Doctor of Philosophy
Sydney Business School
Poulos, Christopher John, Exploring the rehabilitation patient journey, Doctor of Philosophy thesis, Sydney Business School, University of Wollongong, 2011. http://ro.uow.edu.au/theses/3516
Rehabilitation services are a critical component of the Australian health care system. They improve outcomes for patients with disabling conditions resulting from serious illness or injury, free up acute hospital capacity and decrease the burden of disability. Yet health system redesign strategies in Australia have largely neglected both the interface between acute care and rehabilitation and the patient journey within rehabilitation. Improving the effectiveness and efficiency of the patient journey through the acute hospital and into and through the rehabilitation episode has the potential to enhance patient outcomes and increase hospital capacity.
Program of research
This program of research, presented as six publications, takes a health systems approach to the investigation of the rehabilitation patient journey. It focuses on the management of potential rehabilitation patients in acute care, the rehabilitation selection and transfer process, and the inpatient rehabilitation episode. The purpose of the research is to improve health service provision and utilisation for this cohort of patients and to suggest further areas for investigation.
A literature review focusing on rehabilitation patient classification and the role of utilisation review in determining level of care appropriateness identified concurrent utilisation review as a suitable method to investigate the rehabilitation patient journey. The InterQual utilisation review tool was selected for piloting because it was the most contemporary and widely published tool and also contained specific criteria for rehabilitation and subacute level of care appropriateness. Following the pilot, two further studies were conducted, one in acute care and the other within rehabilitation facilities.
Case study of an information management system
A case study on the design, implementation and evaluation of a clinical information management system to improve the logistical aspects of the rehabilitation patient journey is also presented as part of this body of work. This system enables clinicians to manage and track patient referral, consultation outcomes and subsequent transfer to rehabilitation and subacute beds. Its introduction resulted in decreased time to consultation and transfer.
Utilisation review in acute care
In the acute hospital pilot study, patients with diagnoses of stroke, hip fracture or amputation, and other patients referred for rehabilitation assessment, were followed with concurrent utilisation review. Results on 242 acute episodes, representing 2698 bed days, showed that a high proportion (69%) of days of stay did not meet appropriateness for acute care. These findings were consistent with overseas studies. According to the InterQual tool, most patients were appropriate for transfer to rehabilitation much earlier than was current practice. The study found that the InterQual tool had utility in the Australian hospital setting.
In a second, larger acute hospital study, detailed reasons why utilisation review criteria were not met were obtained in addition to concurrent utilisation review findings. Clinical decision making differences between the acute care and rehabilitation teams over patient selection were also examined. Data on 694 acute episodes, (7189 bed days) showed that 56% of days (stroke, hip fracture and joint replacement patients) and 33% of days (other patients, from the time of referral) met acute level of care criteria. Forty five percent of inappropriate days of stay in acute care were due to delays in processes or scheduling within the acute hospital. Being more appropriate for rehabilitation or lower level of care accounted for a further 30% of inappropriate days. From referral, the acute care team and the utilisation review tool deemed patients ready for rehabilitation transfer earlier than did the rehabilitation team (1.4, 1.3 and 4.0 days, respectively). From when deemed medically stable for transfer by the acute care team, 28% of patients subsequently became unstable. From when deemed stable by the rehabilitation team or the utilisation review tool, 9% and 11% of patients, respectively, subsequently became unstable.
Utilisation review in the rehabilitation setting
In a third study, concurrent utilisation review was conducted in inpatient rehabilitation facilities on 267 patient episodes, representing 7359 days of stay. Only 48% of days met appropriateness for a level of care consistent with rehabilitation. Receiving insufficient therapy was the main reason why utilisation review criteria were not met. Other reasons were that the patient was awaiting discharge to long term care or to home, or that they were more appropriate for acute level of care. Therapy time data, available on 208 episodes, showed that therapy was received on only 50% of calendar days, and for an average of 37 minutes per weekday (56 minutes for stroke).
Overall, the research findings suggest that a high proportion of patient days do not meet level of care appropriateness in either the acute or the rehabilitation settings. The acute care findings were consistent with the international utilisation review literature. As this was the first published study of concurrent utilisation review within the rehabilitation setting, comparative data in this context are not available. The reasons why level of care appropriateness were not met are discussed in detail in the respective papers.
The research revealed considerable variability between the acute care teams and the rehabilitation team in the determination of patient appropriateness for rehabilitation and readiness for transfer, and suggested that formal utilisation review could have a decision support role at the interface between acute care and rehabilitation. The findings also highlighted the fact that, for a variety of reasons, patients often remain in acute care when their need is for rehabilitation.
Strategies to improve the selection and transfer process to rehabilitation will aid patient flow. Strategies include improved information and logistical management of patients who may be appropriate for rehabilitation, as well as support for clinical decision making. Models of care that provide rehabilitation in the acute setting will offer benefits for patients who remain in acute care when they have need for rehabilitation. Benefits include more effective use of hospital resources and the prevention of functional decline in patients. Funding models in Australia need to support the provision of rehabilitation in the acute setting.
The research findings also show a need to improve the efficiency of inpatient rehabilitation. The low levels of therapy patients received in these typical public rehabilitation units warrants further investigation, as it might be impacting on patient outcomes and the effectiveness of rehabilitation programs. Locating inpatient rehabilitation services in separate facilities, away from acute hospital support, may also have implications for the patient journey and requires further investigation.