The ultimate goal of rehabilitation is to improve function which will allow and individual to participate independently and fully as possible in their community of choice. Reports from the treatment team, the family and the individual are helpful but can be vastly different and are not quantifiable. At ReMed, we feel that it is critical to use quantifiable outcome data which not only shows progress, but is helpful in advocating for services and proving the value of the rehabilitation and care that a person is receiving.
Mayo Portland Adaptability Index 4 (MPAI-4)
The MPAI-4 is the backbone of ReMed’s outcomes measurement system. The MPAI-4 focuses on function rather than impairment and is a robust tool that is the product of over 20 years of research. It is normed on a national sampling of individuals with acquired brain injury . MPAI-4 scores are converted to T scores, so that they can be compared to a like, representative group. Overall, the MPAI-4 is widely recognized in the field of brain injury and is a very useful tool because of its ease of administration and scoring, the ability for different groups to use the tool to rate and compare, and it allows for staff consensus.
The MPAI-4 is comprised of three subscales, Abilities, Adjustment; Participation and contains 29 variables that are rated.
The following T-score classification should be referenced when reviewing the MPAI 4 data:
- T-scores above 60 suggest severe limitation even as compared to other people with ABI
- T-scores between 50-60 suggest moderate to severe limitations
- T-scores between 40-50 suggest mild to moderate limitations
- T-scores between 30-40 suggest mild limitations
- T-scores below 30 represent relatively good outcomes
For Clients admitted to ReMed’s therapy intensive/neuro-rehabilitation programs, it is expected that gains will be made in the MPAI-4 T scores between admission and discharge. The chart below illustrates this; a reduction in score reflecting improved functioning.
For Clients in ReMed’s Supported Living Programs, it is expected that the MPAI-4 scores will show stability of function, as this is the overall goal for those programs. In 2015, 99% of clients in the SLS programs demonstrated stability in their MPAI-4 T scores. Note that the MPAI-4 T scores in these programs show a significant range, with clients in the more independent Supported Apartment Programs reflecting an average T score of 53, while clients in the Medically Complex Programs reflecting an average T score of 68.
Our Programs Improve the Lives of the Individuals We Serve
The Supported Living clients at ReMed also participate in an average of 15 hours of vocational/cognitive activity per week, in addition to their basic residential activities. These vocational/cognitive activities include volunteer work, competitive employment, supported work, school, brain injury groups, cognitive groups, and Day Programs. Also, these same clients participate in, on average, 39 hours of meaningful leisure activity per week, supporting a stable activity plan which enhances socialization, mood and increases quality of life.
In 2015, 26 discharged residential and outpatient clients were contacted in followup and reported the following:
- 58% of discharged clients reported they were vocationally active
- 92% of discharged clients reported they were living in the community; 67% living in their own apartment or home
- 15% of discharged clients continue to receive some type of support services
- 81% of discharged clients reported overall satisfaction with their lives
- 77% of discharged clients reported still using the compensatory strategies developed while at ReMed
Medical Complexity and Unplanned Hospitalizations
ReMed serves individuals with a variety of medically complex needs, and provides strong physician and nursing support to address those needs. In 2013, three diagnostic categories were identified as reasons for the majority of unplanned hospital admissions; these were Urinary Tract Infections, Upper Respiratory Infections/Pneumonia; and Cellulites. In 2014, the Nursing Committee developed and with the review and approval of the Medical Directors, implemented “Early Intervention Protocols” for each client who had recurrent issues/hospitalizations precipitated by these three diagnoses. These protocols included increased hydration schedules, use of pulmonary vests, frequent monitoring of vital signs and pulse ox levels, monitoring skin status and prevention measures and identifying the parameters which would indicate the need to start early intervention antibiotic protocols. The goal of the early intervention protocols is to avoid hospitalizations and minimize Emergency Department utilization.
In 2015, our 114 residential clients had a total of 27 unplanned hospitalizations, with only 11 of these being due to the three frequent diagnostic categories of UTI, URI and Cellulites. The remaining 16 hospitalizations were due to other medical /surgical issues unrelated to the top three diagnostic categories for re-hospitalizations. The 11 episodes represented a decrease of 45% in unplanned hospitalizations from 2014 for these three diagnostic categories. The Early Intervention Protocols were implemented for 38 client episodes, and hospitalization was avoided for 35 client episodes. As a result of these protocols, client programming remains uninterrupted, deconditioning and other hospital related complications are avoided and overall adverse impact on the client, the family/support system, and the funder is minimized.
ReMed is committed to advancing the field of brain injury rehabilitation. Many of ReMed’s clinicians serve on national committees and boards to help develop and promote best practices. ReMed partners with experts and participates in research opportunities, and has been a primary driver in the development of a National Outcomes Database using the MPAI-4 as the benchmark outcomes measurement tool.
ReMed has been involved in two recent and important research projects related to outcomes in Post Acute Brain Injury Rehabilitation.
“Post Inpatient Brain Injury Rehab Outcomes: Report from the National OutcomeInfo Database”
James F. Malec1 and Jacob Kean1,2
This study examined outcomes for intensive residential and outpatient/community-based post-inpatient brain injury rehabilitation(PBIR) programs compared with supported living programs. The goal of supported living programs was stable
functioning (no change). Data were obtained for a large cohort of adults with acquired brain injury (ABI) from the
OutcomeInfo national database, a web-based database system developed through National Institutes of Health (NIH)
Small Business Technology Transfer (STTR) funding for monitoring progress and outcomes in PBIR programs primarily
with the Mayo-Portland Adaptability Inventory (MPAI-4). Rasch-derived MPAI-4 measures for cases from 2008 to 2014
from 9 provider organizations offering programs in 23 facilities throughout the United States were examined. Controlling
for age at injury, time in program, and time since injury on admission (chronicity), both intensive residential (n = 205) and
outpatient/community-based (n = 2781) programs resulted in significant (approximately 1 standard deviation [SD])
functional improvement on the MPAI-4 Total Score compared with supported living (n = 101) programs (F = 18.184,
p < 0.001). Intensive outpatient/community-based programs showed greater improvements on MPAI-4 Ability (F = 14.135,
p < 0.001), Adjustment (F = 12.939, p < 0.001), and Participation (F = 16.679, p < 0.001) indices than supported living
programs; whereas, intensive residential programs showed improvement primarily in Adjustment and Participation. Age at
injury and time in program had small effects on outcome; the effect of chronicity was small to moderate. Examination of
more chronic cases (>1 year post-injury) showed significant, but smaller (approximately 0.5 SD) change on the MPAI-4
relative to supported living programs (F = 17.562, p < 0.001). Results indicate that intensive residential and outpatient/
community-based PIBR programs result in substantial positive functional changes moderated by chronicity.
For full article, click on this link – Post Inpatient Brain Injury Rehab Outcomes
Progress Assessed With the Mayo-Portland Adaptability Inventory in 604 Participants in 4 Types of Post–Inpatient Rehabilitation Brain Injury Programs
Vicki Eicher, MSW, Mary Pat Murphy, MSN, CRRN, CBIST, Thomas F. Murphy, James F. Malec, PhD; Archives of Physical Medicine and Rehabilitation. January 2012, Vol. 93, Issue 1, 100-107.
This study examined outcomes for four program types within the Pennsylvania Association of Rehabilitation Facilities: intensive outpatient and community-based rehabilitation (IRC; n=235), intensive residential rehabilitation (IRR; n=78), long-term residential supported living (SLR; n=246), and long-term community-based supported living (SLC; n=45). With the use of a commercial web-based data management system developed with federal grant support, progress was examined on 2 consecutive assessments.
Program types differed in participant age (F=10.69, P<.001), sex (χ2=22.38, P<.001), time from first to second assessment (F=20.71, P<.001), initial MPAI-4 score (F=6.89, P<.001), and chronicity (F=13.43, P<.001). However, only initial MPAI-4 score and chronicity were significantly associated with the second MPAI-4 rating. On average, SLR participants were 9.1 years postinjury compared with 5.1 years for IRR, 6.0 years for IRC, and 6.8 years for SLC programs. IRR participants were more severely disabled per MPAI-4 total score on admission than the other groups. Controlling for these variables, program types varied significantly on second MPAI-4 total score (F=5.14, P=.002). Both the IRR and IRC programs resulted in significant functional improvement across assessments. In contrast, both the SLR and SLC programs demonstrated relatively stable MPAI-4 scores.
Results are consistent with stated goals of the programs; that is, intensive programs resulted in functional improvements, whereas supported living programs produced stable functioning. Further studies using data from this large, multiprovider measurement collaboration will potentially provide the foundation for developing outcome expectations for various types of postacute brain injury programs.
For full article, click on this link - Progress Assessed with the Mayo Portland Adaptability Inventory in 604 Patients in 4 Types of Post-Inpatient Rehabilitation Brain Injury Programs