Inter-professional patient-centred models of care for geriatric rehabilitation: A Bruyère Rapid Review
This rapid review was undertaken to assess the evidence on the effectiveness of multidisciplinary or inter-professional patient-centred models of care for geriatric rehabilitation on length of stay, patient and family satisfaction, function, discharge location and readmission to hospital. In addition, the Bruyère geriatric rehabilitation team asked for evidence about guidance on choosing restorative or compensatory approaches for different patient populations.
There is an increasing need for appropriate models of care for geriatric rehabilitation to address the needs of an aging population such as disability, cognitive impairment, comorbidities and frailty.
Geriatric Rehabilitation is defined as a multidisciplinary set of evaluative, diagnostic, and therapeutic interventions whose purpose is to re store functional ability or enhance residual functional capability in elderly people with disabling impairments. Optimal evidence-based geriatric rehabilitation care is provided by multidisciplinary or inter-professional care teams whose diverse members communicate with each other regularly and collaborate in the care of their patients. The process of care is most effective when all members of the multidisciplinary or inter-professional care team including the patient and family are involved in goal setting and care planning through team meetings.
We searched for relevant systematic reviews and guidelines in Trip Database, the Cochrane Library and PubMed from inception to December 16, 2016. We identified 11 systematic reviews and seven clinical practice guidelines that met our inclusion criteria.
- Clinical guidelines recommend the involvement of a multidisciplinary or inter-professional team for optimal geriatric rehabilitation and regular team meetings for individual patient goal setting.
- Multidisciplinary geriatric inpatient rehabilitation is more effective compared to usual care for short-term function, nursing home admission, patient satisfaction and mortality in patients with hip fracture, medical illnesses, and/or dementia following hip fracture. It also leads to shorter length of stay in patients with mild or moderate dementia.
- There is a need for research on family caregiver involvement in geriatric rehabilitation.
- There is need for standardized measures of effectiveness. Studies of geriatric rehabilitation need to include measures of patient experience including patient and family satisfaction and quality of life.
- There is need for more conclusive evidence on the effectiveness of inpatient geriatric rehabilitation and different models of care for different patient populations.
- There is need for evidence about the effectiveness of different characteristics of the models of care such as frequency, intensity, and duration of interventions as well as the delivery of the interventions and care by different members of the multidisciplinary team.
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There is an increasing demand for appropriate models of care for geriatric rehabilitation to address the needs of an aging population such as disability, cognitive impairment, comorbidities and frailty. Geriatric Rehabilitation is defined as a multidisciplinary set of evaluative, diagnostic, and therapeutic interventions whose purpose is to restore functional ability or enhance residual functional capability in elderly people with disabling impairments. Restorative approaches involve interventions that enable a patient to develop their lost function while compensatory approaches involve interventions that help the patient overcome impairment with the use of aids and tools. Optimal evidence-based geriatric rehabilitation care is provided by a multidisciplinary or inter-professional care team whose diverse members communicate with each other regularly and collaborate in the care of their patients. The process of care is most effective when all members of the multidisciplinary or inter-professional care team including the patient and family are involved in goal setting and care planning through team meetings. Geriatric rehabilitation is often provided after acute hospitalization of the elderly and various strategies have been used including post-acute inpatient rehabilitation, and geriatric day hospitals. Some dedicated multidisciplinary geriatric rehabilitation programs are inpatient geriatric assessment units (GAUs) and the geriatric rehabilitation units (GRUs). In a GAU, there is more emphasis on medical treatment and evaluation, and the rehabilitation goals are usually short term. GAUs reduce hospital-associated deconditioning which is common in multi-morbid patients. Deconditioning is functional decline experienced as a result of hospitalization. In a GRU, there is a greater emphasis on rehabilitation and achieving maximal function.
To assess the evidence on the effectiveness of multidisciplinary or inter-professional patient-centred models of care for geriatric rehabilitation on length of stay, patient and family satisfaction, function, discharge location and readmission to hospital.
A secondary objective was to assess guidance and models of best practice on choosing between compensatory and restorative approaches, and models of providing geriatric rehabilitation such as types of providers and frequency and involvement of caregivers.
We defined the question by consulting with the geriatric rehabilitation team at EBH. We agreed on an a priori question and methods prior to starting.
Eligibility and selection criteria
We included guidelines and systematic reviews if they met the following eligibility criteria:
Population: people receiving geriatric rehabilitation (e.g. people with post-hip fracture, frailty, delirium or cognitive impairment).
We excluded post-arthroplasty and post-stroke patients.
Intervention: inpatient inter-professional patient-centred models of care for geriatric rehabilitation - including goal-setting, level of participation, family involvement, restorative or compensatory goals.
We excluded day hospital interventions.
Comparison: other models of care, before/after, program evaluation
Outcomes: length of stay, patient and family satisfaction, function, discharge location (e.g. home or nursing home), and readmission to hospital.
Outcomes were considered in relation to function prior to the acute event which precipitated admission to acute care since all patients in Bruyère geriatric rehabilitation arrive following admission for acute care.
We searched for relevant systematic reviews and guidelines in Trip Database and the Cochrane Library from inception to December 16, 2016 and identified 752 articles. We did a related article search in PubMed as well as screened references of relevant articles.
We also searched the National Guideline Clearinghouse database for guidelines and websites for individual exemplar models.
The search results were screened and reviewed by two authors. We identified seven relevant guidelines and 11 systematic reviews that met our inclusion criteria.
We assessed the quality of the included reviews and guidelines using AMSTAR and AGREE II respectively. The quality of the systematic reviews ranged from moderate to high and the clinical practice guidelines were of low to high quality.
We also graded the quality of the evidence for each outcome using the GRADE approach. These ranged from very low to moderate.
We included seven clinical practice guidelines and 11 systematic reviews.
The included guidelines for inpatient geriatric rehabilitation were diverse: one Australian and New Zealand guideline and two UK guidelines for the management of hip fractures, four Canadian guidelines – the Ontario MOHLTC Assist and Restore guidelines, the British Columbia Guidelines for Elderly Mental Health Care Planning for Best Practices for Health Authorities and the Greater Toronto Area (GTA) rehab network’s Inpatient Rehab/LTLD Referral Guidelines and the GTA rehab network’s Inpatient Rehab Hip Fracture Clinical Pathway.
All 11 systematic reviews assessed inpatient multidisciplinary rehabilitation in geriatric populations. In four reviews, patients were treated for hip fracture; medical illnesses in four reviews; medical illnesses or surgical conditions in two reviews. One review considered people post-hip-fracture surgery with dementia.
Different controls were assessed: usual care in nine reviews and home-based rehabilitation in one review. In another review different controls were assessed including usual care or orthopedic units. The included studies were done in different countries: Australia, Canada, Germany, Finland, Norway, Spain, Sweden, Taiwan, Thailand, UK, and USA. Three reviews did not indicate the countries where the studies were carried out.
All the included reviews considered the effectiveness of models of geriatric rehabilitation and none considered patient experience and geriatric rehabilitation.
Synthesis of Findings
Findings from systematic reviews
There was an overlap of some included studies across the reviews but because of the diversity in study designs, types of interventions assessed and outcomes reported a quantitative analysis was only done in five reviews. The professions of the multidisciplinary teams were provided in all except one systematic review. The elements of the interventions or models were not described in detail in the included systematic reviews. Different models of inpatient geriatric rehabilitation were assessed in different patient populations in the systematic reviews.
Multidisciplinary teams in included reviews
The multidisciplinary teams included the following professions in different combinations: geriatrician, nurse, physiotherapist, occupational therapist, psychologist, social worker, speech therapist, dietician, nutritionist, podiatrist, support workers, orthopedic surgeon, internist, general practitioner, and pharmacist.
Caregivers were not part of the multidisciplinary teams in any of the reviews. However, weekly team meetings were held and collaboration between the caregivers and the team was encouraged in one study in one of the reviews.
Populations in included reviews
The populations were older adults who were either post-acute hospital admission for medical illness (including heart failure, pneumonia, urinary tract infection, delirium, sepsis, COPD, etc.) or post-hip fracture. One review included patients with dementia following hip fracture. The age range of populations was usually >65. Seven reviews mainly included studies with a mean age of 75 or older.
Interventions in included reviews
The interventions included different health professionals and processes of care, as indicated in Table 3. Four systematic reviews described components of the process of care which included one or more of the following:
multidimensional geriatric assessment (15/17 studies; 11/11 studies; 22/22 studies)
team meetings for goal setting- (weekly or biweekly or thrice weekly) (14/17; 8/11; 18/22)
- Discharge planning or follow-up after hospital discharge (6/17; 8/11; 4/5; 9/22 )
- Other components included:
- Assignment to therapy (10/17)
- Continuity of care (3/11)
- Daily medical review (4/11)
- Staff training and strong communication across multidisciplinary teams (4/5)
- Heightened surveillance for common postoperative complications following hip fracture in older people (5/5)
- Goal setting (11/22)
- Assessment tools (11/22)
- Protocols (3/22)
- Ward environment (3/22)
Additional components for people with dementia were strategies with an emphasis on orientation to the environment, cues, reminiscence and structured, familiarized routines.
None of the reviews assessed variations in effectiveness based on inclusion of different combinations of these components.
Outcomes assessed included length of stay (9 out of 11 reviews), patient and/or family satisfaction (2 out of 11 reviews), functional status (10 out of 11 reviews), discharge location (10 out of 11 reviews) and readmission to hospital (6 out of 11 reviews).
Function was assessed using different scales including the Katz index, Barthel index, ADL score, personal self-maintenance scale, Functional independence measure (FIM), Newcastle Independence Assessment Form (NIAF), Berg balance scale, Timed up and go, sit to stand, and various other scales.
Findings from Clinical Practice Guidelines
All seven guidelines recommended:
- That a multidisciplinary team be used to facilitate the rehabilitation process for these older adults with post-acute medical illness or hip fracture.
- Comprehensive geriatric assessment (CGA) by an interdisciplinary rehabilitation team as the first step to determine:
- If the patient is a candidate for inpatient rehabilitation, is medically stable and ready for rehabilitation.
- The key reason and goals for rehabilitation (to restore function or enhance functional capacity)
- The treatment plan or type of rehabilitation program – Geriatric assessment unit (GAU/MARU), Geriatric rehabilitation unit (GRU)
A comprehensive geriatric assessment (CGA) includes physical, cognitive (including delirium and dementia), affective, social, financial, environmental, and spiritual components that influence an older adult's health. It facilitates rehabilitation and discharge and improves health outcomes.
The NICE guidelines and the Australian NEW Zealand guidelines also recommended continued coordinated multidisciplinary team review.
The integrated inter-professional team may vary according to the type of programs. They could include: geriatric and physiatry specialists, physiotherapists, occupational therapists, speech language pathologists, rehabilitation nurses, and therapy assistants, a range of medical, nursing, pharmacy, dietary and psychiatric professionals, and other team assistants. Unpaid care-givers should be involved in the care process through discussions about goals, plans, and key treatment decisions.
A variety of multidisciplinary service models exist determined by local circumstances and expertise. The geriatric assessment unit (GAU) focuses on the assessment and treatment of both medical and functional problems while the geriatric rehabilitation unit (GRU) focuses mainly on restoring function. The geriatric mixed assessment and rehabilitation unit (MARU) attends to patients with stroke and other disabling conditions.
For hip fracture, there are three in-patient geriatric rehabilitation programs described in the UK: the geriatric mixed assessment and rehabilitation units (MARUs), the geriatric orthopedic rehabilitation unit (GORU), and the ortho-geriatric hip fracture program (GHFP). In addition, early supported discharge (ESD) or intermediate care model can be considered as part of the hip fracture program if the multidisciplinary team remains involved and the patient is medically stable and mentally alert and has not achieved full rehabilitation potential. The Australian and New Zealand guidelines were adapted from the NICE guidelines and have similar recommendations. Care should be provided such that the patient’s risk of delirium is minimized and independence is maximized and additional guidance for people with dementia should be sought. The GTA Rehab Network in Canada recommends the inpatient rehabilitation hip fracture clinical pathway . The latter also recommends the assessment of cognitive status.
The elements of the models were not described. However, the Ontario MOHLTC Assist and Restore guidelines described three types of facility-based interventions for frail seniors and other persons who have experienced a recent loss of functional ability after a medical event or decline in health or are at high risk for imminent institutionalization (in a hospital or LTC home) as a result of functional loss and have the potential to regain that functional loss (‘restorative potential’).
Type 1: Sub-acute complex interventions for people with low level of physical or cognitive ability who may be in transition from acute medical treatment or surgery.
Type 2: Geriatric rehabilitative interventions for people with potential cognitive capacity and endurance to participate in daily, intensive, goal-directed rehabilitative therapy with medical oversight. They require less active medical management than patients receiving Type 1 interventions.
Type 3: Active recuperative interventions for people who may lack physical or cognitive capacity to participate in a rigorous rehabilitative care program. They require less active medical management than patients admitted to Types 1 and 2 interventions.
The GTA inpatient rehabilitation referral guidelines also mentioned two types of interventions: high tolerance short duration or low tolerance long duration interventions. The high tolerance short duration interventions are provided in MARU/GAU for 2-8 weeks and comprise an average of 120 minutes of therapy daily for 5-7 days as tolerated by the patient. Low tolerance long duration interventions in the GRU are provided for 3-6 months and comprise an average of 30 minutes of therapy, 2 sessions per day, 3 times per week as tolerated by the patient.
We identified six exemplars of inpatient geriatric rehabilitation care models, based on suggestions from the clinical leads: Baycrest in-patient rehabilitation program, Bridgepoint Active Healthcare program, St Joseph’s Healthcare London, Parkwood Institute, Lakeridge health, Credit Valley Hospital, Mississauga and The New South Wales (NSW) Rehabilitation Model of Care, Australia. We did not find evidence of effectiveness or patient outcomes for these programs.
Applicability of evidence/implementation
Clinical practice guidelines recommend the involvement of a multidisciplinary or inter-professional team for optimal geriatric rehabilitation. Family care-givers were not involved in any of the rehabilitation teams in the systematic reviews though guidelines recommend their involvement. All but one included systematic review provided the professions of the multidisciplinary teams without describing the interventions they provided.
Multidisciplinary geriatric inpatient rehabilitation is more effective compared to usual care for short-term function, nursing home admission and mortality in patients with hip fracture and/or medical illnesses. The effects are smaller when assessed 3-12 months post-discharge.
Enhanced interdisciplinary inpatient and home-based rehabilitation compared to usual care improved ADL performance and discharge to institutional care in patients with cognitive impairment at 3 months post-hip fracture. Only the effect on ADL performance was maintained at 12 months. There was also a shorter length of stay in patients with mild or moderate dementia.
There is limited information about the components of the individual models of care assessed. Although specific strategies were considered for dementia patients with cognitive impairment, these were not described in detail.
There is a lack of data on patient and family satisfaction with care. Patient satisfaction was greater for post-hip fracture patients in geriatric orthopedic rehabilitation units and home-based rehabilitation.
Strengths and Limitations
We found high-quality systematic reviews and guidelines and used a structured process to synthesize results, including assessment of quality.
There were differences in the patient populations and settings, and the outcome measurements across the studies included in the reviews.
A description of the components of the interventions was lacking but the models of care assessed in the systematic reviews were in agreement with those recommended in the guidelines. There was no mention or description of types of rehabilitation processes such as compensatory or restorative rehabilitation in any of the included reviews or guidelines.
No review had data on patient experience and geriatric rehabilitation.
Only one guideline described the frequency but not the components of geriatric rehabilitation care models.
- Optimal evidence-based geriatric rehabilitation care is provided by multidisciplinary or inter-professional care teams whose diverse members communicate with each other regularly and participate in the care of their patients
- Multidisciplinary geriatric inpatient rehabilitation is more effective compared to usual care for short-term function, nursing home admission and mortality in patients with post-acute admission for medical illnesses, hip fracture and/or dementia following hip fracture.
- For dementia patients with cognitive impairment, strategies with an emphasis on orientation to the environment, cues, reminiscence and structured, familiarized routines should be included in the model of geriatric rehabilitation.
- There is a need for research on family caregiver involvement in rehabilitation.
- Studies of geriatric rehabilitation need to include measures of patient experience including patient and family satisfaction.
- There is need for new studies that describe and assess the effectiveness of different components of geriatric rehabilitation (such as multidisciplinary team, comprehensive geriatric assessment, restorative or compensatory therapeutic strategies or interventions, etc.) to guide best practices in providing care (such as frequency, choice of restorative or compensatory approaches).
Possible Next Steps
- Determine key outcomes to be measured in the unit to assess and monitor standards of practice or quality of care.
There are no core set of outcomes for inpatient geriatric rehabilitation but guidelines recommend the following:
- Functional status
- Length of stay
- Quality of life
- Place of residence/discharge
- Hospital readmission
The choice of assessment tools should be guided by the patient population, the setting and feasibility of implementation. However, the following have been recommended by the COMET (Core Outcome Measures in Effectiveness Trials) Initiative for assessing functional status and quality of life in the rehabilitation of critical illness survivors after hospital discharge.
Physical function and mobility scales were ranked important (score: 3) in consensus:
- the De Morton Mobility Index (DEMMI);
- the Timed Up and Go test;
- the Functional Independence Measure;
- the Short Physical Performance Battery; and
- the Short Form 36—physical function domain.
Tools to assess (instrumental) ADL function:
- the Barthel Index,
- the KATZ-ADL, and
- Lawton’s iADL.
Quality of life - ranked as very important (score 2) in consensus:
- The Short Form 36, and
- The Euro Qol Health questionnaire (EQ-5D); followed by
- The Sickness Impact Profile (ranked as important, score 3)