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Evaluation of comprehensive rehabilitation services for elderly homebound patients with arthritis and orthopedic disability.

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258
EVALUATION OF COMPREHENSIVE
REHABILITATION SERVICES FOR ELDERLY
HOMEBOUND PATIENTS WITH ARTHRITIS AND
ORTHOPEDIC DISABILITY
MATTHEW H. LIANG, ALISON J. PARTRIDGE, MARTIN G. LARSON, VICTORIA GALL,
JENNIFER TAYLOR, CATHY BERKMAN, ROBERT MASTER,
MARIE FELTIN, and JAMES TAYLOR
Fifty-seven elderly homebound patients with arthritis and orthopedic disabilities were randomized to a
goal-oriented outreach rehabilitation program or to
usual treatment. Although 64% of patient goals were
met, there were no overall significant differences in
functional scores, institutionalization, or contentment
between treatment and control periods. Twenty-three
patients had maintained clinical improvement at the end
of the study and some patients were dramatically improved with simple measures. The program’s marginal
costs were modest and consisted primarily of expenses
associated with therapist’s visits. The total costs of
assistive devices and home modifications amounted to
$1,902. Twenty-five percent of the homebound population could benefit from such services but the actual
number who would partake is small.
A million people in the United States are homebound and studies of these individuals indicate that
musculoskeletal disorders and arthritis are the most
~
_
_
From the Departments of Medicine, Rheumatology/lmmunology, Brigham and Women’s Hospital, The Robert B. Brigham
Multipurpose Arthritis Center, Department of Biostatistics, Harvard School of Public Health, Upham’s Corner Health Center, Beth
Israel Hospital Home Care, Jamaica Plain Senior Team, East
Boston Neighborhood Health Center, and the Urban Medical
Group, Inc., Boston, Massachusetts.
Supported by National Institutes of Health grant No. AM20580.
Matthew H. Liang, MD, MPH; Alison J. Partridge, MSW;
Martin G. Larson, DSc; Victoria Gall. RPT; Jennifer Taylor; Cathy
Berkman, MSW; Robert Master, MD; Marie Feltin, MD; James
Taylor, MD.
Address reprint requests to Matthew Liang, MD, Brigham
& Women’s Hospital, 75 Francis Street, Boston, MA 021 IS.
Submitted for publication May 2, 1983; accepted in revised
form September 2, 1983.
Arthritis and Rheumatism, Vol. 27, No. 3 (March 1984)
common causes of being homebound (1,2). A previous study from our center suggested that many individuals with musculoskeletal disorders affecting function could have benefited from simple rehabilitation
measures to improve or maintain function (3). Among
the homebound, 80% receive help from their immediate families and friends and 15% receive care from a
nurse, home health aide, or paid homemaker (4).
Physical and occupational therapy services in our
community are limited by rules of third-party reimbursement. Rehabilitation services focus on acute
conditions whereas chronic or slowly deteriorating
disorders receive less attention.
In 1980 we organized a study with two objectives:
1. To evaluate, in a randomized controlled trial,
the effects of stepped-up rehabilitation versus usual
rehabilitation for improving and maintaining function
of homebound patients with arthritis and musculoskeletal disorders;
2. To document the rehabilitation needs of
homebound arthritis patients as they might be met by
the current state of the art.
DESCRIPTION OF SAMPLE
Recruitment. Patients receiving home care from four
licensed home care programs serving Dorchester, Roxburyl
Brookline, Jamaica Plain, and East Boston were screened
for eligibility with the assistance of their nurses. Eligibility
criteria included the presence of arthritis and musculoskeletal dysfunction: a potential for improvement by rehabilitation techniques as judged by a physician and a physical
therapist; enrollment in the home care program for at least 3
months; and a lack of physical therapy. Distribution of
patients is shown in Table 1. Exclusions included the presence of terminal cancer, extensive stroke, blindness, severe
259
REHABILITATION SERVICES
Table 1. Distribution of subjects by entry criteria. age. and
geographic area
Patients
Community
Age
”umber
7% meeting
criteria
Dorchester
574
75-84
85 +
41
44
43
~128
17.1
34.1
_23.3
_
15.0
Brookline/Roxbury
5 74
75-84
85 +
26
33
-2L
81
7.7
15.2
_27.3
_
16.0
East Boston
514
75-84
85 +
25
28
_36
_
89
12.0
35.7
_36.1
_
29.2
Jamaica Plain
574
75-84
85 +
9
15
15
-~
39
33.3
60.0
66.7
56.4
Total
574
75-84
85 +
101
120
116
14.9
32.5
33.6
INTERVENTION AND STUDY DESIGN
mental illness, or the nurse’s judgment of family situation
that precluded participation in a study.
Of the 337 subjects screened for entry, 244 did not
meet the entry criteria (Table 2). Ninety-three subjects
(27.6%) met the entry criteria and were invited to participate
in the study; 57 (61.3%) agreed to do so. Acceptance rates
were higher among females and differed across health centers but not by age group.
Characteristics of the participants. Forty-six (81%) of
the 57 subjects were female. The average age was 81 years
with a standard deviation of 9.82 years. Forty-three percent
had immigrated to the United States more than 60 years ago;
in half of these people English has remained a second or
barely used language. Five percent had no formal education
and an additional 26% had not attended school beyond
eighth grade.
Sixty-one percent of the participants lived with others and 28% were never left alone in the house. Fifty-four
percent received substantial help from family or friends, for
which no payment was made. Without this help these
Table 2.
patients would have been institutionalized. Forty-two percent were not competent to manage their own financial
affairs. The patients had a variety of comorbid conditions
with cardiovascular problems being the second most common diagnosis (43.9%) after arthritis and orthopedic problems. Mild dementia or senility was present in 14% of the
patients.
Characteristics of the participants are summarized in
Table 3.
Eligible patients were randomized to an experimental
group of goal-oriented outreach rehabilitation treatment and
a “usual treatment” control group and were crossed over at
2 months (Figure 1). Twenty-nine patients started on treatment phase and 28 on control. Both groups continued to
receive nursing, social services, and home health aide services from their homecare programs throughout the course of
the study. Rehabilitation was organized by a multidisciplinary team consisting of a physician (MHL) and a
physical therapist specializing in arthritis and orthopedic
problems (VG). The 8-week rehabilitation program was
based on goals of both the patient and rehabilitation team
established before the intervention. Most goals were related
to mobility (walking, stairs, transfers) but personal care and
other miscellaneous goals were listed.
Interventions to achieve goals included: provision of
equipment and assistive devices, whether reimbursable or
not; modification of environment; or exercises to improve
function, such as walking hourly or dressing oneself. A
safety review of all homes was made and resulting recornmendations were incorporated into the goals. Needs that
could be met by social services were identified and referred
to the home care agency.
For senile patients the program was offered to the
family or caregivers to facilitate patient management and the
functional endpoints were assessed by them. The “best
information available” method rather than “naive reporting” was used (5). When gaps or inconsistencies occurred,
other knowledgeable informants (e.g., family or home health
aide) were questioned to obtain the best available information.
Patients were evaluated at the beginning (FO), 2
months (Fl), 4 months (F2), and 6 months (F3) after study
entry. Outcomes measured included functional status, days
of hospitalization, number of falls, services used, and contentment with life. Covariates such as assessments of comor-
Distribution of subjects failing to meet entry criteria
Ineligible (n = 81)
Exclusions (n = 163)
Primary cause
9%
Primarv cause
%
No improvement potential
Already receiving physical
and/or occupational therapy
Home care <3 months
53.1
40.7
Metastastic cancer
Severe stroke
Blindness/deafness
Other medical condition
Psychiatric
Family situation
6.8
12.9
2.5
44.8
14.7
18.4
6.2
LIANG ET AL
Table 3. Characteristics of participants
bidity, social functioning, and quality of life were rated at the
beginning of the study. For clarity, these measures will be
detailed along with the findings of the study in the following
sections.
Disease severity and comorbidity were rated by the
Cumulative Illness Rating Scale (ClRS) which provides a
rating of 13 organ systems on a 5-point scale: 0 = no
impairment to 4 = extreme impairment ( 6 ) .
Services used, whether paid or given by family or
friends, were rated according to hours’ duration and the
degree of supervision. Institutionalization was recorded in
days. All falls in the home were noted. Treatment time was
divided into direct patient contact and nondirect (telephoning, purchasing, or making equipment).
Dropouts. Seven patients withdrew and 1 patient died
before completing the study. Among 29 who began with
treatment assignment, 2 dropped out before the F1 evaluation, and 1 more withdrew during the F2 evaluation. Of 28
subjects who began with control assignment, 4 dropped out
%
distribution
Characteristics
(n = 57)
Male
19.3
80.7
17.5
45.6
36.8
61.4
38.6
Female
Age under 75
75-84
85 or older
Living with others
Living alone
Hours alone/day
0
1-4
5-12
13-24
28.1
22.8
19.3
29.8
Marital status
Currently married
Not currently married
22.8
77.2
Enrollment
I
CI in ical
evaluation
Treatment plan
6
Evaluation
2 months
2 months
Figure 1. Study design for goal-oriented rehabilitation program.
REHABILITATION SERVICES
26 1
Table 4. Time of therapy and direct costs to patient
Direct therapists'
time ('/?-hour units
per patient)
Range
Median
Mean
Dollar costs of
equipment and home
adaptions*
Mobility
Nonmobility
Mobility
1-20
6.0
6.9
0-13
2.0
2.3
0-905
16.0
53.4
Nonmobility
0- 107
3.0
9.5
* Most frequent interventions: 20 (sets) walker or cane tips. 16
chairibed raisers, 8 toilet rails, 7 raised toilet seats. 5 beds lowered. 4
tub seats, 3 commodes, 3 wheelchairs.
before F1, and 1 after F1, but before starting the treatment
phase. One more subject died before completing the evaluation at the end of the study (F3). lhus, 49 patients are
followed through the end of treatment and control phases,
and 48 followed to the end of the study.
Statistical methods. The crossover study design generated for each patient a comparison from pretreatment to
post-treatment and another comparison from precontrol to
postcontrol. Paired differences (treatment increment minus
control increment) are constructed to assess whether the
direction and magnitude of change were (statistically) the
same during treatment and control phases. Paired t-tests (7)
wcre used to evaluate the statistical significance of these
differences.
RESULTS
Program activities. A total of 380 visits wcre
made by the therapist to the 49 patients. The range of
1/2-hour time units spent with patients on mobility
interventions was 1-20 and on nonmobility interventions was 0-13 (Table 4).The range for nondirect time
(telephoning, purchasing equipment, etc.) was 0-5.
A total of 123 interventions were implemented
during the treatment phase, 88 of which resulted in
clinical improvement. In addition, 33 safety interventions were made which did not affect function itself.
Functional improvement from exercise and increased
activity was negligible (30%) compared with improvement from using an assistive device (77%) o r home
modification (100%).
A total of $I ,902 was spent on assistive devices
and home modifications with a range of 0 4 9 05 per
patient. In 46% of the patients, the expenditure incurred was less than $20, and in 90% it was less than
$100.
Outcome variables. Eighty-two percent of all
goals were mobility oriented. Sixty-four percent of the
patients' mobility goals and 66% of the team mobility
goals were achieved, compared with 56% of patient
goals and 44% team goals achieved in nonmobility
tasks. Overall, 65% of all mobility goals and 15 (47%)
of nonmobility goals were met (Table 5). Twenty-three
patients (or family members) reported continued goalrelated clinical improvement a t F3. This was confirmed by the independent assessor. Failure to reach
o r maintain treatment goals at 6 months could be
explained by other illnesses (i.e., stroke, fractured
femur) in 11 of 25 patients.
Amount of service used 'was recorded on a 4point scale varying from 0-3 hours per day for cleaning, cooking, o r shopping t o 16-24 hours total care and
supervision. Help from all sources was included
whether o r not the helper was paid. The amount of
services used by patients was constant over time.
Most patients required 3-8 hours per day. The change
in services from pre- t o post-treatment did not differ
from the change pre- to postcontrol ( P = 0.5).
Quality of life. Quality of life and satisfaction
wcre assessed by the Quality of Life Index; a 5dimensional 3-point index (8), and a shortened Contentment Index (5) (Figure 2).
Forty-nine subjects were rated on the Quality of
Life Index, for which the possible range of scores is
from 0 (not managing household o r personal care;
feeling very ill; seriously confused, anxious, or depressed) to 12 (self-reliant for household and personal
care; feeling well; appearing calm and positive in
outlook). Mean scores were slightly below mid-scale:
4.7 at FO, 5.2 at F1, 5.1 at F2, and 4.6 at F3. During
treatment, the Quality of Life Index scores improved
by an average of 0.2 units compared with 0.1 units
improvement during the control phase. Clinically and
statistically the treatment-control difference is not
significant ( P = 0.8).
Social and cognitive function was measured by
an informal standardized scale based on an observer's
rating using a 3-point scale to rate concentration,
ability to impart subjective and factual information,
memory, ability to select and take medication as
directed, and decision-making control of living arrangements. A rating of 0 (no impairment) to 12
(extreme impairment) was based on responses given to
other questions in the interview. Engagement in life
and apparent motivation toward the concept of the
Table 5. Functional goals achieved by program
Goals
Mobility
(n = 143)
Other
(n = 32)
Patient-stated
Team-stated
38
55
10
93 (65%)
15 (47%)
Total
5
262
LIANG ET AL
CONTENTMENT INDEX
8.00
11.00
6.X
10.00
5.00
9.00
3.50
8.00
200
7.00
ti
FO
F1
F2
F3
EVALUATION
QUALITY OF LIFE INDEX
6.00
I
‘i
5.25
4.50
3.75
3.00
I
FO
F1
F2
F3
EVALUATION
Figure
Quality of life and satisfaction. C = mean of patients on treatment first; A = mean c. 2atients on
control first: H= 95% confidence interval = mean -t- 1.96 x SD: FO. 1, 2, 3 = functional assessment
sequence.
study were recorded on a 5-point scale at the first
assessment. The Quality of Life Index and observer’s
rating were repeated at each evaluation to give an
objective measure of the patient’s overall situation.
During control phase the observer’s rating did
not change; during treatment it got worse by an
average of 0.2 units, but the difference is not significant (P = 0.35).
Contentment Index could not be obtained for 9
subjects at FO, 16 at Fl, 17 at F2, and 17 at F3 because
of communication problems. Mean contentment
scores generally fell in the middle of the scale and
increased by 0.3 units from start to end of treatment,
but declined by 0.2 units from start to end of control.
Scores improved 0.5 units during treatment, but this
improvement is not statistically significant
(P = 0.4).
Hospitalizations and falls. Hospitalization was
required for 6 of 49 subjects during their treatment
phase and for 5 of 49 during their control phase. Falls
REHABILITATION SERVICES
263
MOBILITY
4.06
PERSONAL CARE
4.00
3.00
T
3.00
'"
T
206
TT
2.00
1.00
1.00
0.00
0.00
FO
F1
F2
EVALUATION
F3
FO
F1
F2
EVALUATION
F3
SUMMARY
400
3.00
200
I
1.00
0.00
'i
T
L
I
F1
F2
F3
EVALUATION
Figure 3. Functional status index: help scores. 0 = mean of patients on treatment first; A = mean of
patients on control first: H= 95% confidence interval = mean r+_ 1.96 x SD; FO, 1, 2, 3 = functional
assessment sequence.
FO
were reported by I 1 of 49 patients during treatment
phase, compared with 8 of 49 during control phase.
Only one of the falls resulted in a fractured bone. Thus
the rates of hospitalization and of falls were similar on
treatment and control phases.
Functional status. The principal outcome of
function was measured by a shortened form of the
Functional Status Index (FSI) (9) (Figures 3 and 4).
For each dimension of function we analyzed 2 specific
activity components: mobility and personal care. We
also analyzed the summary score which averages
scores on mobility, personal care, and 3 other activities.
Changes in Functional Status Index scores
264
LIANG ET A L
MOBILITY
4.00
4.00
3.00
3.00
2.00
1.oo
hi
*.O0
1.00
0.00
/!I
/
0.00
FO
F1
F2
EVALUATION
4.00
F3
SUMMARY
3.00
T
2.00
1.oo
0.00
L
FO
F1
F2
F3
EVALUAT10 N
Figure 4. Functional Status Index: difficulty scores. 0 = mean of patients on treatment first; A = mean of
patients on control first;&-/
95% confidence interval = mean
1.96 x SD; FO, I , 2, 3 = functional
assessment sequence.
L
-
were, in general, quite small. None of the means for
any activity changed by as much as 0.5 units ( i s . , onehalf of an FSI level) from FO through F2.
Similarly, mean changes from pretreatment to
post-treatment, and from pre- to postcontrol were
small, less than 0.3 units in absolute value. T-tests of
the paired differences indicate that they are not statis-
_f
tically different from zero: from the 6 paired t-tests, the
smallest P value was observed for mobi1ity:dificulty
scores ( P = 0.18).
To assess the course of functional impairment
from the start to the end of the study, we computed
FSI differences (FeF3) for each of the 6 activity
component: dimension combinations. The help scores
REHABILITATION SERVICES
all got worse, by 0.4 units for mobility, 0.5 units for
personal care, and 0.4 units for summary scores. Each
difference was significant at the P = 0.0002 level.
Difficulty scores in contrast were slightly worse, but
did not significantly change ( P = 0.60) for personal
care, summary score, or mobility ( P = 0.20).
DISCUSSION
Katz (10) emphasized the importance of treating functional deficits in the aged person and hypothesized an ordered regression of functional ability (bathing, dressing, going to the toilet, transferring,
continence, and feeding).
In this study, stepped-up outreach and physical
and occupational therapy services did not reverse
functional decline in the group as a whole. This lack of
an effect may be real or may result from inadequate
sample size or insensitive measures of outcome. Prior
estimates of statistical power to detect change between groups were not possible since measurement
error and expected differences were unknown.
Research in elderly patients presents special
methodologic problems (1 1) and the measurement
error of instruments used may have exceeded the
differences that one might expect. Of 31 patients
judged by the therapist as being improved at the end of
treatment, only 39% had improved FSI help scores,
and 58% had improved FSI difficulty scores. In 13
patients judged to be clinically unchanged, 39% had
improved help scores and 54% had impraved difficulty
scores. In contrast, of the 5 patients judged to be
clinically worse at the end of treatment, all had worse
help and difficulty scores. Examples of patients who
benefited include the following.
Case 1. A 92-year-old Irish woman with severe
rheumatoid arthritis “rocked” to get up and
“flopped” to sit down, which made transfers both
painful and extremely difficult. By having the bed
raised with blocks, transfer became easier, and by
having the kitchen chair raised, she was able to sit
down to eat, something she had been unable to do for a
year. The total cost of the modifications together with
replacement tips for her walker to promote safety and
also a small stool to elevate her feet was $17.
Case 2. After the death of her husband, Mrs. S.,
a 72-year-old woman, developed active rheumatoid
arthritis and had become increasingly depressed and
dependent on her family, requiring help with all transfers. By having a raised toilet seat installed and a 4inch foam cushion cut for her chair, she was able to
265
transfer alone. A bedside commode for night use
allowed the family to have an uninterrupted night’s
sleep.
Case 3. An 87-year-old married woman with
osteoarthritis and hypertension had become increasingly less mobile. A move to a safer, modern second
floor apartment meant she could no longer go outside
and further reduced her incentive to remain active.
Compliance with a simple exercise program was poor,
but she became independent with the aid of a raised
seat, toilet bars, and raised chair blocks.
The results of this study need careful interpretation and perhaps cannot be generalized to patients in
other areas. The subjects in this study were considerably “sicker” than those studied in many reports on the
elderly in that all were homebound, all required regular nursing care or supervision, 14% were senile, and
29% required more than 8 hours help per day. Their
overall condition contributed to limited expectations
for improvement during the treatment phase and a
tendency toward further deterioration over time.
Most interventions were completed in less than
8 weeks and many could have been done by minimally
trained home health aides or even family members
using a therapist for consultation. The average costs of
the interventions were modest. Our study indicates
that 25% of the homebound population could benefit
from such services but that the number of homebound
patients who avail themselves of even a free program
of rehabilitation is small.
Home care would appear to be a rational,
humane, and economical alternative to institutionalization, but studies are scant, poorly designed, and
conflicting. A review of the literature shows a lack of
consensus on the cost effectiveness of add-on services
over an extended period (12-17). Weissert and his
associates evaluated demonstration projects authorized under Section 222 of the Medicare law, by an
experimental design, and found that homemaker services were significantly more costly, and although the
experimental group lived longer, it also had a higher
rate of hospitalization than the control group. It was
hypothesized that screening patients at risk of institutionalization for these services might have improved
cost savings (16).
Our program improved functional ability for
some and could slow down functional decline and the
need for institutionalization. Future studies should be
directed at identifying those subgroups that might
benefit from such an intervention. Our data suggest
that these patients usually have higher baseline func-
266
LIANG ET AL
tion as measured by the FSI, higher health status and
education, fewer active medical problems, and less
social and cognitive impairment a t the outset. Most of
the interventions could have been implemented by
current home care programs. A n inexpensive way of
disseminating these services would be t o teach community nurses and home health aides how to identify
and managc reversible deficits in their patients with
arthritis disability. T h e total cost of the program was
$16,000 excluding the c o s t s associated with its evaluation. If the above criteria had been applied to select
patients for the program, t h e marginal cost t o a
homecare program would have been $9,600.
T h e critical determinant for institutionalization,
however, is usually not functional capacity but the
lack of social supports (18). T h u s one would not
expect that institutionalization would b e averted even
with improved function. Whether providing goal-oriented rehabilitation service prevents gradual declining
function or the rate of its decline is moot. Add-on
services need to be judged by actual and marginal
costs incurred and whether potential exists f o r immediate or long-term changes in care requirements or
survival (14). A s t h e examples above suggest, simple
rehabilitation interventions can have a great impact on
health care costs in the individual patient, but this may
not be apparent overall when selection criteria are not
used.
ACKNOWLEDGMENTS
We are indebted to Nurse Coordinators Eileen Kirk,
Beth Tortilani (Uphams Corner Health Center); Robin Sherman, Cathy Bauer (Jamaica Plain Senior Team); Ann Lovett
(Beth Israel Hospital Home Care Program); and Kit Grealis
(East Boston Neighborhood Health Center) and to their
staff to Drs. Ron White, Vicki Cargill, and the Carney
Associates for referring their patients to the program; to
Elizabeth Wright for programming assistance, and to Kim
Franklin and Mary Scamman.
REFERENCES
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I980
15. Hughes SL, Cordray DS, Spiker VA: Evaluation of a
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Cost-effectiveness of homemaker services for the chronically ill. Inquiry 17:230-243, 1980
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GAO/IPE-83-1, Gaithersburg, Maryland, December 7,
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