Archives of Physical Medicine and Rehabilitation journal homepage: www.archives-pmr.org Archives of Physical Medicine and Rehabilitation 2015;96:960-9

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Postacute Rehabilitation Quality of Care: Toward a Shared Conceptual Framework Tiago Silva Jesus, PhD, OT,a Helen Hoenig, MD, MPHb,c From the aHealth Psychology Department, Medical School, University Miguel Herna´ndez, Elche, Spain; bPhysical Medicine and Rehabilitation Service, Durham Veterans Administration Medical Center, Durham, NC; and cDivision of Geriatrics, Department of Medicine, Duke University Medical Center, Durham, NC.

Abstract There is substantial interest in mechanisms for measuring, reporting, and improving the quality of health care, including postacute care (PAC) and rehabilitation. Unfortunately, current activities generally are either too narrow or too poorly specified to reflect PAC rehabilitation quality of care. In part, this is caused by a lack of a shared conceptual understanding of what construes quality of care in PAC rehabilitation. This article presents the PAC-rehab quality framework: an evidence-based conceptual framework articulating elements specifically pertaining to PAC rehabilitation quality of care. The widely recognized Donabedian structure, process, and outcomes (SPO) model furnished the underlying structure for the PAC-rehab quality framework, and the International Classification of Functioning, Disability and Health (ICF) framed the functional outcomes. A comprehensive literature review provided the evidence base to specify elements within the SPO model and ICF-derived framework. A set of macrolevel-outcomes (functional performance, quality of life of patient and caregivers, consumers’ experience, place of discharge, health care utilization) were defined for PAC rehabilitation and then related to their (1) immediate and intermediate outcomes, (2) underpinning care processes, (3) supportive team functioning and improvement processes, and (4) underlying care structures. The role of environmental factors and centrality of patients in the framework are explicated as well. Finally, we discuss why outcomes may best measure and reflect the quality of PAC rehabilitation. The PAC-rehab quality framework provides a conceptually sound, evidence-based framework appropriate for quality of care activities across the PAC rehabilitation continuum. Archives of Physical Medicine and Rehabilitation 2015;96:960-9 ª 2015 by the American Congress of Rehabilitation Medicine

Concerns about quality pervade health care. Countless reports show that substandard care is common1; evidence-based guidelines take too long to diffuse into practice2; hospital-acquired conditions occur all too often3; quality of care differ across patients4; health care expenditures vary geographically and across providers5; and health care services are fragmented, are hard to navigate, and are not patient centered.1,6 This quality chasm calls for transformational changes in the way health care services are organized and made accountable for the quality and value of care delivered.1,7,8 Concerns about quality of care extend to postacute care (PAC) and rehabilitation; however, empirical study has been limited, particularly by efforts to enhance quality. For example, considerable variation exists in the provision of and the outcomes from An audio podcast accompanies this article. Listen at www.archives-pmr.org. Disclosures: none.

PAC rehabilitation services.9 Additionally, fragmentation in the health care system is considered a major threat for the quality of PAC rehabilitation. In the United States, PAC rehabilitation services can be provided in diverse settings (eg, inpatient rehabilitation facilities, skilled nursing facilities [SNFs], long-term care hospitals, home health agencies [HHAs]); however, currently, each of these settings has its own regulations, data sets, and reimbursement mechanisms,10,11 which in turn hinders identifying optimal trajectories of recovery, smooth transitions of care, and the ability to monitor or compare the quality of care across the rehabilitation care continuum.11-13 Moreover, current mechanisms for measuring and reporting on rehabilitation quality of care seem poorly designed and/or narrow in content. For example, rehabilitation consumers report it is difficult to obtain and understand currently available information on rehabilitation quality of care,14,15 in turn leading consumers not to use such information to choose prospective rehabilitation providers.14 Moreover, at least 1 study of PAC rehabilitation found that “no quality measures correlated with any rehabilitation

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Postacute rehabilitation quality framework outcomes,”(p1021) leading the authors to conclude that current quality measures are not specific enough to reflect PAC rehabilitation quality of care.16 Unfortunately, with few exceptions,17,18 most national and even local quality improvement initiatives are designed first to address pressing quality issues in acute medical/surgical health care and applied secondarily to rehabilitation. This phenomenon seems to foster a quality paradox, wherein generic improvement activities (eg, imposed top down by hospital administration) are easily undermined by frontline rehabilitation practitioners who perceive them as suboptimal, distracting, or even counterproductive.19 In summary, there is substantial interest in developing mechanisms for measuring, reporting, and improving the quality of PAC rehabilitation. Unfortunately, current approaches to quality of care activities poorly reflect PAC rehabilitation quality of care. In part, this may be caused by the lack of a shared conceptual understanding regarding what, in the very first place, construes quality of care in PAC rehabilitation.19 Toward catalyzing such crucial development, this article presents the PAC-rehab quality framework: an evidence-based conceptual framework that articulates the elements pertaining to PAC rehabilitation quality of care.

Methods The Donabedian structure, process, and outcomes (SPO) model20 is widely recognized and one of the most used models to frame health care; therefore, it was used to provide the overall structure for the PAC-rehab quality framework, informed by diverse articles that previously have applied the SPO model to rehabilitation.19,21-25 In addition, the International Classification of Functioning, Disability and Health (ICF)26 provided a classification framework for incorporating functional outcomes into the PAC-rehab quality framework. Based on such conceptual foundations, we reviewed the literature on health care quality and PAC rehabilitation to critically revise and adapt the SPO model for rehabilitation and ensure the PAC-rehab quality framework was based on the best available evidence. Not only did the literature review provide substance and illustration to the framework, but it resulted in substantive additions and revisions to the original SPO model and prior adaptations of it for rehabilitation. Therefore, the developmental process for the PAC-rehab quality framework began with a deductive approach (ie, axes and categories provided by foundational articles).19-26 It then was adapted and updated using a systematic inductive approach via a comprehensive review of the literature. Rather than a Cochrane-style systematic review, which is most suitable for narrow-based, homogenous topics, this literature review was modeled instead by a commonly used approach for literature reviews of complex health care or health policy topics.27-29 It consisted of a highly iterative and nonlinear process, with stages overlapping each other. For example, we started with sequential

List of abbreviations: HHA home health agency HRQOL health-related quality of life ICF International Classification of Functioning, Disability and Health PAC postacute care SNF skilled nursing facility SPO structure, process, and outcomes

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961 searches of major databases (PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature) mixing broad keywords (eg, quality, rehabilitation, systematic review) and keywords from seminal articles on rehabilitation quality of care.19-26 These iterative searches fed a comprehensive snowballing process (ie, following of reference lists, citation tracking).28 Iterations within search strategies occurred as well, with repeated searches of major databases, further snowballing, feeding additional databases searches, and more snowballing. The search process was extended until the very end of the peer-review process (September 2014). Abstraction of information occurred alongside iterative searches, and information preliminarily abstracted was continuously mapped by scope30 onto evolving drafts of the framework. The final selection of citations occurred during the synthesis stage, when the authors had full appreciation for the breadth of the literature and its contents28 and focused on retaining the most recent, conceptually relevant, and empirically solid citations.

Results Figure 1 provides an overview of the elements included in the framework and their relations. Although the figure, as is typical for the SPO model, reads from left to right, in the article the constituents are described in a stepwise, reverse order from outcomes to their conductive processes and underlying care structures. Outcomes are described first because evidence-based approaches to quality of care increasingly focus on outcomes as the best way both to influence improvements in structure and process and to ensure that quality of care activities make a difference in what really matters: patient outcomes.

Outcomes Outcomes refer to the positive effects produced by health care.20,24 To reflect different time frames and levels of complexity,25 the outcomes axis was divided into the macrooutcomes or end goals of PAC rehabilitation and the immediate and intermediate outcomes, which are their preceding or mediating outcomes. Macro-outcomes Given the focus on functional recovery, the first macro-outcome for PAC rehabilitation is the ICF-based construct of functional performance,26,31 meaning the extent to which individuals in their own environment execute tasks of daily living (activity) and fulfill social roles (participation).26,32 The ICF is ambiguous in the operational distinction between activity and participation33; nevertheless, participation has a more complex conceptualization, in part because participation is determined by the dynamic intersection among variables from the person, their social roles, and the environment in which it is performed.33,34 Although there are measures of activity in widespread use (eg, FIM), and indeed they are used to investigate rehabilitation quality of care, the added conceptual complexity of participation is such that its measurement is an active area of research,32 with no single broadly used measure. Patient health-related quality of life (HRQOL) is an umbrella construct which covers domains beyond functional performance that impact quality of life, including symptoms (eg, pain, fatigue) and psychosocial dimensions (eg, mental health, subjective wellbeing, life satisfaction).35,36 The relevance of each of these domains can vary across rehabilitation populations, and its measurement can be adjusted accordingly.37,38 Family/caregiver HRQOL refers to the adjustment of the family and caregivers to

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Fig 1

PAC-rehab quality framework.

the consequences of the patient’s disability (eg, caregiver burden, changes into family dynamics).39 Family and caregiver well-being are targets for educational and psychosocial rehabilitative interventions,40 subject to quality of care monitoring and improvement initiatives. Consumer experience is one of the few direct measures of the patient centeredness of health care. The construct of experience has been preferred over satisfaction because it is less subjective and less expectancy dependent.41 In the United States, the Consumer Assessment of Healthcare Providers and Systems is used to monitor consumer experience with health care. There are Consumer Assessment of Healthcare Providers and Systems measures (https://www.cahps.ahrq.gov) for multiple settings in which PAC rehabilitation care is provided (eg, hospitals, SNFs, HHAs); however, none of them address the rehabilitation aspects of care in particular. Studies of consumers experience with rehabilitation services have been largely qualitative42; however, for the purposes of quality monitoring, quantitative measures are limited and mostly refer to satisfaction measures.43 The patient’s final place of discharge (ie, after completing PAC rehabilitation) is an important macro-outcome given the value that returning home can have for the patient, family, and society. Rehabilitation care can influence the discharge destination by the degree of functional recovery or by enabling appropriate environmental adaptations; however, in monitoring this outcome, one must account (ie, risk adjust) for relevant comorbidities (eg, congestive heart failure) and fixed external environmental factors (eg, finances, housing, marital status).44,45 The same rationale applies to the other outcomes of the PAC-rehab quality framework, especially macrolevel-outcomes. Finally, health care utilization captures both the quality and value (ie, cost-effectiveness) of PAC rehabilitation. For example, the degree of functional recovery or the prevention of secondary

disabilities (eg, aspiration pneumonia, pressure ulcers, preventable falls) can improve patient’s health while simultaneously reducing costly lengths of stays, rehospitalizations, or preventable followup care.46,47 Immediate and intermediate outcomes Immediate and intermediate outcomes are those most directly influenced by rehabilitation care processes. The dynamic bilateral influence between process and immediate/intermediate outcomes is labeled in figure 1 as process-outcomes interface. The title is meant to convey the highly iterative and integrative nature of process and immediate outcomes in rehabilitation. For example, rehabilitation therapists typically monitor the immediate effects of interventions on the patient and adapt those interventions in an ongoing way to the observed effects on immediate outcomes.48,49 Also, skilled clinicians can constantly readjust interpersonal communication with patients according to the ongoing observation of the patient’s responses to treatment (eg, reinforcing immediate achievements, preventing or managing disappointment).50 Monitoring of immediate/intermediate outcomes can readily trigger revisions in the process of care, in turn rapidly leading to improvements in the immediate/intermediate outcomes. This is a feed-forward improvement mechanism, which complements retrospective quality improvement based on macrooutcomes monitoring.8,25,51,52 Functional capacity is an intermediate outcome that underpins the more distal functional performance. The construct refers to the patient’s underlying ability to function, regardless of the facilitating/hindering role of environmental variables. Body structures and body functions in turn respectively represent the anatomic and physiological underpinnings of that functional capacity.26 Improvements in body structures and body functions (eg, motor, cognitive, bladder or bowel function) are examples of immediate www.archives-pmr.org

Postacute rehabilitation quality framework rehabilitation outcomes. The clinical prevention/treatment of potential comorbid conditions (eg, infection, malnutrition, depression, pain) can also be immediate outcomes because these conditions can interfere with other rehabilitation outcomes directly or indirectly (eg, through affecting the patient’s ability to participate in rehabilitation).53-55 Finally, a set of immediate/intermediate psychosocial and behavioral outcomes (eg, readiness for care engagement, selfefficacy, coping responses) also seem to affect rehabilitation macrolevel-outcomes. For example, patient’s engagement with care recommendations, related to both clinical and psychological readiness factors,53,54 has been shown to affect functional outcomes,56,57 rehabilitation length of stay,53,56 and physical activity after discharge.58 Similarly, higher self-efficacy is linked to better activity outcomes (eg, balancing, walking behaviors),59 and both self-efficacy and adaptive coping responses are associated with higher patient HRQOL.35,36,60

Process Process refers to practitioners’ actions that affect the patients’ outcomes, either directly through the patient care process or indirectly through interprofessional processes (ie, team functioning, improvement process) that are supportive of that care (see fig 1). Patient care process Care process refers to practitioner’s actions that directly interface with patients and therefore directly impact on their outcomes. There are 5 components (guidelines, individualization, amount and timing, coordination of care, specific interventions) altogether accounting for the quality of the rehabilitation care process (see fig 1).21,61 As portrayed, each of these components embed aspects from both the technical and interpersonal dimensions of care (ie, procedural aspects of rehabilitation and provider-patient interactions) (see fig 1), which dynamically interact in the provision of patient care. Guidelines are a way to synthesize and present the body of evidence to clinicians, often in the form of care directives or graded recommendations developed through the systematic review of evidence and at times expert consensus. Comprehensive, evidence-based guidelines exist in rehabilitation synthesizing which technical aspects of care are effective for different clinical conditions62,63 or specific rehabilitation areas (eg, cognitive rehabilitation).64 When implemented, evidence-based guidelines for the technical aspects of care have been shown to improve rehabilitation outcomes.43,65,66 However, adoption of evidencebased guidelines in clinical practice requires implementation of methods (eg, knowledge translation, continuous education, quality improvement activities)67,68 because existing studies show that dissemination does not occur on its own.2 Guidelines also exist for the interpersonal aspects of care, most typically for general medical care.69 However, guidelines have been developed for specialties (eg, cancer care).70 Compelling evidence links guidelines to better consumer experience and health outcomes (eg, through better adherence to recommended care).71,72 Unfortunately, in PAC rehabilitation, the relation of provider-patient communication to outcomes is less well studied,73 hindering the ability of establishing solid, evidence-based guidelines for the interpersonal aspects of rehabilitation care. Evidence-based guidelines should direct practice, but rehabilitation care still needs to be individualized. The need for www.archives-pmr.org

963 individualization occurs at multiple levels of rehabilitation care. For example, a comprehensive assessment includes individualized reasoning about the plethora of factors (ie, clinical, personal, environmental) that underpin any given patient’s disability; similarly, the formulation of care recommendations involves complex, individualized clinical reasoning, balancing not only data from the patient’s assessment but also variables from the provider’s technical expertise (eg, knowledge of the effectiveness of alternative interventions).49 Finally, individualization also occurs when care recommendations are communicated to and aligned with the patient’s unique values and preferences,49,69 whereas both technical (eg, physical examination) and interpersonal (eg, abstraction of information from the patient) care processes dynamically interact to individualize the assessment and treatment plan. The need for a high level of individualization in rehabilitation49,74 and the difficulty of capturing the dynamic contributions to rehabilitation outcomes from both technical and interpersonal care processes6,74 reduces the validity of monitoring rehabilitation quality of care exclusively through measures of guidelines compliance. Initiation, timeliness, frequency, intensity, and duration of interventions are increasingly acknowledged as important aspects of rehabilitation, distinct from the content of the intervention (eg, specific exercises done for 5 vs 15min, continuously vs episodically).75 This applies to technical but also to interpersonal aspects of care whose effectiveness also depend on the timing of implementation. For example, interpersonal communication focused on problem solving or behavior change is more likely effective when the disability has been emotionally integrated, in turn fostered by active listening and empathetic reassurance.69 On the technical side, there is evidence for some conditions of increased effectiveness from providing earlier, more aggressive rehabilitation care,76,77 including therapies initiated in the acute care setting78 or even before the occurrence of the acute event itself (eg, before hip replacement surgery).79 At the other end of the spectrum, rehabilitation can improve functional outcomes long after the inciting event.80 Therefore, quality monitoring and improvement activities must cover PAC rehabilitation care wherever and whenever it is provided. Coordination of care refers to the synchronization of both technical practices and interpersonal messages provided to patients across all of the health care agents interfacing with the patient. The resultant synergies, or lack thereof, affect patient outcomes.17,81,82 At the rehabilitation team level, care coordination is determined by interprofessional team functioning, as subsequently described. However, health care also needs to be coordinated across settings to enable smooth transitions, enable better trajectories of recovery, and prevent rehospitalizations.10,83 Therefore, coordination of care includes system-level factors, such as uniform datasets, integrated electronic records that are shared across providers, and payment structures (eg, bundled payments) and systems to monitor and foster accountability for the quality and value delivered by the entire care continuum.8,10,12,51,83 Specific interventions define the most granular level of rehabilitation care. Hoenig et al21,61 used a systematic approach to categorize specific rehabilitation interventions into the following: exercise, adaptive techniques and assistive devices, physical modalities, prosthetics and orthotics, and education. Technical and interpersonal care processes act on those interventions. For example, the effectiveness of patient education depends not only on the technical content being taught, but also on how well it is communicated (ie, adapted to the patient’s cognitive or

964 communication limitations and personal factors such as culture and health literacy).84,85 More detailed, discipline-specific taxonomies of specific interventions have been developed for use in practice-based research.86 Most recently, an overarching rehabilitation treatment taxonomy has been created to provide a uniform classification of specific interventions in rehabilitation.87 Use of uniform nomenclature to refer to specific interventions across rehabilitation disciplines and care settings will facilitate quality monitoring activities.88 However, this ideal is challenged by the complexity of disability itself and the consequent multiplicity of interventions used in rehabilitative treatments, compounded by the current lack of evidence about the relative merits of specific interventions.89,90 Interprofessional processes The team functioning and improvement processes are crosscutting, interprofessional processes which support the patient care process and their resultant outcomes (see fig 1). Team functioning refers to how rehabilitation team practitioners within and across disciplines collaborate and complement each other’s actions to optimize care coordination and ultimately patient outcomes. Team functioning includes deliberate care planning and information sharing among practitioners (eg, through interdisciplinary team meetings), which are essential elements for the coordination of care.91,92 In turn, those team actions are influenced by the attitudes and action of the team leadership (eg, fostering and coordinating interdisciplinary care). Finally, underlying sociologic factors (eg, team culture, interprofessional relations, broader organizational climate) can support or hinder team functioning and the collective achievement of outcomes.17,92-94 Aspects of rehabilitation team functioning have been shown to be amenable to training with resultant improvement in functional outcomes,81 making team functioning a potential target for quality measurement and improvement.17,82 Besides doing care, increasingly providers are called on to improve their care (ie, to engage in a quality improvement process). This process can be readily taught to clinicians95 and can be scientifically reported.96 Nonetheless, few accounts of quality improvement action are explicitly found in the rehabilitation literature.17,18,67,97 Typically, quality improvement activities start with the systematic monitoring of providers’ performance and follows with the comparison of provider’s current outcomes, processes, or structures against standards and peer providers. It is then followed by identifying particular changes to implement and then by observing their effects on outcomes in a cyclical fashion.98 Beyond the level of individual practitioners, quality improvement processes are increasingly relevant to patient care teams (eg, rehabilitation teams), for example when using the clinical microsystems approach,52 which is a model for redesigning whole team processes to improve the quality and value of care. Furthermore, the microsystem approach is being expanded to a mesosystem approach, which refers to a whole service line (eg, embedding acute and postacute services)99 being proactively planned and made accountable for the quality, outcomes, coordination of care across teams, and its continuous improvement.

Structure The structure of care refers to relatively stable conditions that enable optimized health care processes. Both theory and applied evidence show that structures of care influence outcomes mostly

T.S. Jesus, H. Hoenig through process mediation (see fig 1).20,23 The structural attributes for which we found evidence in the literature of beneficial effects on rehabilitation processes or indirectly on rehabilitation outcomes are subsequently described.21,61 Personnel In addition to adequate ratios and a variety of licensed health care personnel, pertinent to each setting, the quality of rehabilitation staffing depends on the providers’ competencies.100 Personnel competencies have been organized according to the rehabilitation process dimensions they might underpin. Therefore, the PAC-rehab quality framework divides rehabilitation providers’ competencies into the following 4 categories: (1) technical competence (specialty-based procedural skills, knowledge of disability determinants, and both knowledge and skills for an evidence-based practice and individualized clinical reasoning)49,68; (2) interpersonal competence (communication and relation skills pertinent to the interaction with rehabilitation patients/families)101; (3) teamwork competence (interprofessional communication and partnership skills)92,100; and (4) improvement competence (ability to systematically question, monitor, and engage in a continuous improvement process).102 Team leaders have additional competencies related to the skills necessary to coordinate the rehabilitation team functioning and team-based improvement processes.52,94 Facilities and equipment Rehabilitation processes and outcomes benefit from state-of-theart facilities and equipment.61 Telehealth technology can improve access to rehabilitation services, with resultant improvements in quality and outcomes for underserved patients.103 Electronic infrastructure and software also can affect care processes and outcomes by facilitating evidence-based decision-making, external consulting, or remote access to specialized services. Finally, if uniformly gathered, electronic-based administrative data can be used for quality improvement and practice-based research projects.89,90 Organizational management The organizational management can facilitate or create barriers to the quality of PAC rehabilitation. For instance, policies to reward high-quality care, leadership commitment to quality improvement, and sustained investments in a quality infrastructure help ensure that the structural conditions and organizational culture foster quality of care and its improvement. Quality management models (eg, total quality management, 6 sigma, lean thinking) can help guide organization-wide quality improvement initiatives, whereas human resources policies can promote the development of quality improvement expertise (eg, support for quality improvement training, protected time for clinicians to participate in quality improvement activities).93,95,104 Organizational management, and broadly all other elements of the care structure and rehabilitation process, in turn are influenced by the external health care environment (see fig 1), such as (1) policymakers taking actions that affect the health care systems’ quality of care (eg, regulations, financial incentives); (2) third-party payers using value-based reimbursement mechanisms; (3) the educational community developing professional competencies supporting rehabilitation quality; (4) independent external bodies setting or reporting on standards for quality of care; and (5) the research community advancing the measurement capability, riskadjustment models, and the evidence base about the most effective rehabilitation processes and underlying care structures.8,24,88,100 www.archives-pmr.org

Postacute rehabilitation quality framework Environmental context The patient’s environmental context affects, to a greater or lesser degree, favorably or unfavorably, essentially all the outcomes in the PAC-rehab quality framework (see fig 1).26 However, the quantitative measurement of environmental variables and the ability to empirically determine their impact on rehabilitation outcomes is still evolving.34 Among multiple environmental factors, some can affect the rehabilitation process (eg, insurance/financial resources to access appropriate rehabilitation care,83 availability of an informal caregiver), whereas others can be changed by the rehabilitation process itself (see fig 1), with consequent improvement in macrolevel-outcomes. For example, assistive technologies mediate between environmental constructs and individual capabilities and can modify either end of that relation (eg, a ramp modifies the environmental demands, whereas a prosthetic limb improves functional capacity, and either may enable community mobility).105 Therefore, the patient’s environment can be a target for rehabilitation care, and it is instrumental to better outcomes. However, some systemic environmental factors are not amenable to rehabilitation efforts per se (eg, employment opportunities, community-level infrastructure) and are better addressed by national policies, consumer advocacy, or community-based programs in conjunction with PAC rehabilitation.106 Patient centeredness The PAC-rehab quality framework is built around patient-focused definitions of quality, notably that (1) better outcomes for the patient are the ultimate goals for quality of care, (2) the rehabilitation process needs to be patient centric (eg, responsive to needs, values, perspectives, or personal factors of each patient),1,74 and (3) quality metrics need to cover the whole continuum of patient care.10,11,13,51 The importance of these patient-focused quality definitions is the key reason for putting the patient at the center of the PAC-rehab quality framework. However, it is important to recognize that the patient’s outcomes both affect and are affected by family dynamics107; therefore, when we refer to patients and patient centeredness in the PAC-rehab quality framework, it should be extended to include pertinent family/caregivers. In addition, patients have active roles in rehabilitation quality of care. Patients are coproducers of their own rehabilitation process and outcomes (eg, through an active involvement into care decisions, engagement with care activities), a role which can be fostered by providers (eg, through shared decision-making, training on self-management).20,69,72,91 Second, patients can be actively involved in quality measurement and improvement activities, or even in developing the underlying rehabilitation evidence both by participating in research studies and helping to guide the studies themselves (eg, see the Patient Centered Outcomes Research Institute at www.pcori.org). Increasingly, patients are engaged in the development of outcomes measures,108 new intervention models,109 shaping mechanisms for the public-reporting of quality information,14,15 reporting on gaps in quality of care, defining the aspects of health care they value the most,74,110 and participating in quality improvement committees.104

Discussion The PAC-rehab quality framework addresses the quality of care for PAC rehabilitation, by which we mean physical rehabilitation of adults related to an inciting acute event (eg, acute injury, disease, surgery). Most of the framework definitions can apply to other forms of physical rehabilitation (eg, pediatric rehabilitation) www.archives-pmr.org

965 or rehabilitation care for chronic conditions (eg, preventing functional decline); however, review of the literature for those fields would be needed, and some of the framework concepts and their definitions might differ. For example, the rehabilitation of chronic conditions would require an added emphasis on the promotion of self-management,111 whereas parents would be central stakeholders to pediatric rehabilitation.112 It is important to recognize that continuum of PAC rehabilitation care often starts in the acute care setting78 or even before the patient enters the hospital for treatment of an acute condition (eg, prehabilitation before surgery).79 Moreover, typically it includes care delivered by 1, 2, or more PAC settings (eg, inpatient rehabilitation facilities, SNFs, long-term care hospitals, HHAs) and can include care provided in outpatient settings. Patient-centered quality of care initiatives should target the entire continuum of patient’s care rather than specific PAC rehabilitation settings.13,51 The new Continuity Assessment Record and Evaluation tool will help to bring uniformity to data sets among PAC settings, enabling, for example, care coordination and quality monitoring across the PAC continuum.10,11 Also, use of bundled payment mechanisms, aggregating acute and PAC,12,83 could foster accountability for quality and value of care across the care continuum. However the success of such reform, among other determinants, heavily depends on the measures used for quality monitoring. The question of which type of measures (ie, structure, process, outcomes) best reflect the quality of PAC rehabilitation is a tough and crucial question. There is substantive literature supporting the merits of focusing on outcomes for quality monitoring, both conceptually in so far as it assures that the ultimate goals of quality monitoring are met (ie, benefit for patients) and from an empirical standpoint, with data supporting the efficacy of such an approach for improving quality.7,113,114 The importance of focusing on outcomes for quality monitoring does not negate the importance of monitoring process and structure. The monitoring of care processes (eg, guidelines compliance) and their supportive structures (eg, staffing) can uncover substandard aspects of care amenable to quality improvement, whereas the monitoring of outcomes only reveals whether and what results were achieved, not how they might be achieved.24 Nonetheless, so long as outcomes measurement tools and riskadjustment models are well developed, there are comparative advantages for the monitoring of quality primarily, although not exclusively, through outcomes measures. Outcomes measures capture the net effects of all relevant aspects of the care process and their underlying structures, whereas some evidence in both health care and rehabilitation settings hints that performance on process measures have modest to no relations with relevant outcomes or their improvement.16,113,115-118 In addition, little is known about which specific processes and structures or combinations of these lead to better rehabilitation outcomes.87,89,90 Besides, the sheer complexity of disability and rehabilitation can lead either to an overspecification or to a narrow definition of rehabilitation processes; the first is unduly burdensome, whereas the second is potentially harmful.6,88,119 Finally, a reliance on structural or process measures can foster a culture of compliance with preestablished standards, rather than one of competition and innovation that fosters progress and advancement in care standards.7,12,120

Study limitations The PAC-rehab quality framework is primarily conceptual, but it is based on a comprehensive review of relevant literature for the

966 fields of PAC rehabilitation and health care quality. The large and heterogeneous nature of the relevant literature pertinent to both fields made a Cochrane-style systematic review unsuitable. This in turn brings a risk that the literature on which the framework is based might not be sufficiently representative. As a countermeasure to that, in so far as possible, we availed ourselves of recent systematic reviews on the various foci of this framework. Nonetheless, there is an imbalance in both the quality and quantity of supportive literature for different parts of the framework. For example, further research is needed on identifying which and how psychosocial and behavioral variables can affect rehabilitation macrolevel-outcomes35,36,60 and the ways they are underpinned by which care process elements (eg, which interpersonal aspects of care). Those complex relations are further explored elsewhere.121 Similarly, quality improvement processes and quantitative approaches to the measurement of consumers’ experience were found absent for rehabilitation, which undermines the ability of monitoring its patient centeredness. We hope those limitations will serve as a stimulus for further research to strengthen the conceptual framework and support for PAC rehabilitation quality of care. A final major limitation of this article refers to the inherent subjectivity in limiting and organizing all constituents of the PACrehab quality framework and in defining the content of the core set of macrolevel-outcomes or end goals of PAC rehabilitation. Clearly, the emphasis on which outcomes are most important has differed across the field11,31; therefore, the core set of PAC rehabilitation needs to be comprehensive enough to avoid unintended consequences on unmeasured outcomes dimensions, but parsimonious enough to be readily monitored.119 An intellectual exchange among stakeholders is likely to be beneficial toward defining whether or which features of the PAC-rehab quality framework, and particularly its core set of macrolevel-outcomes, are widely endorsed across stakeholders.91

Conclusions Initiatives to measure, report, improve, or even reimburse for higher quality and value of PAC rehabilitation care are likely to grow. However, their optimal development requires a shared conceptual definition of what pertains to and best reflects the quality of PAC rehabilitation. It is hoped that the proposed PACrehab quality framework can foster dialog among stakeholders about quality of care, with further improvements in our shared understanding. Ultimately, that communal perspective would enable advances toward a more coherent and concerted delivering, measurement, and improvement of PAC rehabilitation quality of care.

Keywords Quality of health care; Quality indicators, health care; Rehabilitation

Corresponding author Tiago Silva Jesus, PhD, OT, Rua das Fogaceiras, 4520-322 Fornos, Santa Maria da Feira, Portugal. E-mail address: [email protected] outlook.com.

T.S. Jesus, H. Hoenig

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Postacute rehabilitation quality of care: toward a shared conceptual framework.

There is substantial interest in mechanisms for measuring, reporting, and improving the quality of health care, including postacute care (PAC) and reh...
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