct. capacity rather than deficits provides optimal life experiences for the individual
Why do we need to understand the structure of our healthcare system? How we get paid for services Help clients/ pt.s navigate system Maintain health literacy
Cost of Disability/ GDP In 2005 the United States spent approximately $2 trillion on health care (16% of GDP) By 2015 the cost is projected to rise to $4 trillion (20% of GDP)
Funding: Public Public financing regulated by Center for Medicare & Medicaid Services (CMS)
Funding: Private Private financing through private insurers (traditional insurers & managed care orgs) Out of pocket
Who Makes Decisions Regarding What Is a Covered Service? Centers for Medicare & Medicaid Services (CMS):Federal agency Facility Administrators Allied Health Professionals
CMS Regulations Inpatient Physical Rehabilitation Inpatient physical rehab facility (IRF) 7 Screening Criteria for IRF
7 Screening Criteria for IRF Close medical supervision 24 hour rehabilitation nursing “3-hour Rule” relatively intense level of rehabilitation services (per day) Multidisciplinary team Coordinated care program Significant practical improvement Realistic treatment goals & object
What is the 3-hour rule in a rehab setting? 3-hr rule: 3 hours of therapy for the pt each day, at least one of those therapists have to be a PT or OT. TR is considered to be per diem (lumped into the costs per diem or per day that the patient is paying to stay at the facility)
Administrators are concerned with: Are primarily concerned with: Generating dollars Protecting dollars Complying with regulations Keeping their job
Public funding: Medicare Medicare:Hospital insurance: in-patient care, short-term skilled nursing, skilled rehab care, some home health, hospice Room/board Medically necessary care (physician’s order) and “active treatment” Must be pre-approved by CMS (3 hour rule)
What is Active Treatment According to CMS? Any intervention which: Restores Remediates Rehabilitates Reduces Eliminates *Specific to functional improvement
What Settings Require Active Treatment? Inpatient psychiatric services Partial hospitalization services **Inpatient Physical Rehabilitation services (TR) Acute care services Public school systems
what services are covered and what are not/ why? will NOT pay or cover… Recreation Diversion Maintenance Comfort We need to make sure our interventions are framed in funct. terms in language and doc.
what services are covered and what are not/ why? Covered: standing x 10 mins w/o assistance to complete table top leisure task Identify 1 coping mechanism to assist with Ambulate x 175 feet within community terminology Community reintegration sessions Life mgmt Task sessions – in place of arts &
How Do TR Professionals Establish the Framework for Coverage of Services Become familiar with state and federal regulations Familiarize self with Professional Standards of Practice Know your 3rd Party Payers Get administrative support at the facility level
Steps to obtaining coverage Physician’s Orders Assessment Goals & Objectives Treatment Plan Delivery of Services or Interventions Documentation of Provision of Services/Interventions Reevaluation Discharge Recommendations & Summary
Medicare part A Medicare Part A: Hospital insurance: in-patient care, short-term skilled nursing, skilled rehab care, some home health, hospice Room/board Medically necessary care (physician’s order) and “active treatment” Must be pre-approved by CMS (3 hour rule)
Medicare part B Medicare Part B: Services outside hospital: physicians, outpatient care, home health, medical equipment (O&P, wheelchairs, etc)
Medicare part C Medicare Part C: Blends Part A & B Services are provided by MCO
Medicare part D Medicare Part D: Provides optional prescription drug coverage
Public Funding: Medicaid; State administered Fams meeting Aid to Fams with Dependent Child (AFDC) Pregnant women + child younger than age 6 w. family income below 133% of fed poverty level Child ages 6-19 in household up to poverty level Caretakers of children > age 18
Managed Care Selected group of physicians and hospitals that provide comprehensive services to individuals enrolled in specific healthcare plans Goal is to control healthcare costs while providing high-quality medical care
3 basic tenets of managed care Limited access to the universal providers Payment mechanisms that reward efficiency Enhanced quality through improved monitoring
MCO's Managed Care Organizations (MCO): Focus is prevention so routine visits are encouraged
HMO's Health Maintenance Organizations (HMO): has to be within network to be covered (EMR visits are exception) Staff-model HMO Group-model HMO
POS Point-of-Service Plans (POS): can choose a provider at each point of service
Methods of Payment Fee for service payment (FFS): pay specific amount for each type of service or unit of time; goal for provider is to maximize delivery of care in order to get the $
Methods of Payment Per visit payment: Fixed amount regardless of amount of time or the services provided: no $ incentive for provider--get pt out quickly (SuperCuts)
Methods of Payment Per episode: Providers are given a one-time payment for services with specific dx Large institutions providing medically complex services to specific DRGs
Methods of Payment Capitation: Applies to a group of individuals who are within the network. Provider is given a regular payment (monthly or yearly) to provide all services
Impact of Managed Care on Individuals with Disabilities Health care costs for PWD are significant: Doctor’s fees Hospitalization Prescription medications Adaptive equipment/mobility devices
Limitations of Managed Care for PWD Delay in getting appts or test results Denial of referral to specialists Inaccessible equipment in facilities Inadequate skill of docs to treat disability Need for specific MCO approval if med is not on pre-approved list Lmtd servics to assistive dev
Disease: (from med. model) refers to changes in structure and function of the body systems
Illness: refers to the individual's perception of their symptoms and how they and their family respond to expected symptoms
acute: sudden onset of symptoms that are short term
chronic: symptoms that last indefinitely and are attributed to a cause that may or may not be identified
trajectory: course of an illness over time, plus actions taken by individual and their families to manage or shape this course
course nature or stages of the chronic illness or disability -stable: managed condition, symptoms not progressing -episodic: sympts not always present but flare occasionally -degenerative: continuing breakdown of structure or funct. -exacerbations: sympts wo
Stress: A state in which unusual or excessive demands threaten a person's well-being or integrity -body integ (physical) -independence -self-concept -future(goals, $status) -relationships
Stress reactions all individuals experiencing the same degree of stress should npot be expected to react similarly individuals who are more able to adapt and cope with their situation effectively will manage stress more effectively and will achieve more stable outcomes
coping strategies help to manage and reduce stressors associated with major life events most individuals become reliant on a type of coping skill to restore equilibrium when confronted with a stressful situation Compensation: Rationalization: excuses Diversion of feeli
coping behaviors (2) effective and adaptive: helps reduce stress and develops life to the fullest potentials ineffective and maladaptive: inhibits growth and potential or contributes to phys +/or mental deterioration
Emotional reactions to disability/ loss Grief: reaction to loss -body function -role or position -control -privacy -dignity Fear and anxiety -unknown -unfamiliar env (hospital) Anger: -towards self or displaced towards others
Emotional reactions to disability/ loss Depression: -most common -helplessness -hopelessness -apathy Guilt: -self blame -punishment/karma -if others are involved; assume blame
Lifespan impact: stages of life infancy/childhood school-aged young adult middle age older adult
Injury as a result of violence: GSW, stabbing, beatings from fights traditionally an urban problem, but shifting drigs, gangs, poverty dysfunctional fam environments
injury as a result of violence PTSD, poor coping skills, anger, helplessness, fear, anxiety, take out feelings on rehab staff (don't trust you, authority figure, have problem c structure of prgm)
suggestions for dealing with angry pt's be flexible; give and take know what's important to your pt and don't impose values treat c dignity provide safe, secure env. know about gangs and gang life ("alias") be alert for drug use don't tolerate abusive behavior
Self-concept: how one perceives themselves; an assessment of their own worth, strengths and weaknesses
Self-esteem: evaluative components on an individual's self concept
Body Image: Mental view of one's body with regard to appearance, sexually, and ability to perform physical tasks
Stigma: individual feelings of shame due to disapproval of others and guilt resulting from being discredited or devalued by others
Uncertainty: related to the unknown future, erratic nature of symptoms, unpredictabiity of the progression of the disease or ambuguity of symptoms
invisible disabilities: refers to conditions that have no outward signs that alert casual observers to an individual's condition
impact of disability on family Family adaptation: all fam members experience loss, fear, frustration, anger -common stressors: altered roles/ role reversal, $$, dependency, child care, change in pace, intimacy
Stages of Adaptation and adjustment adjustment: an act of bringing a more satisfactory state adaptation: an act of making fit, often by modification acceptance: the quality or state of receiving with consent
Stages of Adaptation: Denial: this can't be happening to me Despair: anger, hopelessness, uncertainty negotiation: start taking control Adaptation/ adjustment/ acceptance: abandon old ways and adopt new ways; problem-solving approach; +energy
Sexuality: an expression of one's self as a woman or man commonly expressed through phys and emotional closeness
4 categories of sexual adjustment: sexual exploration: concerns about giving/receiving phys. pleasure, exploration of their bodies hypersensitive areas Sexual reintegration: the ability to communicate and be open about one's own sexual needs or desires c a sex partner
4 categories of sexual adjustment: cog-genital dissociation: conscious awareness of "shutting down" or "shutting out" sexuality as a result of focusing on other aspects of managing daily living
4 categories of sexual adjustment: sexual disenfranchisement: individs receive inadequate sex edu., have pre-existing asexual tudes toward PWD, concerns about body image, and receive negative feedback regarding sexuality from health prof's and sex partners
gender differences: Females generally present questions regarding childbearing and reproduction. Males generally present questions regarding erections and intercourse.
barriers to providing sexuality info timing- assuming pt's will ask q's when they're ready feeling the expertise lies elsewhere focus on other aspects of rehab inappropriate behaviors environment
potential problems Autonomic Dysreflexia Verbal and Physical Abuse Sexual Dysfunction Aging
What is Rehab: Controlled environment Optimize individual’s capacity Decrease negative effects of disability Learn new skills (independence) Adapt to physical, emotional, cognitive, social, spiritual changes
Typical Patient Diagnoses Physical disability as a result of traumatic or atraumatic injury/illness Exs: SCI, TBI/ABI, CVA, Orthopedic, Neurological, Med-surgical
Non-traumatic Disabilities Spina bifida, multiple sclerosis, muscular dystrophy, ALS, post-polio syndrome, chronic pain Rehab can be beneficial Congenital disabilities--rehab provided by school system (IDEA, 1975) Problem: transition to adulthood
Types of Insurance Private: HMO's, Self-pay) workers comp Gov: VA, Medicare/ medicaid
Different Types of Rehabs Acute Nursing facilities Local rehab clinics Large regional facilities Specialty hospitals Veteran’s Administration
Model Care Systems Centers that work together to demonstrate improved care, maintain a national database, participate in research & provide continuing education relating to SCI or TBI. Applied for & awarded for 5-year periods of time
SCI model care systems Rehab centers that are committed to innovative projects for the delivery, demonstration, and evaluation of comprehensive medical, vocational, and other rehab services to meet needs of individuals with SCI
TBI model care systems Purpose is to advance medical rehabilitation by increasing the rigor & efficiency of scientific efforts to assess the longitudinal experience of individuals with TBI.
Continuum of Care Acute (ICU, CCU) In-patient Rehabilitation Day Treatment Out-patient Community member
Geographic Differences Urban centers vs. rural centers Where injury happens can make big difference in recovery and rehab Regional insurance differences
Accreditation Tells public that hospital has met stringent set of standards Stamp of approval on facility or program Not guarantee of perfection
Why do rehab’s want accreditation? Attract patients (more business) Convince referring Dr.’s of quality Get paid by insurance companies Concerned with refining and improving services
JCA, CARF JCA: Joint Commission on Accreditation (formerly JCAHO) CARF: Commission on Accreditation of Rehab Facilities Certifies programs not whole facilities For example, a rehab can have a CARF accredited SCI program
rehab team Interdisciplinary Treatment Team Patient, family Physician (physiatrist) Case manager (social work; patient services) Nursing Therapists Peer support
Case Manager 1st contact with patient & family Coordinates benefits, insurance coverage Communicates with insurance co. Progress towards goals Length of stay D/C logistics
Physical Therapist Strengthening & Stretching (ROM) Developing balance Wheelchair skills Transfer training Bed mobility Standing programs Gait training
Occupational Therapist Self care: grooming, bathing, dressing, feeding Occupation Housekeeping Tasks ECU’s Driving Orthotics
Recreational Therapist Optimize strength & skills via recreation activity Explore recreation options Keep active Community re-entry outings Fun, enjoyment
Other Therapies Respiratory therapy Speech therapy Psychologists Vocational Rehab Counselors Sex Counselors Education dept. (family training, pt ed) Peer supporters
Effects of Managed Care Dictate short lengths of stay Per diem rates & patient unit billing Show insurance co. that person is continuing to make gains to keep him/her longer Restrictions on medical tests, limited funds for equipment
Short Length of Stay Insurance issue Patients get basic skills Patient not ready emotionally for rehab Squeeze on services and resources Forces hospital to be more efficient--good thing!
Standard and universal precautions PPE: Personal protective equipment; gloves, gowns, shoe/head covers, masks/ respirators, face+eye protection hand washing needle sticks
Assistive technology Any tool/ apparatus/device/ machine used by a person to accomplish some practical task or purpose in a home, work, or rec setting • Cell phones, computer, glasses, calculator, internet
what does AT enable people to do? AT promotes independence, saving time and energy, and preventing further injury
High tech complex, require precise operations and involve specific materials
low tech devices made from rapidly available materials and are simple, inexpensive, and easy to use
Types of assistive devices: ADL's: pull up socks, hand held shower head, button, weighted spoons or utensils, cooking devices, larger handled items, electric devices etc Mobility Devices: canes and walkers; quad cane- Sharon O. Orthotics
types of AD's cognitive memory aids -adaptive computer aids -controls and switches -environmental modifications (ECU) -Assistive devises in the workplace -Assistive devices for REC -prosthetics; can be cosmetic as well: nose, ear, eye, face -service animals
important considerations: Need to ensure that the device truly meets the needs of the individual and for whom they are intended
Manual w/c basic functions: folding: rigid:
cushion type foam, gel, air, honey comb, alternating pressure
Created by: mmg57