Quality Improvement Through the Introduction of Interdisciplinary Geriatric Hemodialysis Rehabilitation Care

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Abstract

Background

Provision of rehabilitation with the aim of restoring personal independence in elderly hemodialysis patients faces several challenges.

Design

Quality improvement report.

Setting & Participants

First 3 years of experience of an inpatient geriatric hemodialysis rehabilitation program in Toronto. Patients with new-onset disability from prolonged illness or an acute event rendering them incapable of living independently.

Quality Improvement Plan

Provision of in-patient rehabilitation with on-site dialysis; a simplified referral system; preferential admission of elderly dialysis patients; short daily dialysis sessions; integrated multidisciplinary care by experts in rehabilitation, geriatric medicine, and nephrology; and reciprocal continued medical education among staff.

Measures

Outcome measures were percentage of patients discharged home, score on the Functional Independence Measure, and attainment of rehabilitation goals.

Results

In the first 36 months, 164 dialysis patients aged 74.5 ± 7.8 years were admitted. On admission, patients had a mean Charlson comorbidity score of 7.8 ± 2.5, 98% had difficulty walking, and 84% required help with bed-to-chair transfers. After a median of 48.5 days, 111 patients (69%) were discharged home; 15 patients (9%), to an assisted-living setting; 20 patients (12%), to a long-term care facility; and 18 patients (11%), to other facilities for acute or palliative care. Of those completing therapy, 82% met some or all of their rehabilitation goals.

Limitations

The program relied on the leadership and drive of key personnel. Discharge disposition as an outcome can be affected by many factors, and definition of attainment of rehabilitation goals is arbitrary.

Conclusion

The introduction of an integrated dialysis rehabilitation service can help older dialysis patients with new-onset functional decline return to their home. Am J Kidney Dis 00:00-00

Related collections

Most cited references 27

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A validation of the functional independence measurement and its performance among rehabilitation inpatients.

T.Andrew Dodds, Diane Martin, Walter Stolov … (1993)

The Functional Independence Measurement (FIM) is a new functional status instrument for use among rehabilitation inpatients, but its validity and reliability have been only partially established. Because of its rapid dissemination, we sought further evidence concerning the FIM's internal consistency, responsiveness over time, and construct validity. We examined Uniform Data System (UDS) data on 11,102 general rehabilitation inpatients from the Pacific Northwest. Mean age was 65 and 51% were male. The most common diagnoses were stroke (52%), orthopedic conditions (10%), and brain injury (10%). Internal consistency of the FIM was calculated using Cronbach's alpha. To assess FIM responsiveness, we examined differences between admission and discharge FIM scores. For construct validation purposes, we hypothesized that the FIM would vary with age, comorbidity, discharge destination, and impairment severity. Comorbidity was quantified with the Charlson Comorbidity Index. The FIM had a high overall internal consistency (discharge FIM alpha = .93). The FIM registered significant functional gains during rehabilitation (33% FIM score improvement, p < .001), as do many other functional status indicators. The greatest and least functional improvements were observed for traumatic brain injury and low back pain (53% and 8% FIM score improvement, respectively). The FIM discriminates patients on the basis of age, comorbidity, and discharge destination. Severity differences could be distinguished among spinal cord injury and stroke patients. We conclude that the FIM has high internal consistency and adequate discriminative capabilities for rehabilitation patients. It is a good indicator of burden of care, and demonstrates some responsiveness, but its capacity to measure change over time needs further examination and comparison with competing scales.

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Functional disability and health care expenditures for older persons.

T Fried, Wayne E Bradley, M Tinetti … (2001)

The rapidly expanding proportion of the US population 65 years and older is anticipated to have a profound effect on health care expenditures. Whether the changing health status of older Americans will modulate this effect is not well understood. This study sought to determine the relationship between functional status and government-reimbursed health care services in older persons. Longitudinal cohort study of a representative sample of community-dwelling persons 72 years or older. Clinical data were linked with data on 2-year expenditures for Medicare-reimbursed hospital, outpatient, and home care services and Medicare- and Medicaid-reimbursed nursing home services. Per capita expenditures associated with different functional status transitions were calculated, as were excess expenditures associated with functional disability adjusted for demographic, health, and psychosocial variables. The 19.6% of older persons who had stable functional dependence or who declined to dependence accounted for almost half (46.3%) of total expenditures. Persons in these groups had an excess of approximately $10 000 in expenditures in 2 years compared with those who remained independent. The 9.6% of patients who were dependent at baseline accounted for more than 40.0% of home health and nursing home expenditures; the 10.0% who declined accounted for more than 20.0% of hospital, outpatient, and nursing home expenditures. Functional dependence places a large burden on government-funded health care services. Whereas functional decline places this burden on short- and long-term care services, stable functional dependence places the burden predominantly on long-term care services. Declining rates of functional disability and interventions to prevent disability hold promise for ameliorating this burden.

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Interrater reliability of the 7-level functional independence measure (FIM)

R Fiedler, B. Hamilton, Carl Granger … (1994)

The Functional Independence Measure (FIM) is an 18-item, 7-level scale developed to uniformly assess severity of patient disability and medical rehabilitation functional outcome. FIM interrater reliability in the clinical setting is reported here. Clinicians from 89 US inpatient comprehensive medical rehabilitation facilities newly subscribing to the uniform Data System for Medical Rehabilitation from January 1988-June 1990 evaluated 1018 patients with the FIM. FIM total, domain and subscale score intraclass correlation coefficients (ICC) were calculated using ANOVA; FIM item score agreement was assessed with unweighted Kappa coefficient. Total FIM ICC was 0.96; motor domain 0.96 and cognitive domain 0.91; subscale score range: 0.89 (social cognition) to 0.94 (self-care). FIM item Kappa range: 0.53 (memory) to 0.66 (stair climbing). A subset of 24 facilities meeting UDSMR data aggregation reliability criteria had Intraclass and Kappa coefficients exceeding those for all facilities. It is concluded that the 7-level FIM is reliable when used by trained/tested inpatient medical rehabilitation clinicians.

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Author and article information

Contributors

Sarbjit V. Jassal

Journal

Journal ID (nlm-ta): Am J Kidney Dis

Journal ID (iso-abbrev): Am. J. Kidney Dis

Title: American Journal of Kidney Diseases

Publisher: National Kidney Foundation, Inc. Published by Elsevier Inc.

ISSN (Print): 0272-6386

ISSN (Electronic): 1523-6838

Publication date PMC-release: 21 February 2008

Publication date (Print): July 2007

Publication date (Electronic): 21 February 2008

Volume: 50

Issue: 1

Pages: 90-97

Affiliations

[1 ]Division of Nephrology, University Health Network, Toronto, Canada

[2 ]Department of Geriatric Medicine, Toronto Rehabilitation Institute, Toronto, Canada.

Author notes

[* ]Address correspondence to Sarbjit V. Jassal, MB, MD, Assistant Professor, University of Toronto, Staff Physician, University Health Network, 8NU-857, 200 Elizabeth St, Toronto, M5G 2C4 Canada. vanita.jassal@ 123456uhn.on.ca

Article

Publisher ID: S0272-6386(07)00736-6

DOI: 10.1053/j.ajkd.2007.04.011

PMC ID: 7115717

PubMed ID: 17591528

SO-VID: a047c40f-ad54-44f8-bc1e-f5a9c740f4cb

License:

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