Rehabilitation for the seriously ill elderly: models of care and quality indicators

The results of this project not only provide clinicians and policy-makers with knowledge on how to evaluate the impact and quality of rehabilitation services in long-term care (LTC), but also identifies the gaps in knowledge and identify areas for future research for rehabilitation for the seriously-ill elderly.

Research Results

Findings: 331 articles were included in the scoping review. The majority of articles were from the United States (42.5%), with most not reporting the length of stay of included residents (66.8%). Very few articles included residents who were non-ambulatory, bedridden, or with evidence of cognitive impairment. The majority of interventions were delivered and evaluated at the person-level. Performance-based measures (i.e. timed-up and go), activities of daily living (ADLs) and mood were the most frequently reported outcomes. No validated models or tools for determining eligibility for PR services in LTC were included. There was limited evidence in the literature around which QIs could be used to evaluate PR in LTC, though activities of daily living were most frequently suggested. 14 stakeholders participated in the consensus meeting. ADLs and falls were identified as the most important QIs for evaluating PR in LTC, however the importance of measuring QIs in relation to each other (i.e. changes in ADLs relative to falls) and focusing on resident-centered outcomes such as quality of life and mood was emphasized.

Impact of findings: These results suggest that future research consider including all professions involved in delivering PR, length of stay or residents, appropriate inclusion and exclusion criteria to capture a realistic population. A future KT opportunity that may be pursued as a result of this study is working with industry partners (i.e. Osteoporosis Canada and Extendicare Canada) to develop and evaluate PR modules specific to the LTC setting focusing on rehab delivery for short- and long stay residents and those with significant functional and cognitive impairments that are targeted at educating the entire team about PR including all professionals – physical therapy, nursing, recreation, occupational therapy, etc.

Publications, presentations and webinars

For more information on why this research matters, click the links below:

Policy        Families        Researchers

About the Project

Physiotherapy (PT) can maintain or restore function in LTC residents, yet a cost-effective model of delivery remains elusive. In 2013, there were funding cuts to rehabilitation in LTC in Ontario. Our recent environmental scan of LTC stakeholders revealed that access to individualized exercise and rehabilitation has been severely limited since the funding changes and replaced with generic group exercise programs that are not accessible for the seriously ill, frail elderly adults with complex needs. There were calls for guidance on evolving models of care in the face of budget shortages, and quality indicators (QIs) to help advocate for resources for the seriously ill elderly in LTC.

We proposed a scoping review to describe the types of rehabilitation interventions evaluated in LTC (e.g. therapeutic goals, frequency of services and mode of delivery), the outcomes (at the person-, facility- and system-level) used to evaluate the interventions and tools or models used to guide allocation of services. We then mapped the available evidence onto existing QIs and identify which new or existing QIs could be used to evaluate the impact of rehabilitation at the person, facility or system level.

For more details on the project rationale, objectives and research plan, click here.

Project Team

Principal Investigator:

Lora Giangregorio, PhD — University of Waterloo

Co-Investigators:

Katherine Berg, PhD, PT — University of Toronto

John Hirdes, BSc, MA, PhD — University of Waterloo

James Milligan, MD — University of Waterloo Centre for Family Medicine

Alexandra Papaioannou, MD, MSc, FRCPC, PACP — McMaster University

Knowledge Users and Partners:

Ravi Jain, MHSc, MA, BComm(Hons.) — Osteoporosis Canada

Jaimie Killingbeck, BSc, RKin — Schlegel Villages

Carol Miller, DipPT, BA, BAA — Canadian Physiotherapy Association

Paula Neves, Vice President (Quality and Healthcare Innovation) — Extendicare

Michael Sharratt, PhD — Schlegel Research Institute for Aging, University of Waterloo 

Project Contact: Lora Giangregorio — lora.giangregorio@uwaterloo.ca

KS 2014-08

Key words: physical rehabilitation; elderly; quality indicators; long-term care

Key Findings For Families

The results of this project not only provide clinicians and policy-makers with knowledge on how to evaluate the impact and quality of rehabilitation services in long-term care (LTC), but also identifies the gaps in knowledge and identify areas for future research for rehabilitation for the seriously-ill elderly.

Project Contact: Lora Giangregorio — lora.giangregorio@uwaterloo.ca

Key Findings for Families

  • Physical rehabilitation programs are most often made up of multiple exercises that are 45 minutes long, for three times a week over four months
  • Most of the research measured activities of daily living, falls and cognition. But, people who are involved with caring for the elderly in LTC facilities identified falls, quality of life, pain, incontinence, pressure ulcers and responsive behaviours (resulting in use of restraints) as important for evaluating physical rehabilitation in LTC

The results of this study provide important ways for looking at how physical rehabilitation programs can help the elderly in LTC.

  • Activities of daily living, falls, quality of life, pain, incontinence, pressure ulcers and disruptive behaviours are important to measure when seeing how helpful physical rehabilitation is
  • This research also found that there is not very much research looking at the elderly in LTC homes that cannot walk, are bed ridden and have memory problems

Why This Matters

The research that looks at how helpful physical rehabilitation is in LTC residents over 65 years old usually looks at activities of daily living, falls and memory. But, other factors may be important when looking at the use of physical rehabilitation in LTC. Also, there is not very much research that looks at who may benefit by physical rehabilitation in LTC homes.

About This Study

  • This study used scoping review methods. A scoping review is a way to find all research on the physical rehabilitation in the elderly who are in LTC homes
  • Studies were included in this review if they studied the elderly (65+ years old) who live in LTC. The studies that were included in this review looked at how helpful physical rehabilitation was.
  • The results of this review were presented to a group of experts who care for the elderly in LTC homes to get their opinion about what is important to measure when deciding if physical rehabilitation is useful

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Policy

The results of this project not only provide clinicians and policy-makers with knowledge on how to evaluate the impact and quality of rehabilitation services in long-term care (LTC), but also identifies the gaps in knowledge and identify areas for future research for rehabilitation for the seriously-ill elderly.

Project Contact: Lora Giangregorio — lora.giangregorio@uwaterloo.ca

Key Findings for Policy

  • Physical rehabilitation programs were most often multicomponent exercise programs, delivered for 45 minutes, three times a week for four months
  • Most studies evaluated physical rehabilitation in LTC facilities using activities of daily living, falls and cognition. However, key stakeholders identified falls, quality of life, pain, incontinence, pressure ulcers and responsive behaviours (and consequently use of restraints) as important indicators to evaluate physical rehabilitation in LTC

The results of this study provide key outcome measures for evaluating physical rehabilitation programs among elderly LTC residents.

  • This study identified key quality indicators for evaluating the effectiveness of physical rehabilitation programs for the elderly in LTC facilities – activities of daily living, falls, quality of life, pain, incontinence, pressure ulcers and responsive behaviours
  • This study also identified a gap in the evidence around the inclusion of persons who are non-ambulatory, bed ridden and cognitively impairment

Why This Study was Needed

Current research into the effectiveness of physical rehabilitation has focused mainly around activities of daily living, falls and cognition. However, this does not provide a comprehensive view of the use of physical rehabilitation in LTC.

Study Summary

  • A scoping review examining physical rehabilitation interventions among older (65+ years old) residents of LTC facilities was undertaken to identify outcome measures to evaluate these interventions
  • Six medical databases and grey literature sources were systematically searched, and yielded 6,721 references. 707 full text articles, 317 articles and two reports were included
  • The evidence was presented to a group of key stakeholders who added to the list of quality indicators through a consensus process

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Researchers

The results of this project not only provide clinicians and policy-makers with knowledge on how to evaluate the impact and quality of rehabilitation services in long-term care (LTC), but also identifies the gaps in knowledge and identify areas for future research for rehabilitation for the seriously-ill elderly.

Project Contact: Lora Giangregorio — lora.giangregorio@uwaterloo.ca

Key Findings for Researchers

  • Physical rehabilitation programs were most often multicomponent exercise programs, delivered for 45 minutes, three times a week for four months
  • Most studies evaluated physical rehabilitation in LTC facilities using activities of daily living, falls and cognition. However, key stakeholders identified falls, quality of life, pain, incontinence, pressure ulcers and responsive behaviours (and consequently use of restraints) as important indicators to evaluate physical rehabilitation in LTC

The results of this study provide key outcome measures for evaluating physical rehabilitation programs among elderly LTC residents.

  • This study identified key quality indicators for evaluating the effectiveness of physical rehabilitation programs for the elderly in LTC facilities – activities of daily living, falls, quality of life, pain, incontinence, pressure ulcers and responsive behaviours
  • This study also identified a gap in the evidence around the inclusion of persons who are non-ambulatory, bed ridden and cognitively impairment

Why This Study was Needed

Current research into the effectiveness of physical rehabilitation has focused mainly around activities of daily living, falls and cognition. However, this does not provide a comprehensive view of the use of physical rehabilitation in LTC. 

How This Study Addresses the Gap

  • A scoping review examining physical rehabilitation interventions among older (65+ years old) residents of LTC facilities was undertaken to identify outcome measures to evaluate these interventions
  • Six medical databases and grey literature sources were systematically searched, and yielded 6,721 references. 707 full text articles, 317 articles and two reports were included
  • The evidence was presented to a group of key stakeholders who added to the list of quality indicators through a consensus process

Future Research

  • Future studies should include a more heterogeneous population that is representative of LTC residents
  • Indicators identified in this study could help develop care models that provide guidance for health professionals in determining those that may benefit from physical rehabilitation

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Publications

The results of this project not only provide clinicians and policy-makers with knowledge on how to evaluate the impact and quality of rehabilitation services in long-term care (LTC), but also identifies the gaps in knowledge and identify areas for future research for rehabilitation for the seriously-ill elderly.

Principal Investigator

Lora Giangregorio, PhD — University of Waterloo

Publications

McArthur, C., Gibbs, J., Papaioannou, A., Hirdes, J., Milligan, J., Berg, K., Giangregorio, L. Protocol for a scoping review of physical rehabilitation interventions in long-term care: tools, models of delivery, outcomes and quality indicators. BMJ Open; 5(6):e007528-2014-007528.

Presentations

McArthur, C., Gibbs, J., Patel, R., Pappaionnou, A., Neves, P., Killingbeck, J., Hirdes, J., Milligan, J., Berg, K., Giangregorio, L. (September 2015). Physical rehab in long-term care: tools, models of delivery, quality indicators and outcomes. TVN Annual Conference. Toronto, ON.

McArthur, C., Gibbs, J., Pappaionnou, A., Hirdes, J., Milligan, J., Berg, K., Giangregorio, L. (May 1, 2015). Physical rehabilitation interventions in long-term care: a scoping review of interventions, models of delivery, outcomes and quality indicators. GTA Rehab Best Practices Day – Student Poster Session. Toronto, ON.

Webinars

Rehabilitation for the frail elderly: models of care and quality indicators — Lora Giangregorio and Caitlin McArthur

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Rationale

The results of this project will not only provide clinicians and policy-makers with knowledge on how to evaluate the impact and quality of rehabilitation services in long-term care (LTC), but also identify the gaps in knowledge and identify areas for future research for rehabilitation for the seriously-ill elderly.

Principal Investigator

Lora Giangregorio, PhD — University of Waterloo

Rationale: Physical rehabilitation (PR) encompasses both active (i.e. exercise) and passive (i.e. therapeutic modalities) methods to maintain or improve mobility, physical activity, and overall health and wellness, and can be delivered by a host of interdisciplinary team members (i.e. physical therapy, occupational therapy, nursing, etc.). While PR is effective at improving function for residents in long-term care (LTC), it remains unclear which interventions and models of delivery are most appropriate, which outcomes or quality indicators (QIs) can be used to evaluate services at the resident, facility or system level, and what tools or models can be used to determine eligibility for services.

Objectives: A scoping review will be conducted to address the following research questions: (1) What types of PR have been evaluated for efficacy or effectiveness in LTC? (2) Which outcomes or QIs have been used when evaluating PR interventions in LTC, and how can this inform evaluation of PR using existing QIs in the Canadian context? (3) What tools or models exist or have been validated for decision-making in the allocation of PR resources in LTC?

Research Plan: We will conduct a comprehensive literature search in MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Physiotherapy Evidence Database (PEDro) and Occupational Therapy Systematic Evaluation of Evidence database (OTseeker) and a structured grey literature search. Two team members screened articles and abstracted the data. Data abstracted regarding outcomes and QIs will be mapped onto existing, publicly reported QIs used in Ontario.

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