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Abstract: This study aims to compare delivery of acute rehabilitation therapy using metrics reflecting distinct aspects of rehabilitation therapy services. Seven general medical-surgical hospitals in Illinois and Indiana prospectively collected rehabilitation therapy data. De-identified data on all patients who received any type of acute rehabilitation therapy (n = 35,449) were extracted and reported as aggregate of minutes of therapy services per discipline. Metrics included therapy types, total minutes, and minutes per day (intensity), as charted by therapists. Extended hospital stay was defined as a length of stay (LOS) longer than Medicare's geometric mean LOS. Discharge destination was coded as postacute care or home discharge. Substantial variability was observed in types, number of minutes, and intensity of therapy services by condition and hospital. The odds of an extended hospital stay increased with increased number of minutes, increased number of therapy types, and decreased with increased rehabilitation intensity. This comparative approach to assessing provision of acute therapy services reflect differential effects of service provision on LOS and discharge destination. Investigators, policymakers, and hospital administrators should examine multiple metrics of rehabilitation therapy provision when evaluating the impact of health care processes on patient outcomes., Competing Interests: The authors report no conflicts of interest, (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: During the period of hospitalization, patients can develop functional decline. The main aim of our study was to assess the natural trajectory of each activity of daily living (ADL) and to assess how in-hospital exercise could influence short-term trajectory of ADLs., Method: Acutely hospitalized patients (n = 297, 56.5% women) were randomly assigned to the intervention or control (usual care) group within the first 48 hours of admission. An exercise training program was prescribed in 2 daily sessions (morning and evening) of 20 minutes duration during 5-7 consecutive days for the intervention group. The primary endpoint was the change in every ADL (assessed with the Barthel Index) from 2 weeks before admission to hospital discharge., Results: Acute hospitalization per se led to significant in-patient's functional ability impairment in ADLs during hospitalization, whereas the exercise intervention reversed this trend (3.7 points; 95% CI: 0.5-6.8 points). After analyzing the trajectory of each one of the ADLs, patients in the control group significantly worsened all activities, but with a different degree of loss. For the between-group analysis, significant differences were obtained in many ADLs including bathing, dressing, grooming, bladder control, toilet use, transfers, mobility, and climbing stairs (p < .05). The control group had the greatest impairment in all domains analyzed (ie, feeding, bathing, dressing, grooming, bowel control, bladder control, toilet use, transfers, mobility, and climbing stairs; p < .05)., Conclusions: An individualized multicomponent exercise training program in older adults is effective to reverse the loss of specific ADLs that frequently occurs during hospitalization. Each patient profile should receive an individualized prescription of exercise during hospitalizations., Clinical Trials Registration Number: NCT02300896., (© The Author(s) 2021. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background Systematic analysis of the determinants of choice of a treatment modality aids to the understanding of decision process of healthcare utilization. The revealed preference of a single modality may differ according to the nature of disease. Existing studies have not integrated possible causal factors in a model with respect to diseases. This study identifies major determinants and formulates their integral effect on choice of a particular modality on acute and chronic diseases in accordance to socio-behavioural model. Methodology A cross-sectional study on 300 samples using a 30-point questionnaire, developed in Likert scale and dichotomous scale. Possible determinants are tested on choice of CAM in case of acute disease and of chronic disease separately. Results Revealed single modality treatment preference (of CAM) varies widely between acute disease (13%) and chronic disease (58.67%). Bivariate associations are significant for gender (For, overall CAM preference, p=0.001, acute disease, p<0.001, chronic disease, p=0.024), Disease burden (overall and chronic: p<0.001, acute: p=0.008) and previous CAM usage (overall and chronic: p<0.001, acute: p=0.016). Social factor individually has significant influence on choosing CAM both acute (OR=1.096, p<0.001) and chronic disease (OR=1.036, p<0.001). Ideation of philosophical need factor, guided by philosophical congruence with CAM (OR=1.047, p<0.001) is a novel finding of this study. While with multiple logistic regression male gender (p=0.03), social factor (p<0.001), perception of CAM efficacy (p=0.02) and negative ideation about CAM cost-effectiveness (p=0.002) are found to be important in Acute disease; choosing CAM in chronic disease is guided by female gender (p=0.001), making decision in-group (p=0.001), low disease burden (p<0.001), philosophical need factor (p=0.001), and perception of CAM efficacy (p<0.001). Conclusion Demographic, social, cognitive and philosophical factors are important determinants of choosing CAM as a treatment modality over conventional medicine, but they act differently on CAM preference in acute and chronic diseases.

Purpose: To examine the efficacy of an occupational therapy activity pacing intervention with deconditioned older adults in rehabilitation. Method: Randomised, single-blind controlled trial of deconditioned older adults admitted for rehabilitation following treatment of an acute medical condition, allocated to intervention [ n  = 51, males = 14, mean age = 80(8)] or control [ n  = 49, males = 12, mean age = 81(7)] group. The intervention group received individual and group activity pacing education with practice and application of techniques to daily activities and the home environment, while the control group received a typical occupational therapy program, which included brief activity pacing education. Outcomes included participation in daily living skills, health status (including pain and fatigue symptoms), self-efficacy in daily activities and activity pacing techniques using the Australian Therapy Outcome Measures-Occupational Therapy (AusTOMs-OT), Short Form-36 Health Survey (SF-36), Self-Efficacy Gauge and Activity Pacing Assessment. Results: No differences in groups at admission. Comparison at discharge and three months post discharge using 2 × 2 mixed ANOVA demonstrated small differences in only one scale of the activity limitation domain of the AusTOMs-OT. No significant differences were found in other scales or domains of the AusTOMs-OT, nor secondary outcome measures. Conclusion: Activity pacing in addition to typical occupational therapy during inpatient rehabilitation did not demonstrate benefits to participants in the management of their daily activities on returning home post hospitalisation.Implications for rehabilitationActivity pacing has been identified as one of the commonly used occupational therapy interventions utilised with deconditioned older adults in rehabilitation.An activity pacing intervention in conjunction with typical occupational therapy demonstrated no benefits for deconditioned older adults over typical occupational therapy which included basic education on this topic.Continuation of the activity pacing intervention into the outpatient setting may be of benefit to older adults and requires further investigation.

Aims: We hypothesised that a systematic functional assessment in a short stay unit at an emergency department (ED) and/or immediate rehabilitation after discharge will result in sustained or improved physical performance in comparison to a regimen in which neither of these interventions is offered. Methods: A two-way factorial randomised clinical trial was completed in an ED and the primary sector. We enrolled 336 nonsurgical patients of 65 years or older, scoring eight or less in the 30-s chair stand test. The interventions were: 1) Usual assessment; 2) Usual rehabilitation; 3) A systematic functional assessment performed within 48 h of admission, in order to identify those with loss of functional mobility, or at risk thereof; and 4) Immediate rehabilitation initiated within five days after discharge. The primary outcome was the 30-s chair stand test three weeks after admission. Secondary outcome measures were Barthel, EQ-5D-3L, and length of stay (LOS). Results: An intention-to-treat analysis showed no significant difference in the 30-s chair stand test score nor when analysed by groups or by intervention. The changes were approximately 1% when compared to the reference. No significant differences were found in the secondary outcomes. A per-protocol analysis showed that 99% had received assessment as assigned; however, the extent of mobilisation during hospitalisation was not disclosed. Of the patients, 48% were received the post-discharge rehabilitation they were assigned to. Conclusions: Systematic functional assessment and immediate rehabilitation led to no significant differences in physical performance. The study was weakened by the incomplete implementation of mobilisation during hospitalisation and low adherence to protocol on immediate rehabilitation.Implications for rehabilitationA systematic functional assessment within the first 48 h of hospital admission is suitable for the identification of older adults in need of post-discharge rehabilitation when compared to usual assessment.To sustain physical performance in older adults during acute hospitalisation , further research focusing on mobilisation or physical activation is needed in older adults with a loss of functional mobility, or at risk thereof.Further research focusing on physical activation during transition is needed to ameliorate tiredness and inactivity in older adults after acute hospitalisation.

Aim: The aim of this study was to explore whether treatment and probation professionals describe ideals and practices more aligned with the recovery-oriented systems of care (ROSC) model or the acute-care model. Methods : Semi-structured individual interviews were used to gather qualitative data on the ideals and practices of nine probation professionals and nine treatment professionals. Results : Directed content analysis revealed that all treatment professionals interviewed and eight out of nine probation professionals described more ideals and practices in line with the ROSC model than those in line with the acute-care model. Of all the meaning units coded for model alignment, 81.7% aligned with ROSC and 18.3% with acute care. Of the meaning units coded as ROSC, 51.4% were from treatment professionals and 48.6% from probation professionals. Of the meaning units coded as acute care, 30.2% came from treatment professionals and 69.8% from probation professionals. In building a ROSC, it seems the concern is less about buy in for recovery-oriented characteristics and more about shedding characteristics of the acute-care model. Although professionals have many ideals and practices in line with the ROSC model, some acute-care characteristics linger and could continue to exist without intervention.

Background & Aims: Oral health is an integral part of nutrition and rehabilitation. The purpose of this study was to investigate the impact of impaired oral health status on clinical and functional outcomes in post-acute in-hospital rehabilitation., Methods: We conducted a prospective cohort study of hospitalized patients undergoing rehabilitation at a 225-bed post-acute rehabilitation hospital in Japan. All newly admitted patients were eligible to enroll during the two-year research period. Oral health status was evaluated on admission using the Revised Oral Assessment Guide (ROAG). Nutritional status, assessed using the Mini Nutritional Assessment-Short Form; activities of daily living, assessed by Functional Independence Measure motor scores; home discharge; all-cause in-hospital mortality; and length of hospital stay were measured as clinical and rehabilitation outcomes. Multivariate analyses were used to determine whether the ROAG score on admission was associated with these outcomes at discharge., Results: Of the 1066 patients enrolled, 1056 were included in the final analysis. The mean age was 70 ± 17 years. Fifty-two percent of patients were women. Stroke (21.7%) and musculoskeletal disorders (30.5%) were the most common reasons for admission. Slight or moderate to severe oral health problems were detected in 609 (57.7%) and 163 (15.4%) patients, respectively. Eighteen patients died during hospitalization. The ROAG score at admission was independently associated with Functional Independence Measure motor scores at discharge (P = 0.022), home discharge (P = 0.005), in-hospital mortality (P = 0.039), and length of hospital stay (P = 0.045), after adjusting for potential confounders., Conclusions: Impaired oral health status may be associated with rehabilitation outcomes in hospitalized patients. Early detection of oral health problems and treatment by dental professionals, or through cooperation between medical and dental professionals, should be implemented in these patients., (Copyright © 2018 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Purpose: The purpose of this study was to investigate the cultural and semantic equivalence of the Activity Measure Post-Acute Care (AM-PAC) outpatient short forms after they were translated from American English to Mandarin Chinese. Method: This study was conducted with a composite sample of a group of 483 American adults (mean age 63.1 years, 42.4% males) and 553 Taiwanese adults (mean age 60.6 years, 47.2% males) who were undergoing home care or outpatient rehabilitation services. A confirmatory factor analysis tested the cultural equivalence of the AM-PAC dimensions between the US and Taiwanese samples. Semantic equivalence was tested through an item response theory-based differential item functioning (DFI) analysis. Results: Results of the confirmatory factor analysis demonstrated good model-data fit of the AM-PAC in both the US and Taiwanese samples. Significant DFI was found for six Basic Mobility items, two Daily Activity items, and four Applied Cognition items. A DFI adjusted conversion table was generated to transform the raw scores of the measure for comparisons between the two countries. Conclusions: This study provides evidence to support the conceptual equivalence of the AM-PAC when used in rehabilitation patients between American and Taiwanese cultural contexts. Some DFI items between the two groups were found, suggesting that some differences in semantic understanding of these items between cultures require cross-cultural adjustments. Implications for Rehabilitation Cultural equivalence needs to be tested before applying a clinical measure to another context. The findings of this study supported the three activity domains that the Activity Measure Post-Acute Care measures: Basic Mobility, Daily Activity, and Applied Cognition, which are all important rehabilitation outcomes that need to be assessed and monitored across rehabilitation settings. Differential item functioning was observed between the English and Chinese versions of the Activity Measure Post-Acute Care, indicating that linguistic and cultural differences across countries need to be adjusted for before using the translated measure in clinical practice.

Objectives: Older patients with chronic obstructive pulmonary disease (COPD), hospitalized for an acute exacerbation, often do not receive recommended post-acute pulmonary rehabilitation. This underuse might be related to the impaired clinical and functional status of these patients, who are more likely to present with frailty, comorbidities, and disability. Having developed and implemented a geriatric rehabilitation program for these patients (GR&#95;COPD), the primary aim of this study was to investigate the effectiveness of this program., Design and Intervention: A prospective cohort study with a 3-month follow-up period. Patients who declined the GR&#95;COPD program were considered as controls., Setting and Participants: The study was conducted at the pulmonary department of 2 hospitals. Patients were eligible when hospitalized as a result of an acute exacerbation of COPD and indicated for the GR&#95;COPD program based on standardized criteria., Methods: Primary outcome was defined as change in disease-specific health status measured with the clinical COPD questionnaire (CCQ), secondary outcome as the exacerbation rate ratio during follow-up. To balance potential confounders between the intervention and control group, propensity score-based weighted linear regression analyses were performed., Results: Of the 158 included patients [78 (49.4%) male, mean age 70.8 (±8.1) years, mean forced expiratory volume in 1 second: 35.5 (±12.8) as % of predicted], 78 received the GR&#95;COPD program. The results of the CCQ showed a significant and clinically relevant treatment effect of -0.56 points [95% confidence interval (CI) -0.89, -0.23; P = .001). Patients in the control group had 2.77 times more exacerbations compared with the intervention group (95% CI 2.13, 3.58; P < .001)., Conclusions/implications: This study shows a clinically relevant effect of the GR&#95;COPD program on disease-specific health status and exacerbation rate. Implementation of the program for older patients with severe COPD hospitalized for an acute exacerbation is recommended., (Copyright © 2019 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

There have been no reviews describing the efficacy of the combination of both rehabilitation and nutritional treatments. This systematic review aimed to assess the effects of nutritional therapy on patients with an acute and critical illness undergoing rehabilitation. Online searches using PubMed (MEDLINE), Cochrane Central Register of Controlled Trials, EMBASE (ELSEVIER), and Ichu-shi Web databases identified 986 articles, and 16 additional articles were found through other sources. Each trial assessed for the risk of bias using the Cochrane Collaboration's tool, and the quality of the body of evidence with The Grading of Recommendations Assessment, Development and Evaluation approach. Two randomized controlled trials were included in this review. Jones et al reported that with an enhanced rehabilitation program, there was no effect of nutritional intervention on quality of life (standardized mean difference [SMD] 0.55, 95% confidence intervals [CI] -0.05 to 1.15; P = 0.12). However, Hegerova et al reported positive effects of physical therapy and oral supplements on muscle mass (0.65; 95% CI, 0.36 to 0.93; P < 0.00001) and activities of daily living (SMD 0.28, 95% CI 0.00 to 0.56; P = 0.05). Strengthened nutritional intervention with enhanced rehabilitation treatment for patients with acute and critical illness may possibly be effective for increasing muscle mass, as well as for improving activities of daily living within a short period after discharge.

Objective: To update a previous review on whether additional physical therapy services reduce length of stay, improve health outcomes, and are safe and cost-effective for patients with acute or subacute conditions., Data Sources: Electronic database (AMED, CINAHL, EMBASE, MEDLINE, Physiotherapy Evidence Database [PEDro], PubMed) searches were updated from 2010 through June 2017., Study Selection: Randomized controlled trials evaluating additional physical therapy services on patient health outcomes, length of stay, or cost-effectiveness were eligible. Searching identified 1524 potentially relevant articles, of which 11 new articles from 8 new randomized controlled trials with 1563 participants were selected. In total, 24 randomized controlled trials with 3262 participants are included in this review., Data Extraction: Data were extracted using the form used in the original systematic review. Methodological quality was assessed using the PEDro scale, and the Grading of Recommendation Assessment, Development, and Evaluation approach was applied to each meta-analysis., Data Synthesis: Postintervention data were pooled with an inverse variance, random-effects model to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs). There is moderate-quality evidence that additional physical therapy services reduced length of stay by 3 days in subacute settings (mean difference [MD]=-2.8; 95% CI, -4.6 to -0.9; I 2 =0%), and low-quality evidence that it reduced length of stay by 0.6 days in acute settings (MD=-0.6; 95% CI, -1.1 to 0.0; I 2 =65%). Additional physical therapy led to small improvements in self-care (SMD=.11; 95% CI, .03-.19; I 2 =0%), activities of daily living (SMD=.13; 95% CI, .02-.25; I 2 =15%), and health-related quality of life (SMD=.12; 95% CI, .03-.21; I 2 =0%), with no increases in adverse events. There was no significant change in walking ability. One trial reported that additional physical therapy was likely to be cost-effective in subacute rehabilitation., Conclusions: Additional physical therapy services improve patient activity and participation outcomes while reducing hospital length of stay for adults. These benefits are likely safe, and there is preliminary evidence to suggest they may be cost-effective., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: This study examined the feasibility and acceptability of developing a recovery-oriented book club in an acute inpatient psychiatric setting, and the impact of participation on measures of hope and recovery orientation., Method: Participants were recruited from an inpatient psychiatric hospital and assigned to control ( N = 13) or experimental ( N = 13) conditions. Participants completed the Herth Hope Index (HHI) and the Mental Health Confidence Scale (MHCS) at baseline and follow-up. Book club participants completed a satisfaction survey. ANOVA was performed to examine changes on HHI and MHCS., Results: No significant differences were found between conditions on HHI or MHCS. On the satisfaction survey, most book club participants agreed "somewhat" or "strongly" that the intervention increased self-understanding (92.3%) and hope (61.6%)., Conclusions and Implications for Practice: Book club groups may help individuals in inpatient psychiatric settings feel more hopeful. Future research may examine the adaptability of this intervention for outpatient settings. (PsycINFO Database Record, ((c) 2018 APA, all rights reserved).)

Introduction: Age-related loss of muscle mass and strength, sarcopaenia, burdens many older adults. The process is accelerated with bed rest, protein intakes below requirements and the catabolic effect of certain illnesses. Thus, acutely ill, hospitalised older adults are particularly vulnerable. Protein supplementation can preserve muscle mass and/or strength and, combining this with resistance exercise training (RT), may have additional benefits. Therefore, this study investigates the effect of protein supplementation as an addition to offering RT among older adults while admitted to the geriatric ward and after discharge. This has not previously been investigated., Methods and Analysis: In a block-randomised, double-blind, multicentre intervention study, 165 older adults above 70 years, fulfilling the eligibility criteria, will be included consecutively from three medical departments (blocks of n=20, stratified by recruitment site). After inclusion, participants will be randomly allocated (1:1) to receive either ready-to-drink, protein-enriched, milk-based supplements (a total of 27.5 g whey protein/day) or isoenergetic placebo products (<1.5 g protein/day), twice daily as a supplement to their habitual diet. Both groups will be offered a standardised RT programme for lower extremity muscle strength (daily while hospitalised and 4×/week after discharge). The study period starts during their hospital stay and continues 12 weeks after discharge. The primary endpoint is lower extremity muscle strength and function (30 s chair-stand-test). Secondary endpoints include muscle mass, measures of physical function and measures related to cost-effectiveness., Ethics and Dissemination: Approval is given by the Research Ethic Committee of the Capital Region of Denmark (reference no. H-16018240) and the Danish Data Protection Agency (reference no. HGH-2016-050). There are no expected risks associated with participation, and each participant is expected to benefit from the RT. Results will be published in peer-reviewed international journals and presented at national and international congresses and symposiums., Trial Registration Number: NCT02717819 (9 March 2016)., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Study Design: Prospective observational multicenter study., Objectives: Investigation of content, duration and adjustment of physical therapy for the rehabilitation of ambulation in acute spinal cord injury (SCI)., Setting: European Multicenter Study of SCI (EMSCI)., Methods: Physical therapy interventions during acute in-patient rehabilitation of eighty incomplete SCI patients (AIS B, C, D all lesion levels) were recorded using the SCI - Intervention Classification System. Mobility was documented using the Spinal Cord Independence Measurement (SCIM III), demographics and clinical data were retrieved from the EMSCI database., Results: Overall recovery of locomotor function was categorized into three outcome groups (G1-G3). Of 76 initial wheelchair-using patients, 53.9% remained wheelchair user (G1), 25% regained moderate (G2) and 21.1% good walking (G3) capability. Strength training was the most frequently applied intervention of body function/-structure across all outcome groups (about 30% of all interventions), while interventions focusing on muscle tone and respiration were predominantly applied in wheelchair-dependent patients. Activity-focused interventions of transfer, transition, sitting were trained most intensively in outcome group G1, while walking and swimming were increasingly trained in patients with moderate and good walking outcomes. Physical therapy interventions of assistive and active trainings as well as corresponding training environments changed with the recovery of locomotor function., Conclusions: Physical therapy of locomotor function is targeted to individual patients' conditions and becomes adjusted to the progress of ambulation. Although the involved clinical sites were not following explicitly standardized rehabilitation programs, common patterns can be discerned which may form the basis of prospective standardized programs.

Physical inactivity has been shown to exacerbate negative side effects experienced by pediatric patients undergoing cancer therapy. Exercise interventions are being created in response. This review summarizes current exercise intervention data in the inpatient pediatric oncology setting. Two independent reviewers collected literature from three databases, and analyzed data following the PRISMA statement for systematic reviews and meta-analyses. Ten studies were included, representing 204 patients. Good adherence, positive trends in health status, and no adverse events were noted. Common strategies included individual, supervised, combination training with adaptability to meet fluctuating patient abilities. We recommend that general physical activity programming be offered to pediatric oncology inpatients., (© 2017 Wiley Periodicals, Inc.)

An early, intensive rehabilitative therapy accelerates the recovery of the functions of patients. It contributes to a reduction in the complication rate as well as an improvement in physical and social functioning/participation in the long-term follow-up. Early rehabilitation must be strengthened on the basis of the existing structures: the creation and maintenance of adequately qualified early-stage rehabilitation facilities, at least in hospitals with priority and maximum supply contracts. Patients with long-term intensive care and polytrauma must be rehabilitated as soon as possible (intensive medical rehabilitation).Specialists in physical and rehabilitative medicine, rehabilitative geriatrists, neurologists, orthopaedists and accident surgeons and other regional physicians must cooperate in a targeted manner. Exclusion criteria using corresponding OPS codes must be canceled. Additional specialist physician groups (anesthetists and intensive care physicians, general practitioners, accident and thoracic surgeons, internists) must be sensitized to the importance of early rehabilitation.In the case of more than 500,000 hospital beds, 25,000 beds should be identified as age- and diagnosis-independent early-care beds in the country-specific bed-care plans. A cost-covering financing of the different, personal and cost-intensive early rehabilitation must be ensured. A phase model similar to the BAR guidelines for neurological-neurosurgical early rehabilitation is to be considered for other disease entities.In order to make the rehabilitation process as successful as possible, medical (acute) treatment, medical rehabilitation, occupational integration and social integration have to be understood as a holistic event and are effectively interrelated, as a continuous process which accompanies the entire disease phase-wise. For this purpose, a continuous case management or a rehabilitation guidance has to be established., Competing Interests: Interessenkonflikt: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: To determine whether an enhanced occupational therapy discharge planning intervention that involved pre- and postdischarge home visits, goal setting, and follow-up (the HOME program) would be superior to a usual care intervention in which an occupational therapy in-hospital consultation for planning and supporting discharge to home is provided to individuals receiving acute care., Design: Randomized controlled trial., Setting: Acute and medical wards., Participants: Individuals aged 70 and older (N = 400)., Measurements: Primary outcomes: activities daily living (ADLs; Nottingham Extended Activities of Daily Living) and participation in life roles and activities (Late Life Disability Index (LLDI))., Results: Occupational therapist recommendations differed significantly between groups (P < .001) (HOME n = 892 recommendations; control n = 329 recommendations). There was no difference between groups in ADLs (Nottingham Extended Activities of Daily Living scale (NEADL): β = -0.17, 95% confidence interval (CI) = -0.99-0.66) or participation (LLDI-Frequency: β = -0.23, 95% CI = -2.05-1.59; LLDI-Limitation: β = -0.14, 95% CI = -2.86-2.58). Both groups maintained prehospital functional status at 90 days, and there was no difference between groups in the number of people with unplanned readmissions (HOME 23.5%, n = 43; control 21.9%, n = 37). When groups were combined, being male (P = .03) or having lower perceived participation because of physical problems (P = .04) resulted in higher risk of unplanned readmissions., Conclusion: HOME discharge planning, which had a strong emphasis on task modification, well-being, and prevention strategies, implemented twice as many occupational therapy recommendations as the in-hospital only consultation, which had a greater emphasis on equipment provision, but HOME did not demonstrate greater benefit in global measures of ADLs or participation in life tasks than in-hospital consultation alone. It is not recommended that home visits be conducted routinely as part of discharge planning for acutely hospitalized medical patients. Further work should develop guidelines for quality in-hospital consultation., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Background: The Hospital Elder Life Program (HELP) has been shown to effectively prevent delirium and functional decline in older patients in acute care, but has not been examined in a rehabilitation setting. This pilot study examined potential successes and implementation factors of the HELP in a post-acute rehabilitation hospital setting., Methods: A mixed methods (quantitative and qualitative) evaluation, incorporating a repeated measures design, was used. A total of 100 patients were enrolled; 58 on the pilot intervention unit and 42 on a usual care unit. Group comparisons were made using change scores (pre-post intervention) on outcome measures between pilot unit patients and usual care patients (separate analyses compared usual care patients with pilot unit patients who did or did not receive the HELP). Qualitative data were collected using focus group and individual interviews, and analyzed using emergent coding procedures., Results: Delirium prevalence reduced from 10.9 % (n = 6) to 2.5 % (n = 1) in the intervention group, while remaining the same in the usual care group (2.5 % at both measurement points). Those who received the HELP showed greater improvement on cognitive and functional outcomes, particularly short-term memory and recall, and a shorter average length of stay than patients who did not. Participant groups discussed perceived barriers, benefits, and recommendations for further implementation of the HELP in a rehabilitation setting., Conclusions: This study adds to the limited research on delirium and the effectiveness of the HELP in post-acute rehabilitation settings. The HELP was found to be feasible and have potential benefits for reduced delirium and improved outcomes among rehabilitation patients.

Hospitalization induces functional decline in older adults. Many geriatric patients fail to fully recover physical function after hospitalization, which increases the risk of frailty, disability, dependence, re-hospitalization, and mortality. There is a lack of evidence-based therapies that can be implemented following hospitalization to accelerate functional improvements. The aims of this Phase I clinical trial are to determine 1) the effect size and variability of targeted interventions in accelerating functional recovery from hospitalization and 2) the feasibility of implementing such interventions in community-dwelling older adults. Older patients (≥65years, n=100) will be recruited from a single site during hospitalization for an acute medical condition. Subjects will be randomized to one of five interventions initiated immediately upon discharge: 1. protein supplementation, 2. in-home rehabilitation plus placebo supplementation, 3. in-home rehabilitation plus protein supplementation, 4. single testosterone injection, or 5. isocaloric placebo supplementation. Testing will occur during hospitalization (baseline) and at 1 and 4weeks post-discharge. Each testing session will include measures of muscle strength, physical function/performance, body composition, and psychological function. Physical activity levels will be continuously monitored throughout study participation. Feasibility will be determined through collection of the number of eligible, contacted, and enrolled patients; intervention adherence and compliance; and reasons for declining enrollment and study withdrawal. This research will determine the feasibility of post-hospitalization strategies to improve physical function in older adults. These results will also provide a foundation for performing larger, multi-site clinical trials to improve physical function and reduce readmissions in geriatric patents., (Copyright © 2016. Published by Elsevier Inc.)

Background: Evaluations of the impact of interventions for resource allocation purposes commonly focus on health status. There is, however, also concern about broader impacts on wellbeing and, increasingly, on a person's capability. This study aims to compare the impact on health status and capability of seven major health conditions, and highlight differences in treatment priorities when outcomes are measured by capability as opposed to health status., Methods: The study was a cross-sectional four country survey (n = 6650) of eight population groups: seven disease groups with: arthritis, asthma, cancer, depression, diabetes, hearing loss, and heart disease and one health population 'comparator' group. Two simple self-complete questionnaires were used to measure health status (EQ-5D-5L) and capability (ICECAP-A). Individuals were classified by illness severity using condition-specific questionnaires. Effect sizes were used to estimate: (i) the difference in health status and capability for those with conditions, relative to a healthy population; and (ii) the impact of the severity of the condition on health status and capability within each disease group., Findings: 5248 individuals were included in the analysis. Individuals with depression have the greatest mean reduction in both health (effect size, 1.26) and capability (1.22) compared to the healthy population. The effect sizes for capability for depression are much greater than for all other conditions, which is not the case for health. For example, the arthritis group effect size for health (1.24) is also high and similar to that of depression, whereas for the same arthritis group, the effect size for capability is much lower than that for depression (0.55). In terms of severity within disease groups, individuals categorised as 'mild' have similar capability levels to the healthy population (effect sizes <0.2, excluding depression) but lower health status than the healthy population (≥0.4)., Conclusion: Significant differences exist in the relative effect sizes across diseases when measured by health status and capability. In terms of treating morbidity, a shift in focus from health gain to capability gain would increase funding priorities for patients with depression specifically and severe illnesses more generally.

Background/aim: Older adults admitted to an acute hospital setting with an illness often experience deconditioning. Although occupational therapists frequently work with deconditioned older adults in inpatient rehabilitation programmes, limited information exists regarding the type of interventions used and how these interventions are provided. This study aimed to determine the level of consensus among Australian occupational therapists about occupational therapy service delivery and interventions commonly used during inpatient rehabilitation with older adults who have become deconditioned during acute hospital admission for a medical illness., Methods: The Delphi technique was used to reach consensus among expert occupational therapists regarding service delivery and interventions commonly used in an ideal clinical setting. Data were analysed from three rounds of surveys and the percentage of agreement between clinicians were calculated., Results: Twenty-six participants completed round one survey, with 24 completing subsequent surveys (92% response rate). Fifteen commonly used interventions were identified, including showering/dressing, light meal preparation and home assessment. Consensus was reached on commonly used aspects of service delivery, including intervention provision, programme length, team members and follow up after discharge., Conclusion: Results generated may assist in guiding occupational therapists in the attributes of service delivery and the type of interventions currently considered best practice when working with deconditioned older adults in a rehabilitation setting. The information provides preliminary data for effectiveness studies., (© 2015 Occupational Therapy Australia.)

Objectives: To explore the impact of contact isolation on the change in functional independence measure (FIM) score, FIM efficiency score, and length of stay., Design: Retrospective matched case control study., Setting: Tertiary care hospital (academic medical center)., Participants: Persons admitted to an acute inpatient rehabilitation facility at a tertiary care hospital from July 2009 through December 2010., Methods: Retrospective chart review by obtaining patient data regarding contact isolation status, patient demographics, and rehabilitation diagnosis. Two hundred charts were reviewed, which resulted in identification of 20 patients in contact isolation. These patients subsequently were matched to patients not in contact isolation based on age, rehabilitation diagnosis, and type of insurance. Admission and discharge FIM scores were obtained for these 40 study subjects (20 cases and 20 matched controls)., Main Outcome Measurements: The primary study outcome measurements were change in FIM score (discharge FIM score minus admission FIM score), FIM efficiency score (change in FIM score divided by length of stay), and length of stay., Results: Compared with patients not in contact isolation, patients in contact isolation showed no statistically significant difference in FIM score change, a lower FIM efficiency score (P = .010), and a 39% longer length of stay (P = .017) when adjusting for confounders., Conclusions: This study identifies contact isolation as a likely variable that is associated with increased length of stay and decreased FIM efficiency score in patients in an acute inpatient rehabilitation facility. Further study is needed to identify the role or mechanisms by which contact isolation is involved in these adverse effects so that interventions may be developed to counteract them., (Copyright © 2014 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

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., (© The Author(s) 2014 Reprints and permissions:]br]sagepub.co.uk/journalsPermissions.nav.)

The aging of the population and changes in family and social structures have led to increasing care needs for elderly persons following an acute disease or accident, with consequent concerns regarding costs and sustainability within the public health system. The main objective of postacute care (PAC) is to restore the functional capabilities of the patient after an acute event and contribute to determine the patient's outcome and future healthcare requirements. With this background, we carried out a systematic review of the published literature from 1990 to 2011 focused on the following aspects of PAC: a) objectives; b) estimations of the need and the indicators for access to it, and c) transfer strategies from acute care to PAC. The results of this review indicate that PAC is an efficient approach to improve patients' quality of life and to sustain the public healthcare system. The choice of candidates for PAC should be based on both health and social indicators, and the overall process viewed in a cross-sectional manner in order to avoid increases in total cost., (Copyright © 2013 Elsevier España, S.L. All rights reserved.)

A rising number of patients require continuing or palliative services and this means that they will need to transition from one model of healthcare delivery to another. If it is generally recognised that patient vulnerability to inadequate services increases when the setting in which patient receives care changes, it is usually taken to be the result of poor coordination of services or personnel. Recognising that an integrated system is essential to adequate access, the point that I put forward in this paper is that the centrality of acute care services affects the way in which chronic and palliative services are structured and, consequently, their availability. I argue that the problem originates in the manner in which some of the foundational concepts of the acute care model are imported into the other models of care delivery. In order to make this case, I review the three main models of healthcare service delivery by focusing my analysis along three axes: the goal of the care model; the predominant understanding of autonomy implicit in the model; and, the main actors in the care relationship. By examining how the various concepts translate from one model to the next, I discuss what I identify to be one of the main conceptual obstacles to less problematic transitioning, the notion of autonomy and the corresponding view of the patient as an isolated agent.

Objective: To evaluate the effect of specialist geriatric medical management on the outcomes of at risk older people discharged from acute medical assessment units., Design: Individual patient randomised controlled trial comparing intervention with usual care., Setting: Two hospitals in Nottingham and Leicester, UK., Participants: 433 patients aged 70 or over who were discharged within 72 hours of attending an acute medical assessment unit and at risk of decline as indicated by a score of at least 2 on the Identification of Seniors At Risk tool., Intervention: Assessment made on the acute medical assessment unit and further outpatient management by specialist physicians in geriatric medicine, including advice and support to primary care services., Main Outcome Measures: The primary outcome was the number of days spent at home (for those admitted from home) or days spent in the same care home (if admitted from a care home) in the 90 days after randomisation. Secondary outcomes were determined at 90 days and included mortality, institutionalisation, dependency, mental wellbeing, quality of life, and health and social care resource use., Results: The two groups were well matched for baseline characteristics, and withdrawal rates were similar in both groups (5%). Mean days at home over 90 days' follow-up were 80.2 days in the control group and 79.7 in the intervention group. The 95% confidence interval for the difference in means was -4.6 to 3.6 days (P=0.31). No significant differences were found for any of the secondary outcomes., Conclusions: This specialist geriatric medical intervention applied to an at risk population of older people attending and being discharged from acute medical units had no effect on patients' outcomes or subsequent use of secondary care or long term care.

Objective: This pilot study investigated the effects of acute neuropsychological intervention for relatives of patients with severe brain injury., Methods: Participants were enrolled in an intervention group comprising 39 relatives, and a control group comprising 47 relatives. The intervention consisted of supportive and psycho-educational sessions with a neuropsychologist in the acute care setting., Results: The intervention group completed self-report scales in the acute setting and after the intervention at admission to sub-acute rehabilitation. The control group completed the self-report scales only at admission to sub-acute rehabilitation. Outcome measures included selected scales from the Symptom Checklist Revised 90 (SCL-90-R), the Short Form 36 (SF-36), and a visual analogue quality of life scale. The intervention group showed a significant decrease in anxiety scores from the acute to the sub-acute setting (t = 2.70, p = 0.010, d = 0.30), but also significantly lower Role Emotional scores (t =  2.12, p = 0.043, d =  0.40). In the sub-acute setting, an analysis of covariance model showed a borderline significant difference between the intervention and the control group on the anxiety scale (p =  0.066, d = 0.59)., Conclusion: Any effects of the acute neuropsychological intervention were limited. Further research is needed to explore the effects of different interventions in more homo-genous and larger groups of relatives.

Background: The measurement and valuation of quality of life forms a major component of economic evaluation in health care and is a major issue in health services research. However, differing approaches exist in the measurement and valuation of quality of life from a health economics perspective. While some instruments such as the EQ-5D-3L focus on health-related quality of life alone, others assess quality of life in broader terms, for example, the newly developed ICECAP-O., Objective: The aim of this study was to utilize two generic preference-based instruments, the EQ-5D-3L and the ICECAP-O, to measure and value the quality of life of older adult patients receiving post-acute care. An additional objective was to compare the values obtained by each instrument with those generated from two community-based general population samples., Method: Data were collected from a clinical patient population of older adults receiving post-acute outpatient rehabilitation or residential transition care and two Australian general population samples of individuals residing in the general community. The individual responses to the ICECAP-O and EQ-5D-3L instruments were scored using recently developed Australian general population algorithms. Empirical comparisons were made of the resulting patient and general population sample values for the total population and dis-aggregated according to age (65-79 and 80+ years) and gender., Results: A total of 1,260 participants aged 65-99 years (n = 86 clinical patient sample, n = 385 EQ-5D-3L general population sample, n = 789 ICECAP-O general population sample) completed one or both of the EQ-5D-3L and ICECAP-O instruments. As expected, the patient group demonstrated lower quality of life than the general population sample as measured by both quality-of-life instruments. The difference in values between the patient and general population groups was found to be far more pronounced for the EQ-5D-3L than for the ICECAP-O. The ICECAP-O was associated with a mean difference in values of 0.04 (patient group mean 0.753, SD 0.18; general population group mean 0.795, SD 0.17, respectively, p = 0.033). In contrast, the EQ-5D-3L was associated with a mean difference in values of 0.19 (patient group mean 0.595, SD 0.20; general population group mean 0.789, SD 0.02, respectively, p ≤ 0.001)., Conclusions: The study findings illustrate the magnitude of the difference in patient and general population values according to the instrument utilized, and highlight the differences in both the theoretical underpinnings and valuation algorithms for the EQ-5D-3L and ICECAP-O instruments. Further empirical work is required in larger samples and alternative patient groups to investigate the generalizability of the findings presented here.

Background: This study examined the impact of school-based mental health programs on children's school outcomes and the utilization of acute mental health services., Methods: The study sample included 468 Medicaid-enrolled children aged 6 to 17 years who were enrolled 1 of 2 school-based mental health programs (SBMHs) in a metropolitan area sometime during school year 2006-2007. A multilevel analysis examined the relative effects of SBMHs on children's absence, suspension, grade promotion, use of acute mental health services, as well as the association of child and school-level factors on the outcomes of interest., Results: Little change in average number of days absent per month and no significant change in the use of acute mental health services were found. The mean number of days suspended per month out-of-school decreased from 0.100 to 0.003 days (p < .001). The percentage of children promoted to the next grade increased almost 13% after program enrollment (p < .01). Program type did not predict outcome changes except grade promotion., Conclusions: Despite the positive effect of school-based mental health programs on some school outcomes, the lack of difference between programs suggests the need to identify active mechanisms associated with outcome to make the delivery of care more efficient., (© 2013, American School Health Association.)

Aim: To examine whether rehabilitation therapy type would be associated with transitions to skilled nursing facilities (SNF) in community-living seniors with acute medical illnesses., Methods: Using administrative and clinical data, multivariate regression analysis examined the relationship between the extent of rehabilitation therapy and transitions to SNF in all participants, as well as participants by physical function at admission., Results: In all participants (n=929), the intensified rehabilitation therapy was associated with a lower probability of transitions to SNF (14% vs 21%; odds ratio [OR] 0.59; 95% confidence intervals [CI] 0.22-0.96; P=0.02). In participants with mild physical limitations (n=270), less frequent transitions to SNF occurred when patients received intensified rehabilitation therapy [16% vs 23%; OR 0.46; 95% CI 0.17-0.94; P=0.01]. In participants with moderate to severe physical limitations (n=265), the decreased frequency of transitions to SNF associated with rehabilitation therapy became more pronounced (18% vs 28%; OR 0.34; 95% CI 0.07-0.89; P=0.004). By contrast, in participants without physical limitation (n=394), the number of transitions to SNF did not change significantly when they received intensified rehabilitation therapy (P=0.53)., Conclusions: We found a significant relationship between intensified rehabilitation therapy and the decrease of transitions to SNF in community-living seniors with acute medical illness. The magnitude of this relationship increased in participants with more physical limitations, but not in participants without physical limitations at admission., (© 2012 Japan Geriatrics Society.)

Aim of the Study: To evaluate the impact of residential intermediate care (IC) on the cognitive status of post-acute older patients and its correlation with the improvement in physical independence., Methods: This prospective observational study involved 299 subjects (116 males and 183 females; mean age 80.1 ± 8.3 years) transferred to IC. The Mini Mental State Examination (MMSE) and a panel of laboratory and functional parameters were evaluated upon admission to IC (T0) and at the time of discharge (T1). The functional evaluations included the Cumulative Illness Rating Scale, the Barthel Index (BI) and the Morse Fall Scale (MFS). Afterwards, the patients were grouped on the basis of their MMSE score at T1: those with an unchanged or worse MMSE score (group A) and those with a better MMSE score (group B). The laboratory and functional parameters of the two groups were then compared., Results: There was a significant improvement between T0 and T1 in the MMSE score (18.1 ± 7.5 vs 19.6 ± 7.3, P < 0.001) and the BI (42.1 ± 27.7 vs 53.6 ± 30.0, P < 0.001), as well as brain natriuretic peptide, C-reactive protein and blood glucose levels. Group B had a significantly better BI (57.7 ± 29.1 vs 47.2 ± 31.5, P = 0.003) and a slightly better MFS. There was a close relation between the MMSE scores and BI., Conclusions: Residential IC is a type of rehabilitation that favourably affects the cognitive status and physical independence of older post-acute patients.

Background: Many older adults become dependent in one or more activities of daily living (ADLs: dressing, bathing, transferring, eating, toileting) when hospitalized, and their prognosis after discharge is unclear., Objective: To develop a prognostic index to estimate one-year probabilities of recovery, dependence or death in older hospitalized patients who are discharged with incident ADL dependence., Design: Retrospective cohort study., Participants: 449 adults aged ≥ 70 years hospitalized for acute illness and discharged with incident ADL dependence., Main Measures: Potential predictors included demographics (age, sex, race, education, marital status), functional measures (ADL dependencies, instrumental activities of daily living [IADL] dependencies, walking ability), chronic conditions (e.g., congestive heart failure, dementia, cancer), reason for admission (e.g., neurologic, cardiovascular), and laboratory values (creatinine, albumin, hematocrit). Multinomial logistic regression was used to develop a prognostic index for estimating the probabilities of recovery, disability or death over 1 year. Discrimination of the index was assessed for each outcome based on the c statistic., Key Results: During the year following hospitalization, 36 % of patients recovered, 27 % remained dependent and 37 % died. Key predictors of recovery, dependence or death were age, sex, number of IADL dependencies 2 weeks prior to admission, number of ADL dependencies at discharge, dementia, cancer, number of other chronic conditions, reason for admission, and creatinine levels. The final prognostic index had good to excellent discrimination for all three outcomes based on the c statistic (recovery: 0.81, dependence: 0.72, death: 0.78)., Conclusions: This index accurately estimated the probabilities of recovery, dependence or death in adults aged 70 years or older who were discharged with incident disability following hospitalization. This tool may be useful in clinical settings to guide care discussions and inform decision-making related to post-hospitalization care.

With advances in monitoring and telemedicine, the complexity of care administered in the home to properly selected patients can approach that delivered in the hospital. The challenges include making sure that qualified personnel regularly visit the patient at home, both individually and in teams; information is accurately communicated among the caregiver teams across venues and over time; and patients understand the information communicated to them by providers. Despite these challenges, the benefits of treating chronically or terminally ill patients at home are significant. Among the most important are improved patient satisfaction and reduced cost. Numerous studies have shown that most patients prefer to spend their convalescence or their last days at home. The financial benefits of enabling patients to recover or to die at home are significant.

Given the preferential tax treatment afforded nonprofit firms, policymakers and researchers have been interested in whether the nonprofit sector provides higher nursing home quality relative to its for-profit counterpart. However, differential selection into for-profits and nonprofits can lead to biased estimates of the effect of ownership form. By using "differential distance" to the nearest nonprofit nursing home relative to the nearest for-profit nursing home, we mimic randomization of residents into more or less "exposure" to nonprofit homes when estimating the effects of ownership on quality of care. Using national Minimum Data Set assessments linked with Medicare claims, we use a national cohort of post-acute patients who were newly admitted to nursing homes within an 18-month period spanning January 1, 2004 and June 30, 2005. After instrumenting for ownership status, we found that post-acute patients in nonprofit facilities had fewer 30-day hospitalizations and greater improvement in mobility, pain, and functioning., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Aim: The aim was to describe gerontological rehabilitation nursing in an acute hospital setting from nursing staff's points of view., Background: In the model of gerontological rehabilitation nursing, older people are active operators in their own rehabilitation process. It is the task of nursing staff, together with the patient, their relatives and a multiprofessional team, to support the patient's commitment to the rehabilitation goal., Methods: In this study, a cross-sectional design was used. Registered nurses (RNs) and practical nurses (PNs) (n = 367) from four different hospitals responded to the questionnaire. Data analysis was carried out with spss using descriptive statistics., Results: The majority of nursing staff (66%) considered that older rehabilitation patients thought that rehabilitation was activity undertaken by physiotherapists aimed at improving patients' functional abilities. The wards in question have well-functioning rehabilitation teams. The rehabilitation of older patients is a goal-oriented activity. Despite this, not everyone was aware of the goals. Essential patient care and promotion of rehabilitation were well attended to by nurses. Emotional support was emphasised in maintaining the motivation of older people., Conclusions: Because RNs and PNs, unlike other professionals, see older rehabilitation patients 24 hours a day and are able to assess their possibilities of coping independently with essential tasks, nursing staff could have an active role in the rehabilitation team. The education of nursing staff must focus on boosting self-esteem and teaching independent decision-making in promoting the rehabilitation of older persons and the assessment of their progress., Implications for Practice: Nurse managers must arrange further education for nurses in promoting the rehabilitation of older persons. Nurse managers must also arrange time for the multiprofessional team to discuss and agree joint rehabilitation goals., (© 2011 Blackwell Publishing Ltd.)

Background: Geriatric assessment and treatment including an interdisciplinary team is a well accepted method to improve functionality and mortality in the elderly. Nevertheless, only little evidence and limited data are available concerning the outcome of this approach in an acute care setting and early rehabilitation., Patients and Methods: All patients included in a comprehensive geriatric program within 1 year were eligible for inclusion in a retrospective chart analysis. Admission to the program was allowed after counseling by an experienced geriatrician applying pre-defined criteria including significant deconditioning, preserved rehabilitation prognosis and/or ongoing instable medical condition requiring an acute care setting. Patients who refused therapy or died within the first week of treatment were excluded. A telephone interview was performed 6 months after patient discharge and data concerning mortality, functional course and quality of life (activities of daily life ADL) were retrieved. All patients were treated in an acute care setting in two geriatric and general internal medicine wards., Results: A total of 138 patients were included in the program. In 128 cases data concerning the 6 month mortality could be retrieved and 92 patients agreed to participate in a complete telephone interview. Mortality within the early rehabilitation course was 4%, the 6 month mortality however was 28%. Functionality improved during early rehabilitation and a median increment of 10 points in the Barthel index was found (range 0-100). Analysis of individual increments showed high interindividual variability throughout the whole range of the ADL score at the beginning of the treatment. Concerning the 6 month course after hospital discharge functionality remained at a steady median value but showed a large range of both increasing and decreasing ADL values. Analysis of predictors by logistic regression revealed the ADL score on admission to the early rehabilitation program as the predominant predictor overriding other factors such as depression or cognitive impairment. An ADL value ≤15 on admission was a strong predictor for an unfavorable outcome in early rehabilitation defined as death or an ADL increment ≤10. An ADL value ≤15 on admission was also a strong predictor for overall mortality within 6 months. On the other hand an ADL value ≤15 on admission was a strong predictor for a steady or increasing functionality among the survivors of the 6 month postdischarge interval., Conclusions: The mortality rate in the early rehabilitation course in this preliminary and observational study was relatively low and may be explained by both the exclusion of patients not surviving the first week of treatment and an effective inclusion algorithm. The high overall 6 month mortality rate may also be explained by the selection of patients focusing on those severely functionally impaired. This subpopulation of elderly inpatients in acute care units reveals a high vulnerability to critical incidents. Besides scale effects there is also a remarkable variability in the 6 month postdischarge course pointing to heterogeneity and different patterns concerning the time course of functionality.

Introduction: In Australia, as in many other developed countries, the current healthcare environment is characterised by increasing differentiation and patient acuity, aging of patients and workforce, staff shortages and a varied professional skills mix, and this is particularly so in rural areas. Rural healthcare clinicians are confronted with a broad range of challenges in their daily practice. Within this context, the challenges faced by rural acute care clinicians were explored and innovative strategies suggested. This article reports the findings of a study that explored these challenges across disciplines in acute healthcare facilities in rural New South Wales (NSW), Australia., Methods: A mixed method approach, involving a consultative, participatory 3 stage data collection process was employed to engage with a range of healthcare clinicians from rural acute care facilities in NSW. Participants were invited to complete a survey, followed by focus group discussions and finally facilitated workshops using nominal group technique., Results: The survey findings identified the respondents' top ranked challenges. These were organised into four categories: (1) workforce issues; (2) access, equity and opportunity; (3) resources; and (4) contextual issues. Participants in the focus groups were provided with a summary of the survey findings to prompt discussion about the challenges identified and impact of these on their professional and personal lives. The results of the final workshop stage of the study used nominal group process to focus the discussion on identifying strategies to address identified challenges., Conclusions: This study builds on research conducted in a large metropolitan tertiary referral hospital. While it was found that rural clinicians share some of the challenges identified by their metropolitan counterparts, some identified challenges and solutions were unique to the rural context and require the innovative solutions suggested by the participants. This article provides insight into the working world of rural healthcare clinicians and offers practical solutions to some of the identified issues. The findings of this study may assist rurally based healthcare services to attract and retain clinical staff.

Aggressive assessment and management of the secondary complications in the hours and days following spinal cord injury (SCI) leads to restoration of function in patients through intervention by a team of rehabilitation professionals. The recent certification of SCI physicians, newly validated assessments of impairment and function measures, and international databases agreed upon by SCI experts should lead to documentation of improved rehabilitation care. This chapter highlights recent advances in assessment and treatment based on evidence-based classification of literature reviews and expert opinion in the acute phase of SCI. A number of these reviews are the product of the Consortium for Spinal Cord Medicine, which offers clinical practice guidelines for healthcare professionals. Recognition of and early intervention for problems such as bradycardia, orthostatic hypotension, deep vein thrombosis/pulmonary embolism, and early ventilatory failure will be addressed although other chapters may discuss some issues in greater detail. Early assessment and intervention for neurogenic bladder and bowel function has proven effective in the prevention of renal failure and uncontrolled incontinence. Attention to overuse and disuse with training and advanced technology such as functional electrical stimulation have reduced pain and disability associated with upper extremity deterioration and improved physical fitness. Topics such as chronic pain, spasticity, sexual dysfunction, and pressure sores will be covered in more detail in additional chapters. However, the comprehensive and integrated rehabilitation by specialized SCI teams of physicians, nurses, therapists, social workers, and psychologists immediately following SCI has become the standard of care throughout the world., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Study Objective: To evaluate the association between self-reported sleep quality among older adults during inpatient post-acute rehabilitation and one-year survival., Design: Prospective, observational cohort study., Setting: Two inpatient post-acute rehabilitation sites (one community and one Veterans Administration)., Participants: Older patients (aged ≥ 65 years, n = 245) admitted for inpatient post-acute rehabilitation., Interventions: None., Measurements and Results: Within one year of post-acute rehabilitation, 57 participants (23%) were deceased. Cox proportional hazards models showed that worse Pittsburgh Sleep Quality Index (PSQI) total scores during the post-acute care stay were associated with increased mortality risk when controlling for amount of rehabilitation therapy received, comorbidities, and cognitive functioning (Hazard ratio [95% CI] = 1.11 [1.02-1.20]). Actigraphically estimated sleep was unrelated to mortality risk., Conclusions: Poorer self-reported sleep quality, but not objectively estimated sleep parameters, during post-acute rehabilitation was associated with shorter survival among older adults. This suggests self-reported poor sleep may be an important and potentially modifiable risk factor for negative outcomes in these vulnerable older adults. Studies of interventions to improve sleep quality during inpatient rehabilitation should therefore be undertaken, and the long-term health benefits of improved sleep should be explored.

Objectives: To describe the amount and patterns of ambulatory activity in hospitalized older adults over consecutive hospital days., Design: Observational cohort study., Setting: University teaching hospital Acute Care for Elderly (ACE) unit., Participants: Adults aged 65 and older (N = 239) who wore a step activity monitor during their hospital stay., Measurements: Total number of steps per 24-hour day. Mean daily steps were calculated based on number of days the step activity monitor was worn., Results: Mean age was 76.6 ± 7.6; 55.1% of participants were female. Patients took a mean number of 739.7 (interquartile range 89-1,014) steps per day during their hospital stay. Patients with shorter stays tended to ambulate more on the first complete day of hospitalization and had a markedly greater increase in mobility on the second day than patients with longer lengths of stay. There were no significant differences in mean daily steps according to illness severity or reason for admission., Conclusion: Objective information on patient mobility can be collected for hospitalized older persons. Findings may increase understanding of the level of ambulation required to maintain functional status and promote recovery from acute illness., (© 2010, Copyright the Authors. Journal compilation © 2010, The American Geriatrics Society.)