Attending to Inclusion: People With Disabilities and Health-Care Reform

Rehabilitation Institute of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
PM&R (Impact Factor: 1.53). 10/2009; 1(10):957-63. DOI: 10.1016/j.pmrj.2009.09.001
Source: PubMed
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    ABSTRACT: This article reviews theories and conceptual models that may be helpful in evaluating quality of care in rehabilitation, with a focus on the seminal Donabedian model of structure, process, and outcomes. In addition, this article reviews a variety of new theories and conceptual models that have been developed to expand the Donabedian model in areas specific to rehabilitation (eg, the multidisciplinary team, assistive technology), and it covers new approaches developed to help with implementing changes to improve quality. Directions for future research and development are identified, including the need for consensus and consistent use of terminology and measures and the need for quality measures with greater breadth, depth, and granularity that capture the complex interactions between the structure and processes of care unique to rehabilitation of physical disability.
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    ABSTRACT: The current biomedical and psychosocial frameworks that form the conceptual basis of medicine today are insufficient to address the needs of the medically complex and environmentally challenged populations of patients often cared for by physical medicine and rehabilitation specialists. The expanded biopsycho-ecological model of health, illness, injury, and disability operating through mechanisms of Health Environmental Integration (HEI) encourages a more complete understanding of illness, injury, activity limitation, and participation restriction as arising at the interface between the person and the environment. HEI recognizes complex interacting multilevel functional hierarchies beginning at the cellular level and ending at the individual's experience of the environment. Although the foci of illness and injury are within the body and mind, the physical and social environments contain elements that can cause or exacerbate disease and barriers that interact in ways that lead to injuries and disabilities. Furthermore, these environments hold the elements from which treating agents, facilitators, and social supports must be fashioned. The highly integrative biopsycho-ecological framework provides an expanded basis for understanding the objective causes and subjective meanings of disabilities. Disabilities are reduced through HEI by seeking to maximally integrate the body and mind (the self) with both the surrounding physical environment and other people in society. HEI offers mechanisms for interdisciplinary research, an expanded framework for education and empowerment, and a blueprint for optimizing day-to-day clinical care at both the individual patient and treatment population levels in the ever-changing scientific, political, and policy environments.
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    ABSTRACT: This study aimed to describe the conceptual foundation and development of an activity limitation and participation restriction staging system for community-dwelling people 70 yrs or older according to the severity and types of self-care (activities of daily living [ADLs]) and domestic life (instrumental ADLs (IADLs)) limitations experienced. Data from the second Longitudinal Study of Aging (N = 9447) were used to develop IADL stages through the analyses of self- and proxy-reported difficulties in performing IADLs. An analysis of activity limitation profiles identified hierarchical thresholds of difficulty that defined each stage. IADL stages are combined with ADL stages to profile status for independent living. IADL stages define five ordered thresholds of increasing activity limitations and a ``not relevant'' stage for those who normally have someone else do those activities. Approximately 42% of the population experience IADL limitations. To achieve a stage, a person must meet or exceed stage-specific thresholds of retained functioning defined for each activity. Combined ADL and IADL stages define 29 patterns of activity limitations expressing the individual's potential for participating in life situations pertinent to self-care and independent community life. ADL and IADL stages can serve to distinguish between groups of people according to both severity and the types of limitations experienced during home or outpatient assessments, in population surveillance, and in research.
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