1 Rehabilitation news and advances from carolinas rehabilitation, a part of carolinas healthcare system winter 2012 carolinasrehabilitation.org inside... PAGE 2 Quality Reporting Comes to Inpatient Rehab New Physician Receives Prestigious Award PAGE 3 Falls Prevention PAGE 4 Political Participation in the TBI Patient Population PAGE 5 Carolinas Rehabilitation Sponsors TBI/SCI Conference PAGE 6 Measuring the Effectiveness of Gait Training PAGE 7 Emotion Processing After Brain Injury PAGE 8 Carolinas Rehabilitation News A t Carolinas Rehabilitation, we have a simple mandate to make no compromises in our commitment to care. Carolinas Rehabilitation provides the full continuum of care, from acute inpatient rehabilitation to extensive outpatient physician and therapy services. Our ties with Carolinas HealthCare System give us access to other services home healthcare, skilled nursing facilities, state-of-the-art technology, expert physicians which allows us to provide an exceptional level of care to our patients. But we re not content to just give the best rehab care possible we re intent on redefining best practices in our field. A system on the move We re working toward our mandate in many ways, and here are some you ll learn about in this issue of Within Your Reach: We re identifying new ways to improve quality of care and safety throughout our system. A new Hand- Off Protocol (HOP) in our falls prevention program reduced the falls rate in our four hospitals by more than 25 percent in We want to be a leader in defining and improving quality measures that are specific to inpatient rehabilitation. We re taking our best research and clinical innovations to peers hosting events such as the October 2012 regional conference on traumatic brain injury/spinal cord injury that brings together clinicians from institutions in North and South Carolina, and through EQUADR SM (Exchanged Quality Data for Rehabilitation), a quality network we created that connects inpatient rehab facilities nationwide. The EQUADR SM network helps us share information, Letter from the Medical Director Redefining rehabilitation care ideas and best practices with peer institutions to drive quality improvement and increase the safety of inpatient services for rehab patients at our facilities and elsewhere. We re bringing the best technology to patient care, such as the ReWalk system exoskeleton that helps patients with paralysis or paresis learn to walk again. We re also committed to supporting our clinical researchers, such as Mark Hirsch, PhD. We welcome a new research director, Janet Niemier, PhD, who will promote ongoing innovation at Carolinas Rehabilitation through research. In 2013, we re opening two new hospitals in Charlotte s neighboring communities of Pineville and Concord, adding jobs and providing comprehensive services to rehab patients. These facilities will enable family members to be closer to their loved ones and more involved in the rehab process an essential component of a patient s successful recovery. enhancing quality of life We re always seeking ways to work more efficiently, effectively and compassionately. We take this mandate to heart because every innovation and improvement we make is not only an advancement of our program, but also a real enhancement in the health and well-being of a patient who s suffered a life-changing event. Sincerely, William Bockenek, MD Medical Director, Carolinas Rehabilitation Chairman, Physical Medicine and Rehabilitation
2 Quality reporting comes to inpatient rehab suzanne snyder, fache, mba, pt Administrative Director, Carolinas Rehabilitation-Mercy Q uality reporting is nothing new for inpatient acute care but, until now, it wasn t part of the inpatient rehab world. That changed on Oct. 1, 2012, when Medicare began requiring quality reporting for inpatient rehabilitation. Failure to report will mean a 2 percent reduction in reimbursements for 2014, so this is an important issue for hospitals. And although for now the new physician receives prestigious award obias Tsai, MD, a pediatric T physiatrist who recently joined the staff at Carolinas Rehabilitation and Levine Children s Hospital, received the 2012 Corbett Ryan Pathways Pioneer award from the American Academy for Cerebral Palsy and Developmental Medicine at the organization s annual meeting in Toronto, Canada on Sept. 13. Dr. Tsai was nominated by a colleague for: representing excellence in the pursuit of and quality of life being motivated and accomplishing personal and vocational/professional goals having a positive attitude and a creative approach to the pursuit of education serving as a role model and demonstrating sensitivity to others. reimbursement structure is only based on reporting, there s every indication that, in the future, Medicare reimbursements for inpatient rehab services will be based on performance. What does this mean for physicians? For inpatient rehab, the reporting currently requires only two measures: pressure ulcers catheter-associated urinary tract infections (UTIs) UTIs are most often measured by infectious disease specialists, but physicians can play a critical role in reporting and classifying pressure ulcers, whether they know it or not. The more clear, concise documentation of pressure ulcers you can give, the better. Clear documentation helps identify who the pressure ulcer belongs to whether it developed at another facility or during the patient s care on that physician s service. If you have questions about best methods for documentation, speak to your medical coders or wound care experts for help. What s Ahead Consensus in the rehab quality community is that these two measures are the first of many to come. The National Quality Forum (NQF) has already endorsed a list of Join our community For more information about ideas and best practices relating to quality benchmarking, visit additional measures for inpatient rehab, and Medicare is expected to give heavy weight to these recommendations. They could go into effect as early as New NQF-endorsed measures include: incidence of potentially preventable venous thromboembolism (VTE) staff immunization percentage of short-stay patients who are admitted with a scheduled pain medication regimen and who self-report a decrease in pain intensity or frequency percent of patients who were assessed and appropriately given the seasonal influenza vaccine percent of patients who were assessed and appropriately given the pneumococcal vaccine Two measures are still under development: functional outcomes and hospital readmissions. The latter was indicated as a measure of interest for current requirements, but it wasn t implemented in the first wave because there were too many questions. Ultimately, it s expected to be added and, when that happens, physicians will want to carefully monitor procedures for discharging patients from their service. about the author: Suzanne Snyder, FACHE, MBA, PT, is on the board of directors for the American Medical Rehabilitation Providers Association and is co-chair of the association s Quality Committee for inpatient rehabilitation. She frequently serves as a technical expert on many Medicare and MedPAC committees, as well as for the National Quality Forum, where she is scheduled to present in May Images on any of these pages may be from one or more of these sources: 2012 Thinkstock and 2012 istockphoto.com. 2 carolinasrehabilitation.org
3 Falls prevention Carolinas Rehabilitation s program is tailored to meet patients special needs when it comes to preventing falls Ben Wells, PT, CSHA Accreditation and Patient Safety Coordinator, Carolinas Rehabilitation M ost hospitals use fallsassessment tools to identify who among their patient population is at a high risk of falling. But at Carolinas Rehabilitation, all patients are considered high-risk patients. Many of our patients have suffered traumatic brain injuries, strokes or spinal cord injuries. Essentially every patient who comes through our doors has some condition or injury that puts them at high risk for falling. Identifying at-risk patients Carolinas Rehabilitation went beyond the typical standards for assessing falls risk in their patient population. In 2011, a multidisciplinary team of therapists, nurses, physicians and others reviewed falls data at one of its hospitals. The team found that they could develop a better system both for defining the level of supervision that a patient needs and for clearly communicating that need to all staff members. Patients at Carolinas Rehabilitation go back and forth several times a day from the nursing unit to therapy, so they re seeing nurses; physical, occupational and speech therapists; physicians; and perhaps other clinicians respiratory therapists, dietitians, wound specialists or psychologists. Our goal was to establish common definitions and expectations for identifying and managing a person s risk, so that all members of that patient s team would be on the same page. As a result, they developed the Hand-Off Protocol (HOP), and it s steadily reducing fall rates in Carolinas Rehabilitation patients. The HOP uses criteria based on behavior, cognition and safety awareness, in addition to the standard Hendrich Falls Risk Assessment tool, to identify patients who are at the highest risk of falls. Every patient who needs to be on the HOP has signs posted on his or her wheelchair and room so every staff member immediately knows what level of supervision is needed. A form also documents the rationale for placing that patient on the HOP. This form is reviewed at least weekly during a careteam conference to assess whether the risk has changed and if the patient is still appropriate for the HOP. This new system helps us establish which patients shouldn t be left alone while out of bed and who should be handed off directly from one staff member to another. But just as important, it helps us instantly communicate that need with everyone on a patient s team. Evidence-based protocols The HOP has evolved through the Plan, Do, Study, Act Performance Improvement Program. Initially, the program used seat belt alarms for a select number of patients. Based on the successes of that strategy, Carolinas Rehabilitation is placing seat belt alarms on the wheelchairs of almost every admitted patient. But a patient on the HOP is assigned a room in close proximity to a nursing station or other clinical staff area so that the clinician has a direct line of sight to that patient. When necessary, a physician orders a restraint for those at the highest risk. An occupational therapist visits every patient during his or her first day in the hospital. During this visit, a bathroom needs assessment is made and hospital staff is alerted if it s determined that a patient will require additional assistance when using the bathroom. Positive results The HOP was first tested at one of Carolinas Rehabilitation s four hospitals in April 2011; after demonstrated success, it was implemented at the other hospitals the following October. Although it was only active in one site for most of 2011, Carolinas Rehabilitation measured a 13.5 percent reduction in falls in that year alone. For 2012, Carolinas Rehabilitation will report a falls reduction rate between 25 and 30 percent. The HOP has earned a Silver Touchstone award from Carolinas HealthCare System for its effectiveness. The program has also been presented at the Association of Rehabilitation Nurses conference and to EQUADR SM network members, a Carolinas Rehabilitationestablished, national network of inpatient rehabilitation hospitals that focuses on quality measures and improvement. Falls prevention is a clear way to improve every quality measure for the patient and the hospital. Preventing a fall shortens a patient s stay, helps him or her move to the next level of care more quickly, avoids new injury and saves money. But it takes both effort and strategy to prevent a fall, especially among rehab patients who don t always realize how vulnerable they are to falling. Our nurses, therapists, physicians and administrators all worked together to create this system, and we re seeing that it is effective. To refer a patient to Carolinas Rehabilitation, call REHAB51 ( ) 3
4 Clinical research Political participation in the TBI patient population Ensuring adequate access to the democratic process Mark A. Hirsch, PhD, Clinical Researcher esearch on political participation University and the University of North R is a particularly timely topic, Carolina at Charlotte. Individuals with TBI especially as a result of this expressed the view that cognitive capacity year s presidential elections and increased to vote should not be a factor in voting media attention on traumatic brain injury but that some people with high levels of (TBI) due to reports of sports injuries and cognitive impairment should not vote if the prevalence of TBI among veterans. they do not understand what is going on. Recently, the Department of Defense Individuals who chose not to vote were likely initiated a pilot program to test voting to list social stigma issues as the reason for technology for wounded warriors. not voting. African-Americans with TBI were statistically more likely than other groups to Relationship between request cognitive help at the polls. political participation and tbi In a related study, the research team The majority of U.S. states have compared political knowledge of individuals constitutional language, statutes or court with TBI to that of average college decisions that, if applied as worded, could students who had taken an introductory bar individuals with TBI from voting. In course in political science at a large public an ongoing National Institutes of Healthfunded study on voting, 55 individuals knowledge about the 2008 North Carolina university in North Carolina. Local political with moderate to severe TBI and 27 family election was assessed by administering members of individuals with TBI were a questionnaire asking about local party followed to the polls in Mecklenburg County candidates and the overall workings of the and interviewed about their experiences American government with questions with voting during the 2007 general taken from the United States Citizen and election and 2008 national presidential Immigration Services (USCIS) citizenship election. Responses to standardized tests exam question bank. Results included: of voting capacity and political literacy Individuals with TBI ( 6 months were evaluated by a research team from post-tbi; 38 males/17 females; range Carolinas Rehabilitation, Rutgers University, years of age; 63 percent had voted) the University of Pennsylvania, Indiana recalled less about the 2008 national if individuals with tbi fail to vote, they don t have a voice in the federal and state programs, products and services designed for them. presidential election and the USCIS than college students. (Participants with TBI scored an average of 4.2 out of 10 points on the USCIS, while college students scored an average of 6.6 out of 10 points on the USCIS.) On average, individuals in the TBI sample would not pass the citizenship test. The average score of the college students was barely passing, and 6 out of 22 did not pass the test. On the test of local political knowledge, individuals with TBI scored equal to the students on knowledge about the 2008 North Carolina election. Neither gender, race, education, marital status, whether participants followed politics, or the amount of time since the election that the tests were administered were related to election knowledge or total political knowledge. TAKEAWAY: If individuals with TBI fail to vote, they don t have a voice in the federal and state programs, products and services designed for them. Unless measures are taken, this may disable democracy. Cognitive capacity-to-vote issues could be addressed in rehabilitative settings that may facilitate voting, political and civic participation. Rehabilitative centers can collaborate with patient advocacy and disability-rights groups, political scientists, economists and community associations to promote political participation. Strategies to address low voter participation and interventions to increase political participation are desperately needed. 4 carolinasrehabilitation.org
5 Conference participants were able to speak with local and national vendors from medical, assistive technology and durable medical equipment companies. Acknowledgements: Partial funding by Carolinas HealthCare Foundation and community participation in a research grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHHD) and National Institute of Mental Health (NIMH) #R21HD and NIH ARRA administrative supplement grant #3R21HD S1. The author gratefully acknowledges the individuals living with TBI and family members who contributed to the study as participant co-researchers. The author also acknowledges this study s co-investigators and their affiliations: Andrew M. Ball 1 ; Michael Dickerson 2 ; Flora M. Hammond 1,3 ; Jason H.T. Karlawish 4 ; Mary Klenz 5 ; Martha E. Kropf 6 ; Jessica Link 6 ; Allison K. Bickett 1 ; Christine S. Davis 6 ; Lisa A. Schur 7 ; Douglas L. Kruse 7 ; Julia Nelson 1,6 ; Susan Saunders 1 ; Monique Stamps 8 ; and Becka Tait 5. Affiliations: 1 Carolinas Rehabilitation 2 Mecklenburg County Board of Elections 3 Indiana University 4 University of Pennsylvania 5 league of Women Voters of North Carolina, Charlotte Chapter 6 university of North Carolina at Charlotte 7 Rutgers University 8 Disability Rights and Resources of Charlotte References: 1. Department of Defense, DOD to test voting technology for wounded warriors. Federal Voting Assistance Program (FVAP). July 25, Accessed May 14, Davis C, Nelson J, Hirsch MA, et al. An exploratory examination of political empowerment and voting among individuals with TBI. Brain Injury. 2010;24(3): Link JN, Kropf M, Hirsch MA, et al. Assessing voting competence and political knowledge: Comparing individuals with traumatic brain injuries and average college students. Election Law Journal. 2012;11(1): Karlawish JA, Bonnie RJ, Appelbaum PS, et al. Addressing the ethical, legal, and social issues raised by voting by persons with dementia. JAMA. 2004;292(11): Carolinas Rehabilitation Sponsors TBI/SCI Conference A dvanced Rehabilitation Ideas for Traumatic Brain Injury (TBI) and Promoting Health and Wellness for Spinal Cord Injury (SCI) was held in Charlotte, on Oct. 15 and 16, This multidisciplinary conference featured lecture and hands-on sessions offering current information for healthcare providers and students. The conference shared evidence-based practices and advanced techniques for treating TBI/SCI patients, says Lisa Hunt, OT, clinical coordinator of Outpatient Therapy at Carolinas Rehabilitation. We wanted clinicians to be able to use these strategies and techniques in their day-to-day practices at their respective sites. Want more? To access resources from this conference, including the keynote address by Kevin Guskiewicz, PhD, visit carolinasrehabilitation.org/conferences. To refer a patient to Carolinas Rehabilitation, call REHAB51 ( ) 5
6 Clinical research Measuring the Effectiveness of Gait training D id you know that the average moderately active person walks about 7,500 steps each day? That s approximately 216 million steps in a lifetime. Walking is good for maintaining and improving the brain s health, among other things. Walking patterns are difficult to measure with the naked eye. Rehabilitation professionals use specialized equipment to objectively measure walking and use this information in designing and evaluating the effectiveness of rehabilitation programs. Assessing the pediatric population Carolinas Rehabilitation received a grant from the Children s Miracle Network to pursue clinical and research areas using a portable, automated, computerized gait analysis system called the GAITRite portable electronic walkway (CIR Systems, A patient walks on the GAITRite portable electronic walkway while a clinician measures her motor system control and coordination. Inc., Pa.). When an individual walks on the instrumented carpet, sensors are activated, registering the position and pressure of each footfall. This provides objective assessments of standardized gait parameters, such as single support time, double support time, cadence, gait velocity and step length. An added feature is an integrated metronome that can be useful for dual-task studies and training gait in individuals with a variety of motor coordination problems. This offers the rehabilitation professional information about the health of the individual s motor system, motor control and motor coordination. GAITRite will be used in future clinical areas and research studies, including assessing movement in children with a variety of neuromuscular impairments and evaluating brain health in pediatric patients who have sustained a concussion. Studies in various patient populations Carolinas Rehabilitation researchers have conducted studies on gait in a variety of neuromuscular and orthopedic populations, including studies of early outcomes of clubfoot deformity after Ponseti treatment and gait in individuals with early diagnosed Parkinson s disease. This has been accomplished by partnering with a variety of departments within Carolinas Medical Center, including the Department of Neurology and faculty and fellows within the Department of Orthopedics and Orthopedic Engineering Research Laboratory under the direction of Rick Peindl, PhD, at CMC. Several GAITRite studies are on the drawing board or ongoing within the Carolinas Trauma Network Research Center of Excellence. These studies include investigations of the near- and long-term effects of concussive or mild traumatic brain injuries (mtbi) on quality of life, as well as studies to reduce the occurrence of geriatric fractures and fragility. Currently, GAITRite will be used in a pilot study to assess residual impairment in balance and gait at 1 week and 3 weeks after the mtbi occurred. The effects of the mtbi are often subtle and difficult to measure. It is hoped that GAITRite will pick up on residual deficits that often remain undetected with standardized paper-and-pencil tests, so that patients can be referred to rehabilitation programs for secondary prevention. Refer your patient for gait training If you re interested in learning more about GAITRite, contact Mark A. Hirsch, PhD, at 6 carolinasrehabilitation.org
7 Clinical research Emotion Processing After Brain Injury P rior research demonstrates that persons with traumatic brain injury (TBI) often have difficulty determining emotion from facial expressions. Poor interpersonal skills, which are associated with impaired affect recognition, are linked to a wide array of negative outcomes. An ongoing groundbreaking study by an international team of rehabilitation researchers from Carolinas Rehabilitation, Southern Ontario, Canada and Wellington, New Zealand has investigated the effect of three treatment programs on empathy, daily behaviors and relationship quality among 71 individuals with TBI randomized to one of three treatment groups. Treatment interventions included: 1. teaching emotion recognition through Facial Affect Recognition 2. teaching participants to recognize emotions based on context in short stories, Stories of Emotional Inference 3. referring a group that didn t incorporate any emotional training to Cognitive Training Major findings of this study were presented at the 2012 American Congress of Rehabilitation Medicine in Vancouver, October Results included that people with TBI were: better at recognizing emotion from film clips that provide more information about emotion than an isolated facial or vocal expression more likely to mistakenly identify neutral emotions as being negative emotions (e.g., angry) less likely to feel sad or fearful in response to sad or fearful film clips than their peers more likely to have significant trouble References: identifying, describing and understanding 1. Neumann D, Zupan B, Babbage DR, et al. their own emotions Affect recognition, empathy and dysosmia after Participants with smell impairments traumatic brain injury. Arch Phys Med Rehabil. had significantly more trouble with 2012;93(8): emotion recognition and empathy. 2. Babbage DR, Yim J, Zupan B, et al. Furthermore, smell deficits were also a Meta-analysis of facial affect recognition good indicator of problems recognizing difficulties after traumatic brain injury. emotions from faces. Neuropsychology. 2011;25(3): TAKEAWAY: Emotion processing deficits are quite common after TBI. Approximately 30 to 50 percent of individuals with moderate to severe TBI have significant difficulty reading emotions from facial expressions compared to their peers. These characteristics appear to be amenable to interventions. To refer a patient to Carolinas Rehabilitation, call REHAB51 ( ) 7
8 Carolinas Rehabilitation 1100 Blythe Blvd. Charlotte, NC how to reach us WITHIN YOUR Reach PRSRT STD U.S. POSTAGE PAID Lebanon Junction, KY Permit No. 19 recycle-logo_2options_v2.ai Carolinas Rehabilitation 1100 Blythe Blvd., Charlotte, NC REHAB51 ( ) carolinasrehabilitation.org Follow us on Twitter 2012 Carolinas Rehabilitation What s Carolinas Rehabilitation Conference Participation States. Poster presentation: 10th Acta Update on the Accreditation Council Vishwa Raj, MD, Oncologica Symposium: European for Graduate Medical Education and several Cancer Rehabilitation & Survivorship Physical Medicine and Rehabilitation colleagues Symposium. Sept. 17, 2012; Milestone Project. with Carolinas Copenhagen, Denmark. Presented by Rehabilitation Vishwa Raj, MD, and J. H. Norton, MD. William Bockenek, MD, will speak at the Association of Academic Physiatrists in presented at the Focus of Care for an Individual with New Orleans, La.; March 7, 2013: Update Metastatic Thymoma to the Spine on the Accreditation Council for Graduate Collaborating for Success: and Incomplete Paraplegia: A Case Medical Education Physical Medicine and Administrators and Physicians. Oral Study. Poster presentation: 10th Acta Rehabilitation Milestone Project. following conferences: presentation: 10 Annual Medical Oncologica Symposium: European Rehabilitation Education Conference Cancer Rehabilitation & Survivorship published Articles and Expo of the American Medical Symposium. Sept. 17, 2012; Raj V, Groves C, Kim H, Bomberger Rehabilitation Providers Association. Copenhagen, Denmark. Presented by C, Norton JH. Variations in Functional Oct. 16, 2012; San Diego, Ca. Presented Vishwa Raj, MD. Outcome Stratified by Discharge th by Vishwa Raj, MD, Robert Larrison and Disposition and Oncological Treatment Strategies for Successful Integration Groups After Acute Inpatient of Inpatient Rehabilitation Into the Rehabilitation for Brain Tumor Patients. Successful Medical Necessity Oncological Spectrum of Care. Oral The Open Rehabilitation Journal. Documentation Improvement Strategies. presentation: Best Practices in Cancer 2012;(5): Oral presentation: 10th Annual Medical Survivorship and Cancer Rehabilitation, Rehabilitation Education Conference Mindstream. July 19, 2012; Chicago, Ill. New staff members and Expo of the American Medical Presented by Vishwa Raj, MD, Suzanne Janet Lynne Niemeier, PhD, ABPP, Rehabilitation Providers Association. Snyder, FACHE, MBA, PT, and Robin joined Carolinas Rehabilitation Oct. 15, 2012; San Diego, Ca. Presented Lilly, MBA. as Research Director in the Department Suzanne Snyder, FACHE, MBA, PT. by Vishwa Raj, MD, and Suzanne of PMR/Carolinas Rehabilitation. She William Bockenek, joins us from Virginia Commonwealth MD, presented at the University where she served as Rehabilitation of Brain Tumor Patients: American Academy Associate Professor and Director of Outcomes Based on Discharge of Physical Medicine Neuropsychology and Rehabilitation Disposition at a Freestanding Inpatient and Rehabilitation; Psychology Services. Her area of clinical Rehabilitation Facility in the United Nov. 17, 2012: expertise is traumatic brain injury. Snyder, FACHE, MBA, PT.