503 Midterm
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| Disablement process | The health impact of disease/illness:
Organ level: impairment
Individual level: disability
Social group/community level: handicap
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| 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
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| 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
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| 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
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| 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
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| 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”
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| 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.)
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| 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.
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| 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)
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| ICF part II of structure | 2. Personal factors: gender, race, education, occupation, human factors( past experience, temperament, and other intrinsic characteristics; state of mind)
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| ICF "Experience" of disability | focuses on the individual and his or her personal resources, health condition, and individual environment.
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| Health: | Health- components of health and components of well being
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| Function | Function – all body functions, activities, and participation in society
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| Disability | Disability – any impairment, activity limitation, or participation restrictions resulting from a health condition or personal societal, or environmental factors
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| Inpairment | Impairment – deviation from certain generally accepted population standards of function (WHO,2001)
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| 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
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| 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
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| 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
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| 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)
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| Funding: Public | Public financing regulated by Center for Medicare & Medicaid Services (CMS)
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| Funding: Private | Private financing through private insurers (traditional insurers & managed care orgs)
Out of pocket
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| Who Makes Decisions Regarding What Is a Covered Service? | Centers for Medicare & Medicaid Services (CMS):Federal agency
Facility Administrators
Allied Health Professionals
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| CMS Regulations Inpatient Physical Rehabilitation Inpatient physical rehab facility (IRF) | 7 Screening Criteria for IRF
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| 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
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| 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)
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| Administrators are concerned with: | Are primarily concerned with:
Generating dollars
Protecting dollars
Complying with regulations
Keeping their job
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| 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)
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| What is Active Treatment According to CMS? | Any intervention which:
Restores
Remediates
Rehabilitates
Reduces
Eliminates
*Specific to functional improvement
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| What Settings Require Active Treatment? | Inpatient psychiatric services
Partial hospitalization services
**Inpatient Physical Rehabilitation services (TR)
Acute care services
Public school systems
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| 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.
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| 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 &
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| 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
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| 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
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| 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)
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| Medicare part B | Medicare Part B:
Services outside hospital: physicians, outpatient care, home health, medical equipment (O&P, wheelchairs, etc)
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| Medicare part C | Medicare Part C:
Blends Part A & B
Services are provided by MCO
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| Medicare part D | Medicare Part D:
Provides optional prescription drug coverage
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| 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
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| 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
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| 3 basic tenets of managed care | Limited access to the universal providers
Payment mechanisms that reward efficiency
Enhanced quality through improved monitoring
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| MCO's | Managed Care Organizations (MCO):
Focus is prevention so routine visits are encouraged
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| HMO's | Health Maintenance Organizations (HMO): has to be within network to be covered (EMR visits are exception)
Staff-model HMO
Group-model HMO
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| POS | Point-of-Service Plans (POS): can choose a provider at each point of service
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| 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 $
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| 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)
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| 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
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| 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
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| 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
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| 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
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| Disease: | (from med. model) refers to changes in structure and function of the body systems
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| Illness: | refers to the individual's perception of their symptoms and how they and their family respond to expected symptoms
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| acute: | sudden onset of symptoms that are short term
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| chronic: | symptoms that last indefinitely and are attributed to a cause that may or may not be identified
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| trajectory: | course of an illness over time, plus actions taken by individual and their families to manage or shape this course
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| Emotional reactions to disability/ loss | Depression:
-most common -helplessness -hopelessness -apathy
Guilt:
-self blame -punishment/karma -if others are involved; assume blame
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| Lifespan impact: stages of life | infancy/childhood
school-aged
young adult
middle age
older adult
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| Injury as a result of violence: | GSW, stabbing, beatings from fights
traditionally an urban problem, but shifting
drigs, gangs, poverty
dysfunctional fam environments
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| 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)
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| 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
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| Self-concept: | how one perceives themselves; an assessment of their own worth, strengths and weaknesses
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| Self-esteem: | evaluative components on an individual's self concept
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| Body Image: | Mental view of one's body with regard to appearance, sexually, and ability to perform physical tasks
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| Stigma: | individual feelings of shame due to disapproval of others and guilt resulting from being discredited or devalued by others
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| Uncertainty: | related to the unknown future, erratic nature of symptoms, unpredictabiity of the progression of the disease or ambuguity of symptoms
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| invisible disabilities: | refers to conditions that have no outward signs that alert casual observers to an individual's condition
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| 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
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| 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
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| 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
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| Sexuality: | an expression of one's self as a woman or man
commonly expressed through phys and emotional closeness
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| 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
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| 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
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| 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
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| gender differences: | Females generally present questions regarding childbearing and reproduction.
Males generally present questions regarding erections and intercourse.
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| 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
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| potential problems | Autonomic Dysreflexia
Verbal and Physical Abuse
Sexual Dysfunction
Aging
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| 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
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| Typical Patient Diagnoses | Physical disability as a result of traumatic or atraumatic injury/illness
Exs: SCI, TBI/ABI, CVA, Orthopedic, Neurological, Med-surgical
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| 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
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| Types of Insurance | Private: HMO's, Self-pay)
workers comp
Gov: VA, Medicare/ medicaid
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| Different Types of Rehabs | Acute
Nursing facilities
Local rehab clinics
Large regional facilities
Specialty hospitals
Veteran’s Administration
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| 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
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| 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
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| 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.
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| Continuum of Care | Acute (ICU, CCU)
In-patient Rehabilitation
Day Treatment
Out-patient
Community member
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| Geographic Differences | Urban centers vs. rural centers
Where injury happens can make big difference in recovery and rehab
Regional insurance differences
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| Accreditation | Tells public that hospital has met stringent set of standards
Stamp of approval on facility or program
Not guarantee of perfection
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| 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
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| 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
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| rehab team | Interdisciplinary Treatment Team
Patient, family
Physician (physiatrist)
Case manager (social work; patient services)
Nursing
Therapists
Peer support
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| Case Manager | 1st contact with patient & family
Coordinates benefits, insurance coverage
Communicates with insurance co.
Progress towards goals
Length of stay
D/C logistics
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| Physical Therapist | Strengthening & Stretching (ROM)
Developing balance
Wheelchair skills
Transfer training
Bed mobility
Standing programs
Gait training
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| Occupational Therapist | Self care: grooming, bathing, dressing, feeding
Occupation
Housekeeping Tasks
ECU’s
Driving
Orthotics
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| Recreational Therapist | Optimize strength & skills via recreation activity
Explore recreation options
Keep active
Community re-entry outings
Fun, enjoyment
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| Other Therapies | Respiratory therapy
Speech therapy
Psychologists
Vocational Rehab Counselors
Sex Counselors
Education dept. (family training, pt ed)
Peer supporters
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| 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
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| 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!
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| Standard and universal precautions | PPE: Personal protective equipment; gloves, gowns, shoe/head covers, masks/ respirators, face+eye protection
hand washing
needle sticks
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| 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
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| what does AT enable people to do? | AT promotes independence, saving time and energy, and preventing further injury
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| High tech | complex, require precise operations and involve specific materials
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| low tech | devices made from rapidly available materials and are simple, inexpensive, and easy to use
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| 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
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| 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
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| important considerations: | Need to ensure that the device truly meets the needs of the individual and for whom they are intended
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| Manual w/c basic functions: | folding:
rigid:
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| cushion type | foam, gel, air, honey comb, alternating pressure
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