Inpatient Rehabilitation in Canada

Transcription

1 Inpatient Rehabilitation in Canada N a t i o n a l R e h a b i l i t a t i o n R e p o r t i n g S y s t e m

2 All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying and recording, or by any information storage and retrieval system now known or to be invented, without the prior permission in writing from the owner of the copyright, except by a reviewer who wishes to quote brief passages in connection with a review written for inclusion in a magazine, newspaper or broadcast. Requests for permission should be addressed to: Canadian Institute for Health Information 495 Richmond Road Suite 600 Ottawa, Ontario K2A 4H6 Phone: Fax: ISBN (PDF) 2008 Canadian Institute for Health Information How to cite this document: Canadian Institute for Health information, Inpatient Rehabilitation in Canada, (Ottawa: CIHI, 2008). Cette publication est aussi disponible en français sous le titre Réadaptation pour patients hospitalisés au Canada, ISBN (PDF) The 18-item FIM instrument and the Rehabilitation Client Groups referenced herein are the property of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. Rehabilitation Client Groups: Copyright 1997, Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc., all rights reserved.

3 Inpatient Rehabilitation in Canada, Table of Contents Acknowledgements... v Executive Summary...vii Introduction and Background... 1 Objectives of the Report... 1 About the Canadian Institute for Health Information (CIHI)... 2 About the National Rehabilitation Reporting System... 3 The National Rehabilitation Reporting System Data Set... 3 The FIM Instrument... 4 Scope of Participation in the National Rehabilitation Reporting System... 4 Data Quality and the National Rehabilitation Reporting System... 5 Chapter 1. Characteristics of Inpatient Rehabilitation Clients... 7 Chapter Key Findings... 7 Facility Type... 7 Admission Class... 8 Source of Referral to Rehabilitation... 9 Days Waiting for Admission How have wait times changed over time? Demographic Characteristics Length of Stay Reasons for Discharge Services Referred to at Discharge Where do people go after their inpatient rehabilitation stay? Chapter 2. Rehabilitation Client Groups Chapter Key Findings Overall Distribution of Rehabilitation Client Groups Rehabilitation Client Group by Type of Facility Days Waiting for Admission Demographic Characteristics Total Function Scores Change in Total Function Scores From Admission to Discharge Do all clients improve in function during their inpatient rehabilitation stay? Length of Stay How has length of stay (LOS) changed over time? Length of Stay Efficiency Pre-Admission and Post-Discharge Living Setting... 32

4 Conclusions and Future Directions Appendix A: NRS Glossary of Terms Appendix B: Rehabilitation Client Groups (RCGs) Definition of Rehabilitation Client Group (RCG) Appendix C: FIM Instrument Subscales and Domains Appendix D: Methodological Notes Scope of Participation in the National Rehabilitation Reporting System Records Included in This Report Tables and Statistics for This Report Data Suppression Computations Appendix E: List of Quick Stats Tables List of Tables Table 1-1 Facility Types in the NRS, Table 1-2 Table 1-3 Table 2-1 Demographic Characteristics of Inpatient Rehabilitation Clients With Data in the NRS, Canadian Population for 2006 and Inpatient Rehabilitation Clients With Data in the NRS by Age Group and Sex, Demographic Characteristics of Inpatient Rehabilitation Clients With Data in the NRS by RCG, Table D-1 NRS Clients With Multiple Episodes of Care,

5 List of Figures Figure 1-1 Figure 1-2 Figure 1-3 Figure 1-4 Type of Admission to Inpatient Rehabilitation by Facility Type, Source of Referral to Inpatient Rehabilitation by Facility Type, Distribution of Days Waiting for Admission to Inpatient Rehabilitation, Cumulative Length of Stay in Inpatient Rehabilitation by Facility Type, Figure 1-5 Reasons for Discharge From Inpatient Rehabilitation, Figure 1-6 Figure 2-1 Figure 2-2 Figure 2-3 Figure 2-4 Figure 2-5 Figure 2-6 Figure 2-7 Services Referred to After Discharge From Inpatient Rehabilitation, Distribution of Inpatient Rehabilitation Clients by Rehabilitation Client Group, Distribution of Rehabilitation Client Groups by Facility Type, Median Days Waiting for Admission to Rehabilitation by Rehabilitation Client Group, Distribution of Admission and Discharge Total Function Scores of Inpatient Rehabilitation Clients, Distribution of Change in Total Function Score From Admission to Discharge, Admission and Discharge Total Function Scores by Rehabilitation Client Group, Median Length of Stay of Inpatient Rehabilitation Clients by Rehabilitation Client Group, Figure 2-8 Cumulative Length of Stay for Selected RCGs, Figure 2-9 Receipt of Paid Health Services in the Home After Discharge for Clients Who Were Living at Home Prior to Admission by Rehabilitation Client Group,

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7 Acknowledgements Acknowledgements The Canadian Institute for Health Information (CIHI) wishes to acknowledge and thank the National Rehabilitation Reporting System (NRS) team for its contribution to Inpatient Rehabilitation in Canada, This report was produced by the Rehabilitation program area at CIHI. This report could not have been completed without the generous support and assistance of staff at participating NRS facilities. CIHI 2008 v

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9 Executive Summary Executive Summary Through analysis of client and facility characteristics, Inpatient Rehabilitation in Canada, presents a snapshot of the clients who received rehabilitation in inpatient rehabilitation facilities that participate in the National Rehabilitation Reporting System (NRS) and the outcomes of their care. The goal of the report is to enhance knowledge about inpatient rehabilitation services in participating facilities across the country. This report reveals a number of key findings pertaining to clients admitted to inpatient rehabilitation facilities that participate in the NRS: The vast majority of clients were successful in their rehabilitation programs; 89% of them returned to their pre-admission living setting following discharge from inpatient rehabilitation, with 84% returning to a private house or apartment. In addition, 91% of clients were determined to have sufficiently met their service goals upon discharge. Almost half (47%) of all clients received rehabilitation relating to orthopedic conditions, with an additional 16% receiving rehabilitation following a stroke. Greater gain, on average, in Total Function Score is seen for clients in major multiple trauma (29.6) and burn (22.6) Rehabilitation Client Groups (RCGs); lesser gain, on average, in Total Function Score is seen for clients in pulmonary (11.3) and arthritis (11.6) RCGs. In addition, the report reveals some distinct differences in the client groups, demographics and lengths of stay of clients admitted to specialty and general rehabilitation facilities. Clients in the brain dysfunction, spinal cord injury and burn RCGs, among others, were much more likely to be admitted to a specialty facility than to a general facility, whereas clients in the orthopedic, debility and arthritis RCGs, among others, were much more likely to be admitted to a general facility. Differences seen in the demographics and lengths of stay between the two facility types may very well be related to the differences in client groups admitted. Information in this report will be of interest to clinicians and managers in the facilities that participate in the NRS, as well as to system planners, policy-makers, researchers and the public. While inpatient rehabilitation is only one part of the continuum of rehabilitation, the report s findings suggest that it provides an important role in ensuring that Canadians maintain functional independence and autonomy after an injury or illness or following surgery. CIHI 2008 vii

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11 Introduction and Background Introduction and Background Objectives of the Report Inpatient Rehabilitation in Canada, is the fifth public report based on data from the National Rehabilitation Reporting System (NRS). The Canadian Institute for Health Information (CIHI) developed the NRS to support inpatient rehabilitation service planning and policy development. Data are available for inpatient rehabilitation episodes from fiscal year onwards. This year s report provides information on inpatient physical rehabilitation services that occurred between April 1, 2006, and March 31, 2007, in participating rehabilitation facilities. This report was developed to provide information for people involved with or interested in the provision of inpatient rehabilitation services, including clinicians, hospital managers, system managers and policy-makers. The overall goal of the report is to enhance knowledge about inpatient rehabilitation services in participating facilities across the country. In doing so, CIHI hopes to facilitate discussion on the current state of hospital-based rehabilitation and on future challenges and opportunities facing the sector. Specific objectives for this report are: to provide background information on the NRS; to present aggregate data from the NRS; and to stimulate discussion on the information needs for the inpatient rehabilitation sector and further enhancement of the NRS. Inpatient Rehabilitation in Canada, contains two chapters. While there may be few changes in patterns of rehabilitation services in a single year, data received since the NRS s inception make trending analyses possible. A few of these trends are highlighted in text boxes throughout the report. Chapter 1 provides an overview of the socio-demographic characteristics of the clients who were discharged from participating facilities following rehabilitation during Chapter 2 presents information on clients, as grouped in the Rehabilitation Client Groups (RCGs) i reported in the NRS. Indicators are presented for the various groups, including days waiting for admission to rehabilitation and reasons for discharge. This chapter also introduces analyses on clinical outcomes assessed during inpatient rehabilitation. i. Rehabilitation Client Groups (RCGs) adapted with permission from the UDSMR impairment codes. Copyright 1997 Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc., all rights reserved. CIHI

12 Inpatient Rehabilitation in Canada, While many readers may be familiar with the concepts used within this report, others may be encountering NRS data for the first time. A glossary of terms (Appendix A) is included at the end of the report. Appendix B contains a brief description of each Rehabilitation Client Group. More details on the items assessed by the FIM instrument, ii a standardized assessment tool developed by Uniform Data System for Medical Rehabilitation (UDSMR), are available in Appendix C. More detailed notes on specific methodologies used in the report are referenced in Appendix D. These appendices will assist readers in understanding the terms and definitions commonly used in the NRS. Q Wherever the icon above appears beside the text, it indicates that the aggregate data used to produce the figures in this report are available on the CIHI website at by selecting Quick Stats from the menu bar and selecting From Source NRS. A complete list of tables in Quick Stats is also available in Appendix E. NRS Quick Stats are presented in one of two ways: 1. Pre-formatted tables that provide a snapshot of the data. Frequently, these have been published in analytic products such as annual reports or Analyses in Brief. 2. Interactive data that provide a dynamic presentation of health statistics, in which data can be manipulated, printed and exported. About the Canadian Institute for Health Information (CIHI) CIHI collects and analyzes information on health and health care in Canada and makes it publicly available. Canada s federal, provincial and territorial governments created CIHI as a not-for-profit, independent organization dedicated to forging a common approach to Canadian health information. CIHI s goal: to provide timely, accurate and comparable information. CIHI s data and reports inform health policies, support the effective delivery of health services and raise awareness among Canadians of the factors that contribute to good health. For more information, visit the CIHI website at ii. The FIM instrument and impairment codes referenced herein are the property of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. 2 CIHI 2008

13 Introduction and Background About the National Rehabilitation Reporting System Hospital-based inpatient rehabilitation is an important component of the continuum of health services in Canada. By facilitating the collection of standardized information on rehabilitation clients, the NRS provides an opportunity to enhance the knowledge surrounding inpatient rehabilitation services across the country. These rehabilitation services are provided in specialized rehabilitation facilities or in general hospitals with rehabilitation units, programs or designated beds. Inpatient rehabilitation clients receive services provided by health professionals such as nurses, physiotherapists, occupational therapists and physicians specializing in physical medicine and rehabilitation. These professionals assist clients in maximizing their physical and cognitive function through training and education, and prepare them to return to the community following illness or injury. Clients reported in the NRS include only those with a primary health condition that is physical in nature. As such, the term rehabilitation in the context of NRS reporting does not include rehabilitation services provided for a mental health condition or for drug or alcohol addiction. A cornerstone of the NRS is the concept of human function and the focus of rehabilitation in assisting individuals to achieve maximum independence in daily living, be it at home or in an assisted-living facility. The NRS indicators and reports provide a source of information for defining and describing functional outcomes for individuals who have received rehabilitation services. For greater comparability, this information is grouped according to the nature of the illness or injury. These groups form the basis for NRS reporting and are known as Rehabilitation Client Groups (RCGs). There are 17 major RCGs, including conditions such as stroke, limb amputation and brain injury. (See Appendix B for a complete list.) The National Rehabilitation Reporting System Data Set The NRS data set consists of 75 data elements grouped into the following major categories: Client Identifiers: These are data elements used to identify individual records. Client names are never collected for the NRS database. Socio-Demographics: Information such as birth date, sex, living arrangements and vocational status are collected to describe the types of clients admitted to rehabilitation programs. Administrative: Data are collected on wait times for admission and discharge, service interruptions, and provider types in order to better understand accessibility to rehabilitation, factors influencing length of stay and resource utilization. Health Characteristics: Diagnoses and related co-morbidities at admission provide information on conditions most often seen in a rehabilitation setting and conditions that may affect a client s ability to progress in the rehabilitation program. Activities and Participation: This is the largest section of the NRS data set and contains clinical assessments of motor and cognitive functional abilities of rehabilitation clients. The data are collected primarily using the 18-item FIM instrument and six additional elements developed at CIHI that provide further information on cognitive abilities. CIHI

14 Inpatient Rehabilitation in Canada, Facilities collect the data when clients are admitted to and when they are discharged from an inpatient rehabilitation program. Facilities can also choose to complete an optional follow-up assessment on their clients between three and six months following discharge from the program. Collection of this follow-up information provides an opportunity to assess sustainability of functional outcomes that were gained during rehabilitation, as well as the level of client re-integration into the community. The FIM Instrument The FIM instrument is a standardized assessment tool developed by Uniform Data System for Medical Rehabilitation (UDSMR) and is used in the NRS to measure functional independence. The FIM instrument is a measure of disability and looks at the caregiver burden associated with the level of disability. (See Chapter 2 and Appendix C for more details.) Scope of Participation in the National Rehabilitation Reporting System At the end of the fiscal year, 94 inpatient rehabilitation facilities in seven provinces were submitting data to the NRS. Facilities in Prince Edward Island and Manitoba began submission in Participation in the NRS is primarily voluntary in most provinces and efforts continue to promote the value of NRS participation across the country. 4 CIHI 2008

15 Introduction and Background Data Quality and the National Rehabilitation Reporting System Data quality is paramount to CIHI s work, and analysis of the quality of the data in all reporting systems, including the NRS, is an integral part of maintaining these information systems. CIHI has incorporated five dimensions of data quality into its corporate Data Quality Framework, first implemented during When used as a conceptual framework, these dimensions facilitate the assessment of data quality in many types of system-level data holdings. The framework implementation is part of the larger data quality cycle at CIHI in which issues are identified, addressed, documented and reviewed on a regular basis. It also standardizes information on data quality for users and helps to identify priority issues, which in turn is intended to trigger continuous improvements. The five dimensions of data quality assessed at CIHI are: 1. Accuracy: a measure of how well information within a database reflects what was supposed to be collected 2. Comparability: a measure of the extent to which a database can be properly integrated within broader health information systems 3. Timeliness: a measure of whether the data are available for user needs within a reasonable time period 4. Usability: a measure of how easily the storage and documentation of data allow users to utilize the data intelligently 5. Relevance: a measure of incorporation of all of the above dimensions to some degree, but focusing specifically on value and adaptability CIHI conducts regular data quality assessments on the NRS with respect to coding guidelines, data collection software specifications and other validation procedures in order to identify areas of strength and weakness. The five dimensions stated above are used to guide the ongoing evaluation. Areas needing improvement are flagged for further action. CIHI uses this information both internally for data quality improvement and externally to respond to stakeholder inquiries. CIHI

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17 Chapter 1. Characteristics of Inpatient Rehabilitation Clients Chapter 1. Characteristics of Inpatient Rehabilitation Clients This chapter provides information on all inpatient rehabilitation activity reported to the National Rehabilitation Reporting System (NRS) in the April 1, 2006, to March 31, 2007, reporting period. All of the information is drawn from data in the NRS database at CIHI. As of the fiscal year submission deadline (May 2007), 94 facilities from Newfoundland and Labrador, Nova Scotia, New Brunswick, Ontario, Saskatchewan, Alberta and British Columbia had submitted data to CIHI. At the present time, approximately 86% of the NRS data are submitted by participating NRS facilities in Ontario. Participating facilities submit data that are collected when rehabilitation clients are admitted to the facility and again just prior to discharge. The analyses in this report are based primarily on information from the 33,879 clients who were discharged from participating facilities during and for whom complete admission and discharge assessments were submitted to and accepted by CIHI. Chapter Key Findings Almost two-thirds (64%) of all clients were admitted to general facilities, and one-third (36%) were admitted to specialty facilities. The median length of stay (LOS) for clients in general facilities was 14 days; median LOS for clients in specialty facilities was 30 days. Ninety-one percent of all clients were determined to have sufficiently met their service goals upon discharge. Clients discharged from general facilities were more likely to be referred to home care agencies than those discharged from specialty facilities (43% versus 22%). Most clients (89%) returned to their pre-admission living setting following discharge from inpatient rehabilitation, the majority going back to a private house or apartment (84%). Facility Type Facilities participating in the NRS are classified as either general or specialty. This classification is specific to the NRS and is intended to facilitate comparative reporting; it is not necessarily consistent with facility classification methods used in various provinces or regions. The NRS defines a general rehabilitation facility as a rehabilitation unit or collection of beds designated for rehabilitation purposes. The general rehabilitation facility is part of a general hospital offering multiple levels or types of care. A specialty rehabilitation facility is one that provides more extensive and specialized inpatient rehabilitation services and is commonly a freestanding facility or a specialized unit within a hospital. The rehabilitation team at the facility decides which profile most closely represents its rehabilitation program(s) and categorizes itself as general or specialty when beginning submissions to the NRS. CIHI

18 Inpatient Rehabilitation in Canada, As shown in Table 1-1, in , 71% of facilities submitting data to the NRS classified themselves as general facilities and 29% classified themselves as specialty facilities. Of all clients admitted to NRS participating facilities, 64% were admitted to general rehabilitation facilities and 36% to specialty rehabilitation facilities. Table 1-1 Facility Types in the NRS, General Facilities Specialty Facilities All Facilities Facilities submitting to NRS in Number Percent Number Percent Number Percent Discharges 21, , , Note Refers to clients discharged in with complete admission and discharge assessments. Source National Rehabilitation Reporting System, Canadian Institute for Health Information, Admission Class Admission class refers to the type of inpatient rehabilitation admission. Initial rehabilitation refers to clients who are admitted for the first time to an inpatient rehabilitation facility for a given health condition (RCG). Short stay refers to clients who are primarily admitted to inpatient rehabilitation for a period lasting between 4 and 10 days. Re-admission refers to all clients who have received rehabilitation services relating to a condition for which they had previously received inpatient rehabilitation. Continuing rehabilitation refers to clients who were transferred directly to a rehabilitation facility from another inpatient rehabilitation unit or program for ongoing treatment of the existing illness or injury. The remaining admission class in the NRS is referred to as (un)planned discharge. Due to the short admission time frame (three days or fewer), the data collected on these clients are minimal, and a separate discharge assessment is not completed. In , (un)planned discharges accounted for 2,237 records in the NRS. The majority of analyses in this report include only those 33,879 clients for whom complete admission and discharge assessments were submitted, and therefore do not include the very small number of clients in the (un)planned discharge admission class. For more information, please see Appendix D. Q As seen in Figure 1-1, the majority of clients admitted to inpatient rehabilitation in were classified as initial rehabilitation. When accounting for facility type, general facilities had a lower proportion of initial rehabilitation clients (82%) compared to specialty facilities (95%). In contrast, 99% of clients categorized as short stay were admitted to general facilities, accounting for more than 15% of all admissions to general facilities reported in the NRS. Sixty-five percent of inpatient rehabilitation clients with data in the NRS classified as re-admission or continuing rehabilitation were admitted to specialty facilities, and together these two admission classes accounted for just more than 5% of all admissions to specialty facilities. (Quick Stats Table 1-1) 8 CIHI 2008

19 Chapter 1. Characteristics of Inpatient Rehabilitation Clients Figure 1-1 Type of Admission to Inpatient Rehabilitation by Facility Type, Percent of Clients Initial Rehabilitation Short Stay Re-Admission Continuing Rehabilitation Type of Admission (N = 33,879) General Facilities Specialty Facilities Source National Rehabilitation Reporting System, Canadian Institute for Health Information, Q Source of Referral to Rehabilitation The source of referral in the NRS is the facility, agency or individual that initiated the referral of the client for admission to rehabilitation. Differences exist among the referral sources of clients based on facility type. As shown in Figure 1-2, 69% of NRS clients admitted to general facilities were referred from an inpatient acute care unit of the same facility, and 26% were referred from an inpatient acute care unit of a different facility. In contrast, only 8% of clients admitted to specialty facilities were referred from an inpatient acute care unit within the same facility, while 78% were referred from inpatient acute care at a different facility. This is consistent with the commonly used definition of a specialty facility as being a freestanding building with a focus on rehabilitation services rather than on acute care services, and therefore receiving the majority of their clients from other facilities. (Quick Stats Table 1-2) CIHI

20 Inpatient Rehabilitation in Canada, Figure 1-2 Source of Referral to Inpatient Rehabilitation by Facility Type, Percent of Clients Inpatient Acute Unit, Same Facility Inpatient Acute Unit, Different Facility General Facilities Source of Referral (N = 33,879) Private Practice Specialty Facilities Other or Unknown Sources Source National Rehabilitation Reporting System, Canadian Institute for Health Information, Days Waiting for Admission The days waiting for admission indicator in the NRS refers to the number of days from the date a client is deemed ready for inpatient rehabilitation to the date he or she was actually admitted. The date ready for admission refers to the date that the client was clinically ready to start a rehabilitation program and met the criteria for admission to the rehabilitation facility. The date ready for admission is determined by the rehabilitation program accepting the client or by the referring facility, depending on the admission process at a particular facility. It does not refer to the date the client was put on a waiting list if this was done prior to when the client was clinically ready for rehabilitation. The NRS makes an allowance for the fact that the date ready for admission to rehabilitation is not always easily ascertained. Where this is the case, facilities may indicate on the admission assessment that the date ready for admission was not known. During , the date ready for admission was not known for almost one-sixth (16%) of clients during the fiscal year. Records where the date ready for admission was not known are excluded from the analyses for this section. Therefore, the information and data provided in the following paragraphs are based on the 28,539 records where the date ready for admission was known. As part of its ongoing data quality monitoring activities, CIHI has identified this as a potential issue and has initiated further investigation and action to address coding unknown for this data element. 10 CIHI 2008

21 Chapter 1. Characteristics of Inpatient Rehabilitation Clients Q Figure 1-3 shows that, as with some other indicators, when compared by facility type, differences exist between general and specialty facilities. Among clients who were admitted to a specialty facility, 30% were admitted the day they were deemed ready for admission, and a further 26% waited only one day. Fourteen percent of clients waited more than a week, and 3% waited more than one month. Among clients who were admitted to a general facility, 67% were admitted the day they were deemed ready for admission, and a further 14% waited only one day. Four percent of clients waited more than a week, and less than one-half of one percent waited more than one month. (Quick Stats Table 1-3) This is consistent with the finding that the majority of clients admitted to general facilities were referred by the inpatient acute care unit of that same facility, whereas specialty facilities often receive their clients from another facility. The inter-facility processes required for admission to specialty facilities for rehabilitation may contribute to the variation suggested by the NRS data. It is also possible that the variation may reflect differences in the RCGs seen by the two facility types. For example, a greater number of clients with neurological conditions are seen in specialty facilities and have longer wait times than clients with orthopedic conditions. Chapter 2 contains some analyses to explore this issue further. Figure 1-3 Distribution of Days Waiting for Admission to Inpatient Rehabilitation, Percent of Clients General Facilities Number of Days (N = 28,539) Specialty Facilities Source National Rehabilitation Reporting System, Canadian Institute for Health Information, CIHI

22 Inpatient Rehabilitation in Canada, How have wait times changed over time? Over the last five years, median wait times for admission to general and specialty facilities have remained steady at 0 and 1 day, respectively, indicating that at least half of all inpatient rehabilitation clients wait 1 day or less to be admitted. At the same time, there has been a small downward trend in mean days waiting for admission, which suggests that variation in wait times for admission to inpatient rehabilitation has decreased over the last five years. Of note, in , a small increase in mean wait times is noted, which will be analyzed in the years to come. Mean and Median Wait Times (Days) for Admission to Rehabilitation by Facility Type and Fiscal Year General Facilities Specialty Facilities Mean Median Mean Median Source National Rehabilitation Reporting System, Canadian Institute for Health Information, Demographic Characteristics The demographic data presented in Table 1-2 highlight the profile of inpatient rehabilitation clients with respect to age, sex, living setting, pre-admission support and pre-admission employment level. In , the average age for all clients admitted to inpatient rehabilitation was 71 years. Clients admitted to general facilities were on average older (73 years) than clients admitted to specialty facilities (67 years). Twenty-two percent of clients admitted to specialty facilities were under the age of 55, compared to 10% of clients admitted to general facilities. Q Q It was observed that the majority of clients admitted to all inpatient rehabilitation facilities were female (58%). Based on facility type, a higher proportion of those admitted to general facilities (61%) were female compared to specialty facilities (53%). (Quick Stats Table 1-5) Prior to admission to inpatient rehabilitation, 92% of all clients lived in a private house or apartment. Eighty-three percent of all clients received all or some of the required informal support they needed prior to admission to inpatient rehabilitation. (Quick Stats Table 1-7) 12 CIHI 2008

23 Chapter 1. Characteristics of Inpatient Rehabilitation Clients Thirteen percent of all clients were employed prior to admission, with a higher proportion of pre-admission employment among clients admitted to specialty facilities compared to general facilities (18% versus 10%). This is consistent with a higher proportion of younger clients in specialty facilities compared to general facilities. Table 1-2 Demographic Characteristics of Inpatient Rehabilitation Clients With Data in the NRS, Demographics General Facilities Specialty Facilities All Facilities Female (%) Age (mean) Age group (%): Under Pre-admission living setting (%): Private house/apartment without paid health services Private house/apartment with paid health services Assisted-living setting Residential care Other or unknown Pre-admission informal support level (%): Received all required support Received some of the required support Received none of the required support Did not require support Employed prior to admission (%) Source National Rehabilitation Reporting System, Canadian Institute for Health Information, Table 1-3 compares the distribution of age and sex among the general Canadian population to the distribution of clients admitted to inpatient rehabilitation in (note that this table does not consider clients with multiple episodes of care see Table D-1 in Appendix D). It is noted that people aged 75 years and older represented approximately one-half (48%) of the inpatient rehabilitation population. For comparison, among the general Canadian population this same age group represents only 6%. It is also noted that when compared to the general Canadian population, there are disproportionately more younger males and older females admitted to inpatient rehabilitation. CIHI

24 Inpatient Rehabilitation in Canada, Table 1-3 Canadian Population for 2006 and Inpatient Rehabilitation Clients With Data in the NRS by Age Group and Sex, Age Group Canadian Population Inpatient Rehabilitation Total Male Female Total Male Female Number (thousands) Percent Percent Number Percent Percent <45 19, , , , , , , , , , , Total 32, , Sources Statistics Canada, 2006; National Rehabilitation Reporting System, Canadian Institute for Health Information, Length of Stay Length of stay (LOS) for the purposes of the NRS is calculated as the number of days between a client s admission to and discharge from the rehabilitation facility, excluding any service interruptions. Service interruptions are recorded when rehabilitation services are temporarily suspended due to a change in the client s health status. These interruptions are excluded from LOS calculations in order to obtain a more accurate count of the number of days that clients were able to participate in the rehabilitation program. In , 3% of clients had at least one service interruption reported at some point during their rehabilitation stay. Service interruptions did not affect the median length of stay for NRS clients, which was 18 days including or excluding service interruptions. Q Q Figure 1-4 shows the cumulative length of stay for clients in inpatient rehabilitation by facility type. In , the median LOS for clients in general facilities was 13 days, and it was 30 days for clients in specialty facilities. Twenty-five percent of clients in general facilities had an LOS of 7 days or fewer, while 25% of clients in specialty facilities had an LOS of 15 days or fewer. Seventy-five percent of clients were discharged from general facilities within 24 days, and 75% of clients in specialty facilities were discharged within 49 days. (Quick Stats Table 1-9) Note that for this analysis, the 2,829 records classified as (un)planned discharge have been included. Recall that clients in the (un)planned discharge admission class, by definition, have a length of stay of between one and three days. (Quick Stats Table 1-9) 14 CIHI 2008

25 Chapter 1. Characteristics of Inpatient Rehabilitation Clients Figure 1-4 Cumulative Length of Stay in Inpatient Rehabilitation by Facility Type, Percent of Clients General Median = 13 days Specialty Median = 30 days Cumulative Length of Stay (Days) (N = 36,116) General Facilities Specialty Facilities Note Dotted vertical lines represent the median LOS for clients discharged from general facilities and from specialty facilities, respectively. Source National Rehabilitation Reporting System, Canadian Institute for Health Information, Reasons for Discharge The NRS contains information on the reason for a client s discharge from a participating rehabilitation facility. These data provide information on whether or not a client s rehabilitation goals (determined collaboratively by the rehabilitation team and the client and documented on admission) were met or not met, and whether the client was discharged into the community or was transferred and/or referred to another unit or facility. Other reasons for discharge include the withdrawal of the client from rehabilitation services against professional advice or death. Note that a return to the community does not imply that the client returned to his or her home, should that be his or her pre-admission living environment. Community living can include living environments such as a retirement community or other type of assisted living, or returning to live with a family member. A transfer to another facility generally implies that the client is still residing in the health care system, such as a long-term care facility, or was transferred to acute care for further treatment. CIHI

26 Inpatient Rehabilitation in Canada, Q In , 82% of all clients met their goals and returned to live in the community, and a further 9% met goals and transferred to another unit/facility, for a total of 91% determined to have sufficiently met their service goals at discharge. Eight percent of all clients were reported as not having met their service goals and were either discharged to the community or transferred to another unit or facility. (Quick Stats Table 1-10) Figure 1-5 Reasons for Discharge From Inpatient Rehabilitation, Goals Not Met Goals Met: 8% Referred/ Transferred to Other Unit/Facility 9% Other Reasons 1% Goals Met: Discharged to Permanent Living Setting 82% (N = 33,879) Source National Rehabilitation Reporting System, Canadian Institute for Health Information, Services Referred to at Discharge The types of services or care that clients were most often referred to upon discharge include home, community and ambulatory care services for clients discharged into the community, and residential care or inpatient care for those who continued to reside in the health care system following a stay in rehabilitation. Q During , clients discharged from general facilities were more likely to be referred to home care agencies than clients discharged from specialty facilities (43% versus 22%). Among clients discharged from general facilities, 11% were referred to ambulatory care services and another 11% were referred to a private medical practitioner. Among clients discharged from specialty facilities, 17% were referred to ambulatory care services and 19% were referred to a private medical practitioner. It is important to note that for this indicator only one service can be selected. If clients are referred to more than one service upon discharge, participating facilities are advised to select the most appropriate service based on rehabilitation resources that will be used. (Quick Stats Table 1-11) 16 CIHI 2008

27 Chapter 1. Characteristics of Inpatient Rehabilitation Clients Figure 1-6 Services Referred to After Discharge From Inpatient Rehabilitation, Percent of Clients Home Care Agency Private Medical Practice Ambulatory Care Residential Care Facility Inpatient Acute Care (N = 33,344) Inpatient Rehabilitation Community Services Other Not Referred to Any Services General Facilities Specialty Facilities Source National Rehabilitation Reporting System, Canadian Institute for Health Information, Where do people go after their inpatient rehabilitation stay? Most clients (89%) returned to their pre-admission living setting following discharge from inpatient rehabilitation, the majority of them going back to a private house or apartment (84%). Of those that returned home, almost half (46%) required new or continued paid health services on their return. Of those clients that lived in a private house or apartment prior to inpatient rehabilitation, 9% were discharged to an assisted-living or residential care facility. Further study of the rehabilitation outcomes of the group of clients who are discharged to assisted-living and residential care settings may be of interest to further explore the rehabilitation needs of this group. CIHI

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29 Chapter 2. Rehabilitation Client Groups Chapter 2. Rehabilitation Client Groups Clients are admitted to rehabilitation programs to improve function that may have declined due to injury or illness, or following surgery. Clients with health conditions such as stroke, arthritis and spinal cord injury, for example, that result in the need for rehabilitation can vary significantly in terms of health resource requirements and rehabilitation approaches. Grouping clients according to specific conditions and comparing the data within and across these groups provides information towards understanding variation in client outcomes and rehabilitation service provision. Within the National Rehabilitation Reporting System (NRS), a client is categorized into one of 17 health condition groups, known as Rehabilitation Client Groups (RCGs). The RCG selected for a particular client is based on the condition that best describes the primary reason for the client s admission to the inpatient rehabilitation unit or facility, such as stroke or limb amputation. Some RCGs are further sub-divided in order to facilitate more specific analysis of groups that contain large numbers of rehabilitation clients. The limb amputation RCG, for example, is further subdivided into groups that denote which limb was amputated and at what level the amputation occurred. A full list of RCGs used in the NRS can be found in Appendix B. For the purposes of this report, only the 17 main groups and selected sub-divisions of RCGs are discussed. Where the term Other RCGs appears in a figure or table, two or more RCGs have been grouped together due to small numbers of individuals in those groups. Chapter Key Findings Almost half (47%) of all clients received rehabilitation relating to orthopedic conditions, with an additional 16% receiving rehabilitation following a stroke. Greater gain, on average, in Total Function Score was seen for clients in major multiple trauma (29.6) and burn (22.6) RCGs; lesser gain, on average, in Total Function Score was seen for clients in pulmonary (11.3) and arthritis (11.6) RCGs. Clients admitted with spinal cord dysfunction had the longest median length of stay (43 days), while clients admitted with orthopedic conditions had the shortest median length of stay (12 days). Among clients admitted for stroke, the median length of stay was 34 days, with 25% of clients being discharged within 18 days and 75% of clients being discharged within 51 days. Overall, 84% of all clients that lived at home prior to admission returned home upon discharge. Ninety-two percent of clients admitted for major multiple trauma and 89% for orthopedic conditions returned home, compared with 79% for medically complex, 78% for brain dysfunction and 75% for stroke. CIHI

30 Inpatient Rehabilitation in Canada, Overall Distribution of Rehabilitation Client Groups Almost half (47%) of all NRS clients received rehabilitation for orthopedic conditions, with an additional 16% of clients receiving rehabilitation following a stroke. As seen in Figure 2-1, these two RCGs accounted for nearly two-thirds (63%) of all inpatient rehabilitation clients discharged from participating NRS facilities in Q Clients of all other RCGs were seen less frequently: medically complex clients accounted for 9% of all inpatient rehabilitation clients, brain dysfunction for 5% and debility for 4%. The remaining 19% of clients received inpatient rehabilitation for a number of other conditions, each representing 3% or less of all episodes individually. These client groups include arthritis, cardiac disease, major multiple trauma, pain syndromes and pulmonary disease, among others. (Quick Stats Table 2-1) Figure 2-1 Distribution of Inpatient Rehabilitation Clients by Rehabilitation Client Group, Percent of Clients Orthopedic Conditions Stroke Medically Complex Brain Dysfunction Debility Amputation Spinal Cord Dysfunction Cardiac Pulmonary Neurological Conditions Major Multiple Trauma Pain Syndromes Arthritis Other RCGs Burns Rehabilitation Client Group (N = 33,879) Other RCGs includes Congenital Deformities, Developmental Disabilities and Other Disabling Impairments. Source National Rehabilitation Reporting System, Canadian Institute for Health Information, Rehabilitation Client Group by Type of Facility Although clients admitted for orthopedic conditions and for stroke were the largest groups in both general and specialty rehabilitation facilities during , there were some differences in the distribution of clients across RCGs within the two facility types. As seen in Figure 2-2, of all clients admitted to inpatient rehabilitation for an orthopedic condition, 72% were admitted to general facilities, while only 28% were admitted to specialty facilities. Conversely, specialty facilities experienced a higher proportion of all admissions for spinal cord dysfunction (69%) compared to general facilities (31%). Other 20 CIHI 2008

31 Chapter 2. Rehabilitation Client Groups client groups more commonly seen in specialty facilities included clients with amputation, brain dysfunction, major multiple trauma and burns. Clients with pain syndromes, arthritis and debility were among those more commonly seen in general facilities. Q These findings are consistent with those found in Chapter 1 that showed NRS clients admitted to general facilities were older than clients admitted to specialty facilities, experienced shorter LOS, and also experienced shorter wait times for admission to inpatient rehabilitation once deemed ready for rehabilitation. As shown throughout Chapter 2, these differences seen between facility types may, at least in part, be related to the differences in client group distribution in general and specialty facilities. (Quick Stats Table 2-1) Figure 2-2 Distribution of Rehabilitation Client Groups by Facility Type, Percent of Clients Pain Syndromes Arthritis Debility Medically Complex Orthopedic Conditions Cardiac Pulmonary Stroke Neurological Conditions Amputation Brain Dysfunction Spinal Cord Dysfunction Major Multiple Trauma Other RCGs Burns General Facilities (N = 33,879) Other RCGs includes Congenital Deformities, Specialty Facilities Developmental Disabilities and Other Disabling Impairments. Source National Rehabilitation Reporting System, Canadian Institute for Health Information, Days Waiting for Admission As mentioned in the previous chapter, the reported date that a client was deemed ready for admission to rehabilitation was not known for 16% of clients in As a result, the records of these clients were not included in the following analysis. Overall, clients reported in the NRS for whom a date ready for admission was known had a median wait of zero days for admission to inpatient rehabilitation (that is, half of these clients were admitted the same day they were deemed ready). As shown in Figure 2-3, there was some variation between client groups (RCGs) in terms of wait times. Clients with orthopedic conditions, medically complex conditions, debility, pain syndromes and CIHI

32 Inpatient Rehabilitation in Canada, Q arthritis RCGs all had median wait times of 0 days. Clients in most other RCGs had a median wait time of one day, including stroke, amputation and spinal cord dysfunction, with the exception of brain dysfunction (2 days) and other RCGs (6 days). (Quick Stats Table 2-2) Figure 2-3 Median Days Waiting for Admission to Rehabilitation by Rehabilitation Client Group, Number of Days Orthopedic Conditions Medically Complex Debility Pain Syndromes Arthritis Stroke Amputation Cardiac Spinal Cord Dysfunction Neurological Conditions Rehabilitation Client Group (N = 28,539) Pulmonary Major Multiple Trauma Burns Brain Dysfunction Other RCGs Other RCGs includes Congenital Deformities, Developmental Disabilities and Other Disabling Impairments. Source National Rehabilitation Reporting System, Canadian Institute for Health Information, Demographic Characteristics Chapter 1 presented the distribution of both age and sex of clients admitted to inpatient rehabilitation in participating NRS facilities in In this chapter, the distribution of age and sex are presented for each specific RCG. The data indicate that, as expected, the demographic characteristics can vary widely between client groups. Q Table 2-1 shows that the proportion of female clients was higher among clients in arthritis (76%), orthopedic conditions (69%) and pain syndrome (67%) RCGs. Conversely, the proportion of female clients was lower among clients classified in the brain dysfunction (39%), spinal cord dysfunction (37%), amputation (30%) and burns (23%) RCGs. (Quick Stats Table 2-3) 22 CIHI 2008

33 Chapter 2. Rehabilitation Client Groups Q The mean age of clients was highest in the RCG classified as debility (78 years) and lowest for burns (49 years). As well, more than 50% of clients admitted for orthopedic conditions were older than 75, as were just fewer than 45% of clients admitted for stroke. In contrast, 45% of clients admitted after a spinal cord injury were under the age of 55, as were close to 60% of clients admitted after major multiple trauma. (Quick Stats Table 2-3) Table 2-1 Demographic Characteristics of Inpatient Rehabilitation Clients With Data in the NRS by RCG, Orthopedic Conditions Stroke Medically Complex Debility Brain Dysfunction Cardiac Pulmonary Neurological Conditions Spinal Cord Dysfunction Amputation Major Multiple Trauma Pain Syndromes Arthritis Other RCGs Burns Female (%) Age (mean) Age Group (%) < Source National Rehabilitation Reporting System, Canadian Institute for Health Information, Total Function Scores When clients are admitted to a participating NRS facility, their motor and cognitive functional abilities are assessed within 72 hours of admission using the FIM instrument, developed by Uniform Data System for Medical Rehabilitation (UDSMR). A similar assessment is carried out when the client is discharged from the facility. The FIM instrument contains 18 elements: 13 of these elements assess components of motor function, such as eating and walking (referred to as the motor subscale), and 5 elements assess cognitive abilities, such as communication and social interaction (referred to as the cognitive subscale). A full list of the elements can be found in Appendix C of this report. Each of the 18 FIM instrument elements is rated on a scale from one to seven, with a higher score indicating that the client has a greater level of independence in performing the task involved with that element. The scores for the 18 elements are added together to CIHI

34 Inpatient Rehabilitation in Canada, obtain a Total Function Score, iii which provides a summary measure of the clients overall functional ability. The Total Function Score ranges from 18 to 126, with a higher score indicating a relatively higher overall level of function and independence. Analysis of admission and discharge Total Function Scores provides some information about the variations in functional abilities of clients in the different RCGs. Not all inpatient rehabilitation clients are able to have a full functional assessment at discharge, due to reasons such as unexpected transfer out of the rehabilitation bed. Among the clients discharged in , 4% did not have a full FIM instrument assessment on discharge and therefore did not have a submitted discharge Total Function Score. Q Figures in this report that include analysis of both admission and discharge scores derived from the FIM instrument are based on the 32,114 complete pairs of admission and discharge FIM instrument assessments that were submitted for clients discharged in As shown in Figure 2-4, the mean admission Total Function Score was 85.1 and the median admission Total Function Score was 89. The mean discharge Total Function Score was and the median discharge Total Function Score was 111. (Quick Stats Table 2-7) NRS data reveal that the average admission Total Function Score was higher for those living in a house or apartment if they did not receive paid health services prior to admission than if they had received paid health services (87.4 versus 82.1). In addition, the average admission Total Function Score was lower again for those living in an assisted care setting (76.2) or residential care facility (70.8). These findings are consistent with the intent of the FIM instrument to predict care needs. iii. Total Function Scores referenced in this document are based on data collected using the FIM TM instrument. The 18-item FIM instrument referenced herein is the property of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. 24 CIHI 2008

35 Chapter 2. Rehabilitation Client Groups Figure 2-4 Distribution of Admission and Discharge Total Function Scores of Inpatient Rehabilitation Clients, Number of Clients 2,000 1,800 1,600 1,400 1,200 1, Admission Mean = 85.1 Admission Median = 89.0 Discharge Mean = Discharge Median = Admission and Discharge Total Function Scores (Admission N = 33,876; Discharge N = 32,521) Admission Discharge Source National Rehabilitation Reporting System, Canadian Institute for Health Information, Change in Total Function Scores From Admission to Discharge Improvement in client function, both physical and cognitive, is a key underlying goal of rehabilitation. Whether or not a client returns to his or her pre-injury/illness level of ability, the objective of the clinical team is to maximize function gain so that the client can live as independently as possible. Comparisons between client groups based on the change in Total Function Scores from admission to discharge shed some light on the degree of improvements in motor and cognitive function that are possible and that actually occurred during inpatient rehabilitation stays. A larger increase in Total Function Score from admission to discharge suggests that a greater level of functional improvement (relative to admission) has been achieved. Figure 2-5 illustrates the distribution of change in Total Function Score from admission to discharge in , with a possible range from -108 to 108. For all clients admitted to inpatient rehabilitation, the average Total Function Score change was 19.6, and the median was 19. Note that distribution of change in Total Function Score spikes at 0. This deviation in distribution highlights the 800 clients, or 2.5%, who had no change in Total Function Score between admission and discharge. CIHI

36 Inpatient Rehabilitation in Canada, Figure 2-5 Distribution of Change in Total Function Score From Admission to Discharge, ,400 1,200 Number of Clients 1, Mean = 19.6 Median = Total Function Score Change (N = 32,521) Source National Rehabilitation Reporting System, Canadian Institute for Health Information, Figure 2-6 presents the average change between admission and discharge Total Function Scores for each individual RCG, so that comparisons can be made across NRS client groups. The graph shows that clients in certain client groups are typically admitted to inpatient rehabilitation with higher average admission Total Function Scores (limb amputation, pulmonary and arthritis) than others (stroke, brain and spinal cord dysfunction, neurological conditions, major multiple trauma and burns). In addition, the figure shows that clients in certain client groups show a greater gain in Total Function Score, on average, from admission to discharge. On average, greater gain in Total Function Score is observed in clients in the client groups classified as major multiple trauma (29.6) and burns (22.6), and lesser gain by those in the pulmonary (11.3) and arthritis (11.6) RCGs. Note clients in the latter two RCGs also had the highest Total Function Scores on admission. When assessing improvements in Total Function Score, it is important to consider the starting point, or admission Total Function Score. Client groups with higher average functional abilities on admission have smaller potential gains to be made as measured by the FIM instrument. There were some cases where clients in different RCGs were admitted with similar levels of function but varied in the gains made in function during their stay. For example, clients admitted with neurological conditions and major multiple trauma showed similar average admission Total Function Scores (80.7 and 80.3 respectively). However, those in the major multiple trauma group demonstrated more improvement in function, as measured by change in Total Function Score, on average from admission to discharge than those in the 26 CIHI 2008

37 Chapter 2. Rehabilitation Client Groups Q neurological conditions group (29.6 versus 18.5). As the demographic characteristics and types of injuries and illness seen in these two client groups are examined further, these differences may not be surprising. Clients admitted for major multiple trauma are usually admitted after an acute onset of an injury, as compared to clients with neurological conditions who may be admitted to manage an exacerbation of a chronic condition such as multiple sclerosis or Parkinson s disease. In addition, clients admitted with major multiple trauma tended to be younger than those admitted with neurological conditions (see Table 2-1 for details), which may further influence rehabilitation outcomes. (Quick Stats Table 2-7) Analyzing change in Total Function Score by RCG may provide information to assist in identifying variations in functional improvement in clients with different health conditions. These variations may highlight opportunities to reflect on best practices, standards of care and use of resources within the context of both programs and facilities. Further research is required to investigate these variations and their potential to assist with service delivery. Figure 2-6 Admission and Discharge Total Function Scores by Rehabilitation Client Group, Total Function Score (Range 18 to 126) Other RCGs Stroke Spinal Cord Dysfunction Major Multiple Trauma Neurological Conditions Brain Dysfunction Debility Burns Medically Complex Pain Syndromes Orthopedic Conditions Cardiac Amputation of Limb Pulmonary Disorders Arthritis All RCGs Rehabilitation Client Group (N = 32,521) Other RCGs includes Congenital Deformities, Developmental Disabilities and Other Disabling Impairments. Average Admission Total Function Score Average Discharge Total Function Score Source National Rehabilitation Reporting System, Canadian Institute for Health Information, CIHI

38 Inpatient Rehabilitation in Canada, Do all clients improve in function during their inpatient rehabilitation stay? Approximately 5% of all clients did not experience a gain in function, as measured by their change in Total Function Score. These findings suggest that for a small proportion of clients, inpatient rehabilitation does not positively impact burden of care associated with functional abilities, as measured by the FIM instrument. Among the RCGs, two groups had higher proportions of clients who either stayed the same or declined in function. Twenty-four percent of clients in the arthritis RCG and 19% in the pulmonary RCG did not experience a positive change in function during their stay. In contrast, only 3% of orthopedic clients and 2% of clients with major multiple trauma had no change or a decline in Total Function Score between admission and discharge. Further analysis of client groups with higher proportions of clients experiencing either no change or a decline in Total Function Score may be of interest to provide context and understanding of the goals and outcomes of these inpatient rehabilitation stays. Length of Stay The length of stay in a rehabilitation program can potentially be influenced by many factors, such as the presence of co-morbid conditions, the number of beds in a facility, staffing and the availability of needed post-discharge care resources. As such, caution should be used when interpreting values for rehabilitation lengths of stay. Despite this, it is of interest to note some of the differences in lengths of stay across client groups. Q In , the overall median length of stay in inpatient rehabilitation (excluding service interruptions) was 18 days. As shown in Figure 2-7, clients in the spinal cord dysfunction RCG had the longest median length of stay (43 days), while clients in the orthopedic conditions RCG had the shortest median length of stay (12 days). Clients in both the cardiac and arthritis RCGs also reported shorter median lengths of stay (14 and 13 days, respectively). (Quick Stats Table 2-8) 28 CIHI 2008

39 Chapter 2. Rehabilitation Client Groups Figure 2-7 Median Length of Stay of Inpatient Rehabilitation Clients by Rehabilitation Client Group, Median Number of Days Median = 18 days Orthopedic Conditions Arthritis Cardiac Pain Syndromes Medically Complex Pulmonary Debility Burns Major Multiple Trauma Neurological Conditions Rehabilitation Client Group (N = 33,879) Amputation Stroke Brain Dysfunction Other RCGs Spinal Cord Dysfunction Other RCGs includes Congenital Deformities, Developmental Disabilities and Other Disabling Impairments. Source National Rehabilitation Reporting System, Canadian Institute for Health Information, Figure 2-8 illustrates the cumulative distribution of the length of stay for the three RCGs with the largest proportions of inpatient rehabilitation clients. Among clients admitted to rehabilitation in for orthopedic conditions, the median length of stay was 11 days; 37% of these clients were discharged within 7 days and 77% within 21 days. The median length of stay for medically complex clients was 18 days, with 16% of clients discharged within 7 days and 59% discharged within 21 days. Of these three groups, clients admitted for stroke experienced the longest median length of stay, at 33 days, with 7% of stroke clients discharged within 7 days and 32% of clients within 21 days. This variation in LOS may be attributed, at least in part, to the variation in degree of disability and level of function on admission between these groups. For example, clients admitted after a stroke are more likely to require rehabilitation for both physical and cognitive impairments and may take longer to make functional gains than those admitted for orthopedic conditions. CIHI

40 Inpatient Rehabilitation in Canada, Figure 2-8 Cumulative Length of Stay for Selected RCGs, Percent of Clients days 18 days 33 days Stroke Orthopedic Conditions Medically Complex 100+ Source National Rehabilitation Reporting System, Canadian Institute for Health Information, CIHI 2008

41 Chapter 2. Rehabilitation Client Groups How has length of stay (LOS) changed over time? Overall, the median LOS in inpatient rehabilitation has declined over the past five years, from 22 days in to 18 days in Clients in some RCGs have experienced larger changes in LOS over the past five years. For example, clients admitted for rehabilitation for burns in stayed, on average, 20 fewer days than they did five years before (43 days to 23 days) and clients admitted after a major multiple trauma in stayed 9 fewer days, on average (41 days to 32 days). Of note, the average LOS for clients with amputations increased slightly over the five years from 30 days to 33 days. 60 Length of Stay (Days) Burns Major Multiple Trauma Amputation Pulmonary Pain Syndromes Orthopedic Conditions Fiscal Year Length of Stay Efficiency For the NRS, the length of stay efficiency indicator measures the functional progress made by clients in relation to how long they stayed in rehabilitation. Average length of stay efficiency is calculated by dividing change in Total Function Score by length of stay for each individual client and then taking the average of the individual values. It demonstrates the change in Total Function Score (as measured using the FIM instrument) per day of client rehabilitation. In general, a higher value for length of stay efficiency suggests that client functional status improved to a greater degree in a shorter period of time. As with length of stay, service interruption days are not included in this calculation. CIHI

42 Inpatient Rehabilitation in Canada, Q Q The average length of stay efficiency for all clients discharged from participating rehabilitation facilities in was 1.3. In other words, for each day that a client participated in an inpatient rehabilitation program, his or her Total Function Score increased, on average, more than one point. The average length of stay efficiency ranged from 0.5 for amputation clients to 1.9 for orthopedic clients. (Quick Stats Table 2-8) Care should be exercised when examining length of stay efficiency values. As mentioned earlier, change in Total Function Score and length of stay both of which are used in the calculation of length of stay efficiency can be influenced by multiple factors. This indicator should be used alongside other information such as resource availability, age distribution and admission Total Function Scores for the various Rehabilitation Client Groups in order to provide more insight into the reasons for the variations in length of stay efficiency between the RCGs. Pre-Admission and Post-Discharge Living Setting The NRS data indicate that in , 84% of all clients who were living in a private house or apartment prior to their admission to an inpatient facility returned to this environment following discharge; however, this proportion varied across the RCGs. Ninety-two percent of clients admitted for major multiple trauma and 89% of orthopedic conditions clients returned home, whereas only 79% of medically complex clients, 78% of brain dysfunction clients and 75% of stroke clients returned home. Almost half (48%) of all clients returning home required paid health services on discharge. As Figure 2-9 shows, this varied by RCG; 68% of clients admitted for burns and 58% of medically complex patients required paid health services following discharge, while only 40% of arthritis clients required them. Of those requiring paid health services upon return home, clients were further divided into two groups: those that did not have paid health services prior to admission (76%) and those that did (24%). Compared to other RCGs, higher proportions of clients admitted with orthopedic conditions (42%), pulmonary conditions (44%) and arthritis (48%) did not have paid health services prior to admission but did require them on discharge. (Quick Stats Table 2-13) The average discharge Total Function Score for clients not returning home was The score was much higher for clients returning home (109.8), indicating a much higher level of function. 32 CIHI 2008

43 Chapter 2. Rehabilitation Client Groups Figure 2-9 Receipt of Paid Health Services in the Home After Discharge for Clients Who Were Living at Home Prior to Admission by Rehabilitation Client Group, % Percent of Clients 80% 60% 40% 20% 0% Major Multiple Trauma Burns Orthopedic Conditions Pulmonary Arthritis Pain Syndromes Amputation Neurological Conditions Cardiac Rehabilitation Client Group (N = 30,380) Spinal Cord Dysfunction Medically Complex Brain Dysfunction Stroke Debility Other RCGs All RCGs Other RCGs includes Congenital Deformities, Developmental Disabilities and Other Disabling Impairments. Received Services Before and After Discharge Did Not Receive Services After Discharge Received Services After Discharge Only Did Not Return to House/Apartment Source National Rehabilitation Reporting System, Canadian Institute for Health Information, CIHI

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45 Conclusions and Future Directions Conclusions and Future Directions Inpatient Rehabilitation in Canada, is the fifth public report based on data from the National Rehabilitation Reporting System (NRS) developed and maintained by the Canadian Institute for Health Information (CIHI). Inpatient Rehabilitation in Canada, is one of the only publications that focuses on characteristics of hospitalbased rehabilitation services and clients in Canada. Information in this report provides a snapshot of the clients seen in participating inpatient rehabilitation facilities during , as well as the outcomes they achieved during their stay. These findings show that inpatient rehabilitation supports Canadians in maintaining or gaining functional independence and autonomy after an injury, illness or following surgery. By enhancing the information contained in the NRS through consultation with various hospital and government partners and through further development, future analytical reports released by CIHI will address additional topics of interest to rehabilitation stakeholders. As well, by incorporating additional sources of information, such as published research and other recognized data sources, numerous other questions and themes can be explored, including: whether there is variation in the client groups seen, the distances traveled and client outcomes for inpatient rehabilitation in different geographical regions; to what degree the presence and type of co-morbid conditions influences client outcomes; exploring the relationship between inpatient rehabilitation and other rehabilitation services across the continuum of care; and exploring the influence of organized networks of care or client pathways and the clients seen, as well as the outcomes of their care, in inpatient rehabilitation. As a reporting system, the NRS will continue to provide an opportunity for hospital staff, system managers, funders, policy-makers and other stakeholders to measure activity, to monitor outcomes and to respond to evolving demands and opportunities in Canada s health care system. For more information, contact [email protected] or visit the website of the National Rehabilitation Reporting System at CIHI

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47 Appendix A: NRS Glossary of Terms Appendix A: NRS Glossary of Terms Terms related to the National Rehabilitation Reporting System are taken from the Rehabilitation Minimum Data Set Manual, which is maintained and distributed by the Canadian Institute for Health Information. Refer to this manual for context-specific information relating to these terms. The 18-item FIM instrument assessment and the Rehabilitation Client Groups referenced herein are the property of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. Copyright 1997, Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc., all rights reserved. Admission FIM instrument assessment The baseline functional assessment that is done using the FIM instrument at the time of admission to the rehabilitation program. The FIM instrument should be administered within 72 hours of admission. Average For the purposes of the NRS, defined as the value obtained by adding all of the individual values (for example, FIM instrument scores, days waiting for admission) in a group and dividing that sum by the number of values in the group. Describes the arithmetic mean of a set of values. Continuing rehabilitation One of the available options for coding admission class in the NRS. This is part of a rehabilitation inpatient stay that began in another rehabilitation unit or facility. The client was admitted directly from a rehabilitation program in another unit or facility with the same RCG (see Rehabilitation Client Group). Includes transfers to a rehabilitation unit within the same facility. Date of onset The calendar date of onset of the main rehabilitation condition coded under Rehabilitation Client Group (see Rehabilitation Client Group) that precipitated the admission into rehabilitation. For acute conditions, the date of onset is the date of injury or surgery. For chronic conditions (such as chronic obstructive pulmonary disease), the date of onset is the date of the most recent exacerbation or functional loss that resulted in the admission to the inpatient rehabilitation unit. Date ready for admission The date on which the client meets criteria for admission to the rehabilitation facility and is considered ready to start a rehabilitation program. It does not refer to the date the client is put on a waiting list if this is done prior to when the client is clinically ready for rehabilitation. Date ready for discharge The calendar date that the client is considered ready for discharge from the rehabilitation program. On this date the client meets criteria for discharge according to the rehabilitation team and has met all or most of the rehabilitation goals set for himself or herself. CIHI

48 Inpatient Rehabilitation in Canada, Days waiting for admission One of the NRS indicators relating to accessibility. Defined as the number of days between the date ready for admission and the date of admission to rehabilitation. Discharge FIM instrument assessment The assessment of the client s functional ability using the FIM instrument at discharge. The FIM instrument should be administered within 72 hours before discharge from the rehabilitation program. Episode For the purposes of the NRS, an episode consists of a complete admission and discharge record and encompasses the entire stay in inpatient rehabilitation. The analyses in the NRS reports are primarily based on rehabilitation episodes. Exception: Clients recorded as having an unplanned discharge are still considered to have had a rehabilitation episode in the NRS (see (un)planned discharge). Facility Refers to the site where the rehabilitation beds are grouped and represents the level at which hospitals submit data to the NRS. Often facility is synonymous with hospital. For hospitals with more than one site or location, there may be more than one NRS facility within a hospital corporation. FIM instrument The functional assessment instrument included in the Uniform Data Set for Medical Rehabilitation (UDSMR). It is composed of 18 items (13 motor items and 5 cognitive items) that are rated on a seven-level scale representing gradations from independent (7) to dependent (1) function. The FIM instrument is a measure of disability and looks at the caregiver burden associated with the level of disability. Follow-up FIM instrument assessment The assessment of the client s functional ability using the FIM instrument that is collected between 80 and 180 days after discharge from the rehabilitation program. General rehabilitation facility A facility that provides inpatient rehabilitation services in designated units, programs or beds within a general hospital that has multiple levels of care (rehabilitation, acute care, chronic care, emergency). Rehabilitation clients receive multi-dimensional (physical, cognitive, psycho-social) diagnostic, assessment, treatment and service planning interventions. Informal support Describes the unpaid assistance provided to the client from any individual, including family, friends or neighbours. Informal support excludes formal paid services or formal referred service providers such as volunteers. Initial rehabilitation One of the available options for coding admission class in the NRS. Describes a client s first admission to an inpatient rehabilitation facility for a particular rehabilitation condition (see Rehabilitation Client Group). Length of stay (LOS) The number of days between the date on which the client is admitted to the rehabilitation facility and the date on which the client is discharged from the rehabilitation facility. Any days on which the client could not participate in the rehabilitation program due to a health reason are excluded from the calculation (see service interruption). 38 CIHI 2008

49 Appendix A: NRS Glossary of Terms Length of stay efficiency The change in Total Function Score (see Total Function Score) per day of client participation in the rehabilitation program. Calculated as change in Total Function Score from admission to discharge divided by length of stay (see length of stay). Median The middle value in a group when the values are arranged in an increasing order. If there is an even number of values, the median is the average of the middle two values. Results in an upper and lower half for the set of values. For example, in the series 2, 5, 7, 9 and 12, the value 7 is the median. Not the same as average (see average). Most responsible health condition The primary etiological diagnosis that describes the most significant condition leading to the client s rehabilitation stay. Where multiple conditions exist, it is the one health condition that is most related to the Rehabilitation Client Group and the condition that most of the resources are directed towards (see Rehabilitation Client Group). National Rehabilitation Reporting System (NRS) A national health information system for adult inpatient rehabilitation services. The NRS contains client data collected from participating adult inpatient rehabilitation facilities and programs across Canada. The NRS data elements contain information related to socio-demographic information, administrative data, health characteristics, activities and participation and therapeutic interventions. These elements are used to estimate a variety of indicators including wait times and client outcomes. Pre-hospital living setting Physical environment the client was living in prior to his/her admission to hospital for rehabilitation. For example, a private home or a residential care facility. Provider type(s) Refers to the professional service provider(s) involved in delivering rehabilitation services to the client. Post-hospital living setting Physical environment the client will be living in following discharge from the rehabilitation program. Private practitioner An independent professional to whom the client may be referred at time of discharge for related services following the rehabilitation episode; for example, a physician or a physiotherapist in a private clinic. Re-admission One of the available options for coding admission class in the NRS. The code used for a client admitted to an inpatient rehabilitation facility or unit where the current admission is related to a prior admission for the same rehabilitation condition (see Rehabilitation Client Group). There is no time limit for length of time since the previous admission. Record For the purposes of the NRS, a record consists of the complete information collected on admission (admission record), discharge (discharge record) or follow-up (follow-up record). A completed admission and discharge record for a client constitutes a rehabilitation episode in the NRS (see episode). CIHI

50 Inpatient Rehabilitation in Canada, Rehabilitation Client Group (RCG) The condition that best describes the primary reason for the client s admission to the rehabilitation program. The rehabilitation team determines the RCG at the time of admission. Rehabilitation goals The functional objectives set by the client in partnership with the rehabilitation team. These are determined shortly after admission to the rehabilitation facility and generally form the basis for activities that will be included in the rehabilitation program. Service interruption Occurs when a client is unable to participate in the rehabilitation program due to a health condition that may or may not result in a transfer out of the rehabilitation bed or unit. Service interruptions are generally coded only when the client misses more than one day of active rehabilitation and the condition is felt to impact on the client s progress in rehabilitation. This does not include weekend passes to visit family at home or temporary bed closures. Short stay One of the available options for coding admission class in the NRS. Refers to an inpatient rehabilitation stay lasting between 4 and 10 days. Specialty rehabilitation facility A facility that provides comprehensive inpatient rehabilitation services or specialized rehabilitation programs. This is often a freestanding hospital but can be a specialized unit within a larger acute or chronic care facility. In addition to interventions provided in a general rehabilitation facility, clients in a specialty facility also have access to more comprehensive services such as surgical specialists, orthotics, prosthetics, etc. Total Function Score (FIM instrument) The sum of the scores for all 18 elements on the FIM instrument ranging from 18 to 126. A higher Total Function Score suggests a higher level of independent functioning in activities of daily living and communication. (Un)planned discharge One of the available options for coding admission class in the NRS. Refers to an inpatient rehabilitation stay lasting three days or fewer, including the day of admission. Includes planned and unplanned discharges. In these cases, the admission FIM instrument is typically not completed, but can be included in the NRS record if complete. 40 CIHI 2008

51 Appendix B: Rehabilitation Client Groups (RCGs) Appendix B: Rehabilitation Client Groups (RCGs) The RCGs and selected definitions as referenced in this report are provided below, in descending order of volume (that is, number of records) in the National Rehabilitation Reporting System (NRS). This is not an exhaustive list of RCG definitions available for coding in the NRS. Definition of Rehabilitation Client Group (RCG) The health condition that best describes the primary reason for admission to the rehabilitation program. The appropriate Rehabilitation Client Group is determined at the time of admission by the rehabilitation team and can be modified at discharge if necessary. Orthopedic conditions: Includes cases in which the major disorder is post-fracture of bone, post-arthroplasty (joint replacement) or other pathology relating to bone (excludes conditions related to arthritis). Sub-groups of the orthopedic RCG highlighted in this report include hip fracture, hip replacement and knee replacement, as well as other (any orthopedic condition which does not fall into the first three groups). Stroke: Includes cases with the diagnosis of cerebral ischemia due to vascular thrombosis, embolism or hemorrhage. Cerebral impairment related to non-vascular causes such as trauma, inflammation, tumour or degenerative changes are excluded. Sub-groups of the stroke RCG highlighted in this report are left-sided stroke (right-brain), right-sided stroke (left-brain) and other stroke (for example, bilateral). Brain dysfunction: The non-traumatic brain dysfunction RCG includes cases with such etiologies as neoplasm, metastases, encephalitis, inflammation, anoxia, metabolic toxicity or degenerative processes. The traumatic brain dysfunction RCG includes cases with motor or cognitive disorders secondary to trauma. Amputation of limb: Includes cases in which the major deficit is absence of a limb. Cases for which limb amputation is the major deficit are included even if the need for treatment is principally related to wound care or a stump infection. Spinal cord dysfunction: Includes cases with various forms of quadriplegia/paresis and paraplegia/paresis. The non-traumatic spinal cord dysfunction sub-group includes cases secondary to non-traumatic cause, including post-operative change. The traumatic spinal cord dysfunction sub-group includes cases secondary to traumatic cause. Cases for which spinal cord dysfunction is the major deficit are included even if the need for treatment is principally related to the urinary tract or skin ulceration. Medically complex: Includes cases with multiple medical and functional problems and complications prolonging the recuperation period. Medically complex cases require medical management of a principal condition and monitoring of co-morbidities and potential complications. Rehabilitation treatments are secondary to the management of the medical conditions. The medically complex RCG groups clients by the program/treatment focus rather than the etiology. CIHI

52 Inpatient Rehabilitation in Canada, Debility: Includes cases where clients are generally de-conditioned and there may not be a specific etiology associated with the decline in function. Includes only clients who are debilitated for reasons other than cardiac or pulmonary conditions. Cardiac disorders: Includes cases in which the major disorder is poor activity tolerance secondary to cardiac insufficiency or general de-conditioning due to a cardiac disorder. Neurological conditions: Includes cases with a variety of neurological, muscular dysfunctions and etiologies such as multiple sclerosis, Guillain-Barré syndrome and Parkinsonism. Pulmonary disorders: Includes cases in which the major disorder is poor activity tolerance secondary to pulmonary insufficiency. Underlying etiologies include chronic obstructive lung disease, chronic bronchitis, etc. Arthritis: Includes cases in which the major disorder is arthritis of all etiologies. The arthritis RCG is used for clients entering the rehabilitation program without an immediately preceding orthopedic arthroplastic procedure. Major multiple trauma: Includes cases with more complex management due to involvement of multiple systems or sites following trauma. Pain syndromes: Includes cases in which the major disorder is pain, usually chronic and benign, of various etiologies. Burns: Includes cases in which the major disorder is thermal injury to major areas of the skin and/or underlying tissue. Congenital deformities* Developmental disabilities* Other disabling impairments* *Due to small numbers of records in the NRS, these three RCGs are grouped together and referred to as Other RCGs within this report where indicated. Rehabilitation Client Groups adapted with permission from the UDSMR impairment codes. Copyright 1997 Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc., all rights reserved. 42 CIHI 2008

53 Appendix C: FIM TM Instrument Subscales and Domains Appendix C: FIM Instrument Subscales and Domains Subscale Domain FIM Instrument Items Score Range Motor Self-Care Eating Grooming Bathing Dressing Upper Body 7 to 42 Sphincter Control Transfers Locomotion Dressing Lower Body Toileting Bladder Management Bowel Management Bed, Chair, Wheelchair Toilet Tub or Shower Walk/Wheelchair Stairs 2 to 14 3 to 21 2 to 14 Motor Function Score Range 13 to 91 Cognitive Communication Comprehension Expression 2 to 14 Social Cognitive Social Interaction Problem-Solving 3 to 21 Memory Cognitive Function Score Range 5 to 35 CIHI

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55 Appendix D: Methodological Notes Appendix D: Methodological Notes The following information is presented in order to provide readers with an understanding of the general methodology used to calculate the indicators in this report. More detailed notes on specific methodologies are presented throughout the text, when appropriate. Scope of Participation in the National Rehabilitation Reporting System At the end of the fiscal year, 94 inpatient rehabilitation facilities in seven provinces were submitting data to the NRS. Participation in the NRS is primarily voluntary in most provinces and efforts continue to promote the value of NRS participation across the country. Records Included in This Report There were 36,116 records representing clients discharged from inpatient rehabilitation in A total 2,237 of those records are for clients with an LOS of less than four days. These 2,237 records, whether planned or unplanned discharges, are excluded because a limited amount of information is collected for these clients due to the short length of stay. The FIM instrument admission assessment, for example, can reflect activity over three days to be complete. As such, Function Scores are generally not available for clients staying three days or less in the rehabilitation program. The majority of analyses in this report are based primarily on the remaining 33,879 pairs of complete NRS admission and discharge records for and represent clients who stayed in inpatient rehabilitation for more than three days. These records may have admission dates either in or in earlier fiscal years. Admission records with no corresponding discharge record in the NRS database as of May 15, 2007, the deadline for data submission, are excluded from all analyses. The majority of analyses conducted with data collected using the FIM instrument include only records with complete admission and discharge FIM instrument assessments. In cases where the client is transferred unexpectedly and does not return, there may not be an opportunity to complete a discharge FIM instrument assessment. Of the 33,879 complete NRS records discussed in this report, 32,521 have complete admission and discharge FIM instrument assessments. While the unit of analysis throughout most of this report is the episode of care, it should be mentioned that it is possible for an inpatient rehabilitation client to have more than one episode of care per fiscal period. Table D-1 shows that in , six percent of rehabilitation clients had more than one episode of care reported in the same fiscal year. CIHI

56 Inpatient Rehabilitation in Canada, Table D-1 NRS Clients With Multiple Episodes of Care, Number of Episodes Number Total Number of Clients Percent 1 30, , or more 5 <0.1 Total clients 31, Source National Rehabilitation Reporting System, Canadian Institute for Health Information, Tables and Statistics for This Report For readers who would like to access the aggregate data used to produce the figures presented in the NRS report, source tables are available at under Quick Stats. Throughout this report, references to the Quick Stats tables can be found at the end of relevant paragraphs or sections. For a complete list of tables in this report, refer to Appendix E. Data Suppression This report adheres to CIHI s policies governing the publication and release of health information, developed to safeguard the privacy and confidentiality of data entrusted to CIHI. In compliance with these guidelines, cell counts between one and four within data tables are combined with other cells where appropriate. Three RCGs with small numbers of records have been aggregated into an Other RCGs category. The RCGs that were aggregated in this manner are developmental disabilities, other disabling impairments and congenital deformities. The intent of cell suppression and aggregation is to ensure anonymity, reducing the potential for residual disclosure of personal health information. Computations Statistics within this report and in the web-based tables are generally presented to one decimal place. As a result of rounding, percentages may add to between 99% and 101%. The report also presents mean values of certain characteristics at admission, discharge and the mean change between admission and discharge. Again, due to rounding, the difference between the mean admission and discharge values and the mean change presented may range from -1 to +1. This report uses two statistical measures of central tendency: the median and the mean. The median is the point in a distribution that splits the distribution into two equal parts: half of the values lie below this point and half lie above it. The mean, or average, is calculated by summing all the values of the distribution and dividing that sum by the number of values presented. A mean can be affected by extreme values; therefore, for highly skewed distributions, the median is usually used, as it is less affected by such values. Throughout the report, the mean is referred to as the average and median is referred to as itself. 46 CIHI 2008

57 Appendix E: List of Quick Stats Tables Appendix E: List of Quick Stats Tables The source tables for this report are available on the CIHI website at at by selecting Quick Stats from the menu bar and selecting From Source NRS. *Indicates Quick Stats tables that were referenced in this report. Quick Stats Table Title 1-1 Type of Admission to Inpatient Rehabilitation by Facility Type, * 1-2 Source of Referral to Inpatient Rehabilitation by Facility Type, * 1-3 Distribution of Days Waiting for Admission to Inpatient Rehabilitation, * Average and Median Days Waiting for Inpatient Rehabilitation by Referral Source, Demographic Characteristics of Inpatient Rehabilitation Clients by Facility Type, * 1-6 Proportion of Male and Female Rehabilitation Clients by Age, Pre-Admission Living Setting of Inpatient Rehabilitation Clients, * Inpatient Rehabilitation Clients Receiving Informal Support Prior to Admission by Facility Type, Median Length of Stay in Inpatient Rehabilitation by Type of Facility and Type of Admission, * 1-10 Reason for Discharge from Inpatient Rehabilitation, * 1-11 Services Referred to After Discharge From Inpatient Rehabilitation, * Pre-Admission and Post-Discharge Living Settings of Inpatient Rehabilitation Clients, Distribution of Inpatient Rehabilitation Clients by Facility Type and RCG, * Average and Median Days Waiting for Inpatient Rehabilitation by RCG, * Sex Distribution and Average Age by Sex of Inpatient Rehabilitation Clients by RCG, * 2-4 Age Distribution of Inpatient Rehabilitation Clients by RCG, Age Distribution and Sex of Inpatient Rehabilitation Clients by RCG, Pre-Admission Living Setting of Inpatient Rehabilitation Clients by RCG, Average Admission, Discharge and Change in Total Function Scores by RCG, * Median Length of Stay and Average Length of Stay Efficiency of Inpatient Rehabilitation Clients by RCG, * CIHI

58 Inpatient Rehabilitation in Canada, Quick Stats Table Title 2-9 Average Admission Total Function Score and Median Length of Stay by Rehabilitation Client Group, Inpatient Rehabilitation Clients Reporting Pain at Admission by RCG, Inpatient Rehabilitation Clients Reporting an Improvement in Pain at Discharge by RCG, Reasons for Discharge From Inpatient Rehabilitation by RCG, Discharge Living Setting, Receipt of Paid Health Services After Discharge and Admission and Discharge Total Function Scores by RCG, * 48 CIHI 2008

59 Taking health information further Á l avant-garde de l information sur la santé