Posts Tagged Patient-centered care

[Abstract] Stroke Survivors’ Perspectives on Post–Acute Rehabilitation Options, Goals, Satisfaction, and Transition to Home

Abstract

Background and Purpose: Patients and caregivers have not typically been involved in the selection of a post–acute care (PAC) provider. In 2015, the Centers for Medicare & Medicaid Services proposed the need to involve patients and their families during discharge planning. Engaging patients in rehabilitation decisions encourages shared decision making among patients and their clinicians. The purpose of this study was to examine stroke survivors’ perspectives on their involvement in selecting a PAC provider and their goal setting and their satisfaction with the rehabilitation stay and their discharge advice for stroke survivors, prior to 2015.

Methods: This qualitative study utilized semistructured interviews. Thematic content analysis was performed on interviews involving 18 stroke survivors (mean age = 68 years) related to their involvement in planning for their inpatient rehabilitation facility or skilled nursing facility stay, goal setting, and discharge needs.

Results: More than half the participants were not involved in the selection of their PAC setting and believed that doctors made these decisions. Around two-fifths of stroke survivors reported that they were not involved in rehabilitation goal setting. Most patients were satisfied with their rehabilitation stay. When asked to recommend discharge topics for other stroke survivors, participants recommended additional information on health care services, interventions, and insurance coverage.

Discussion and Conclusion: Despite recommendations to include stroke patients in PAC selection and goal setting, many former inpatient rehabilitation facility and skilled nursing facility patients report not being involved in either aspect of care.

Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A273).

via Stroke Survivors’ Perspectives on Post–Acute Rehabilitation… : Journal of Neurologic Physical Therapy

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[ARTICLE] Use of client-centered virtual reality in rehabilitation after stroke: a feasibility study – Full Text

ABSTRACT

Patient-centered virtual reality (VR) programs could assist in the functional recovery of people after a stroke.

Objectives:

To analyze the feasibility of a rehabilitation protocol using client-centered VR and to evaluate changes in occupational performance and social participation.

Methods:

This was a mixed methods study. Ten subacute and chronic stroke patients participated in the rehabilitation program using games in non-immersive VR for 40 minutes/day, three days/week, for 12 weeks. Sociodemographic information was collected and the outcome variables included were the Canadian Occupational Performance Measure (COPM) and the Participation Scale. A field diary was used to record the frequency of attendance and adherence of participants and an interview was conducted at the end of program.

Results:

There were significant and clinically-relevant statistical improvements in the COPM performance score (p < 0.001; CI = 1.29 − 4.858) and in the COPM satisfaction score (p < 0.001; CI = 1.37 − 5.124), with a difference greater than 4.28 points for performance and 4.58 points for satisfaction. The change in the scores for participation was statistically significant (p = 0.046), but there was no clinical improvement (dcohen = −0.596, CI = −1.862 − 0.671). The majority of participants reported more than 75% consecutive attendance of sessions and there was 100% adherence to the program. In the interviews, the participants described their post-stroke difficulties; how the video game motivated their engagement in rehabilitation; and the improvement of occupational performance and social participation after participating in the program.

Conclusions:

VR is a viable tool for the rehabilitation of stroke patients with functional gains, mainly regarding occupational performance and performance satisfaction.

 

Every year, 16 million people suffer from a stroke, with great economic and social repercussions1. In Brazil, this is the leading cause of disability1,2. A stroke is a sudden syndrome, characterized by sensory, motor, and cognitive-perceptual alterations1. These alterations are associated with disability, limitations in activities of daily life (ADL) and restrictions in social participation, with loss of autonomy and independence3,4.

Different treatment protocols are used in post-stroke rehabilitation, and consist mainly of motor control approaches, and task oriented training5,6,7. Task-based training, mediated by technologies and computerized activities such as virtual reality (VR), has been promising for post-stroke patients8,9. Virtual reality is a technology for interaction between user and operating system using graphic resources that recreate a virtual environment10. One of its advantages is that the environment can be more interesting and pleasant when compared with traditional rehabilitation, increasing motivation, engagement and adherence of patients to the treatment10,11,12.

Recent clinical trials with post-stroke patients demonstrated the effectiveness of VR in the rehabilitation of dynamic balance13,14,15,16; motor function12,17,18,19,20,21; performance and independence in ADL12,14 and quality of life17,19,20,21. However, a systematic review found no significant difference in upper limb function when comparing VR with a conventional therapy8. Differences between groups were found only when VR was added to the usual treatments8. In another review, the VR effects varied from small to moderate for ADL and outcomes for social participation did not change with the intervention9.

Although systematic reviews and meta-analyses on VR effectiveness are growing, they were not conclusive regarding the protocol or intervention parameters, which makes the clinical use of VR difficult8,9,11. Higher frequencies of treatment are preferable; however, these findings were not statistically significant8,9. Personalized VR protocols that consider a specific patient’s requirements seem to offer more benefits. However, it should be noted that these results are also not conclusive and there is no consensus about the issue8,9.

As there is little consistency in the literature indicating better VR protocols to be used in clinical practice, it is fundamental to analyze the viability and the patient response potential regarding the intervention using VR. The studies with better quality methodologies evaluated outcomes related to the body structure and function8,9. To recommend the therapeutic use of VR in post-stroke patients it is essential to develop patient-centered interventions and focus on assessing performance-related outcomes in activity and participation.

A patient-centered practice is an approach that considers the person’s ability to deal with their health condition, to self-manage, to make decisions, to motivate themselves, and adhere to treatment7. In this context, this study aimed to analyze the feasibility of a rehabilitation protocol using patient-centered VR and to evaluate changes in occupational performance and social participation of patients after a stroke. The hypothesis was that VR would increase performance, reduce restrictions in participation, and be a viable tool for outpatient intervention with post-stroke patients.

METHODS

This research was a feasibility study that used mixed methods, including a quantitative and qualitative approach. The quantitative study of the pre- and post-intervention type measured changes in occupational performance and social participation, after a rehabilitation program using VR. The feasibility of the VR was analyzed using qualitative methods. This study was approved by the Institution’s Research Ethics Committee.

Local and participants

The participants were recruited by convenience, at the Rehabilitation Center of the Clinical Hospital of the Federal University of Triângulo Mineiro (HC/UFTM), a public and free rehabilitation service with physical therapy, speech therapy, nutrition, nursing, psychology, and occupational therapy.

We selected participants with primary or recurrent stroke diagnoses, hemiparesis, age 18 or older, of either sex, who were in the rehabilitation program. We excluded participants with strokes older than five years, bilateral hemiparesis, and/or other diseases of the musculoskeletal and central nervous systems, wheelchair users, amputees, visually impaired patients, and those who could not understand or respond to the data collection instruments. The sample was selected from the medical records and by indication of the rehabilitation professionals. A total of 10 patients met the inclusion criteria and agreed to participate in the research.

Evaluation procedures and instruments

The procedures took place between January and August 2017 at the HC/UFTM Rehabilitation Center and was divided into three sequential phases.

Phase 1: Pre-intervention evaluation

The participants responded to a socio-demographic questionnaire and were evaluated according to self-reported occupational performance and social participation.

Occupational performance was measured by the Canadian Occupational Performance Measure (COPM). The patients selected the activities that they needed, but which they had not been able to perform, or were not satisfied with their performance23. The patients assigned a grade of 1-10 to the importance of each activity and selected the five with the most importance. Each activity selected was evaluated for the patient’s performance and satisfaction on a scale from 1-10. The total scores were calculated from the means of the performance and satisfaction. Changes in scores greater than two points indicated a clinically relevant improvement23.

Social participation was measured by the Participation Scale (P-Scale), version 6.0. The participants would compare themselves with a “peer without disability” and respond to how they perceived their own level of participation compared with the “peer”24. The score of any item varied from zero, when the individual did not have restrictions to his participation, to five when the restriction was considered a “big problem”. The total score varied from zero to 90, with smaller values indicating less restriction25.

Phase 2: Intervention

The rehabilitation program using VR was implemented at the HC/UFTM Rehabilitation Center. The literature does not have a standardization of interventions and/or games used in virtual reality programs. Thus, the protocol chosen had the number of sessions and duration following the findings of Aramaki et al26. Therefore, the protocol consisted of three weekly sessions lasting 40 minutes each, developed over 12 weeks, for a total of 36 sessions.

The participants were in an orthostatic position, four meters away from the screen and video game, in a room with natural light. The Xbox 360® was used with Kinect motion sensor technology.

The games were chosen according to the activities indicated in the COPM as difficult to perform in the initial evaluation. These required training in upper-limb and lower-limb motor skills, motor coordination, and cognitive skills. A detailed description of the information for each game and its main effects are shown in the Figure 1.

The sessions began with the game “20,000 Leaks” to familiarize the participant with the video game interface. Each participant played two or three games for 10 minutes each. In order to avoid fatigue, if necessary, a two-minute interval between games took place.

 

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[Abstract] Person-Centered Rehabilitation Care and Outcomes: A Systematic Literature Review

Abstract

Background

Despite growing recognition of person-centered care as an essential component of quality care, little is known about how person-centered care can be implemented in the provision of care services and how it is empirically related to outcomes in the rehabilitation settings.

Objectives

To investigate the extent of implementation of the person-centered care in rehabilitation practices, as well as its effects on relevant outcomes.

Design

Systematic literature review.

Data Sources

Six electronic databases (PubMed, Web of Science, CINAHL, Scopus, PsycARTICLES, and Cochrane library) were searched for articles published between January 2000 and January 2018.

Methods

Based on the inclusion criteria, quantitative studies that examined person-centered rehabilitation interventions and relevant outcomes were included. Study quality assessment, data extraction, and synthesis were performed.

Results

For this systematic review, 17 eligible studies were included and most studies were rated as low-quality. The selected studies were varied concerning the use of the term person-centered care, research design, target population, sample size, setting, intervention, and outcome measures. The most examined interventions in this review were focused on goal setting and shared-decision making processes based on the client-centered approach. The implementation of those interventions varied considerably. Results showed mixed relationships between person-centered care and the outcomes examined in the studies although there was strong evidence regarding the positive effects of person-centered care on occupational performance and rehabilitation satisfaction.

Conclusions

Person-centered care has been increasingly advocated in rehabilitation settings. However, we found that true person-centered care was not fully implemented in rehabilitation practices. Moreover, it appears that person-centered care could positively affect rehabilitation outcomes, such as significant improvements in functional performance and quality of life, however, evidence about these positive effects of person-centered care is not sufficient. More research with rigorous designs is needed.

 

via Person-Centered Rehabilitation Care and Outcomes: A Systematic Literature Review – ScienceDirect

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[Abstract] How do patients describe their disabilities? A coding system for categorizing patients’ descriptions

Abstract

Background

To provide care that meets the values and preferences of patients with disabilities, health care providers need to understand patients’ perceptions and understanding of their disability. No studies have explored patients’ definitions of disability within the healthcare setting.

Objective

The aim of the study was to understand how patients’ define their disability in the healthcare setting and to develop a coding system for categorizing how they describe their disability.

Methods

In 2000 all new outpatients at Mayo Clinic, Rochester, MN completed a form that inquired if they had a disability and if so, to write in the disability. The research team categorized the responses by disability type (e.g.: visual or physical) and how the patient described his disability or “disability narrative” (e.g.: diagnosis or activity).

Results

Within 128,636 patients, 14,908 reported a disability. For adults, lower limb (26%) and chronic conditions (24%) were the most frequent disability type and activity limitations (56%) were the most frequent disability narrative category. For pediatric patients, developmental disabilities (43%) were the most frequently reported disability type and diagnoses (83%) were the most frequent disability narrative category. Patients used different disability narrative categories to describe different disability types. For example, most adults reporting a mental health listed a diagnosis (97%), compared to only 13% of those with lower limb disabilities.

Conclusions

Patients had diverse descriptions of their disabilities. In order for providers and healthcare organizations to provide high-quality care, they should engage patients in developing a consistent, patient-centered language around disability.

Source: How do patients describe their disabilities? A coding system for categorizing patients’ descriptions – Disability and Health Journal

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