Reply To: Discussion Forum 1

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1. What evidence do I have (or need) to identify those factors and levels posing the greatest barriers to rehabilitation in my population?

Using the example of risk of falls in the elderly in NYC: I have statistical evidence from NYC.gov; the New York State Department of Health; CDC data. Additionally, there is hospital level data from emergency room, and injures that occur while inpatient at hospitals. Qualitative data such as surveys, key informant interviews would be helpful to identify at risk populations and their barriers to services for both treatment of falls, and more importantly to services targeting the prevention of falls. Perhaps NYC housing authority can provide information on age of tenants to help drive targeted interventions.

2. How does my own professional expertise and organizational access suggest where I might be most be effective in developing and launching an intervention?
As a physical therapist, I am more naturally drawn to the core levels of the social ecological model (SEM). I have years of targeted intervention therapy on an individual level. I also can impact the household level with home visits and home care through environmental modifications and family training. In the past, I have worked at inpatient rehab centers that incorporate community reintegration such as how to physically navigate public transportation. Patient education includes sharing information about community and transportation services, although that is often managed by the hospital social worker. I have less of an impact as we move to the outer rings of the SEM. As a therapist, I can impact the institutional level of our hospital system by giving feedback and being engaged with hospital wide meetings, although truthfully our voices are often drowned out in wider meetings. I am so interested in learning more about the policy interventions through the superstructural level of SEM through this GRLI experience.
3. What formative research might be needed to understand the precise intervention that would be most appropriate and impactful towards overcoming the challenges I identify?
-Quantitative, longitudinal research demonstrating effect of targeted fall prevention strategies in marginalized populations and outcomes.
-Qualitative research including surveys, key informant interviews and case studies can illustrate and inform the need to allocate resources in fall prevention interventions.
4. When considering potential interventions, what factors related to implementation do I need to consider?
In addition to the following factors, I would utilize the Heath Beliefs Model to maximize efficacy of my intervention. Modeling the Pressure Ulcer Education Program in spinal cord injured patients, I would target teaching to the susceptibility and severity of falls in the elderly; maximize self efficacy and address the benefits of fall prevention and the barriers to such a program.
– Acceptability – is intervention agreeable to the situation
– Adoption- looks on commitment of stakeholders to the intervention
– Cost- is the suggested intervention cost effective
– Feasibility – can it be successful if carried out in our setting or organization
– Fidelity can it be carried out according to the intended protocol
– Penetration to what extent can the chosen intervention be integrated across sittings.
– Sustainability, can it be sustainably maintained in the long term
The given intervention should be (timely, safe and patient centered)
5. What implicit biases may be at work in my culture or context and how do those implicit biases impact an individual’s ability to access and benefit from rehabilitation?
I work at a busy NYC hospital that sees a multicultural patient population. There are a lot of examples of implicit bias, from race to gender and myriad other examples in between. However, I am specifically thinking of age for my answer. I think that often older patients present in the hospital with altered mental status as a result of anesthesia effects of surgery or side effects of pain medicine. However, altered mental status may also indicate an underlying infection or other organic cause. In these cases, if the root cause is not addressed the patient may have, at best a limited ability to participate in rehab services, and at worst an increased risk for fall or worsening medical status. I think there is an implicit bias that diminished mental acuity is acceptable or more prevalent in elderly without proper assessment of patient prior level of functioning through chart history or patient family interview.