[[email protected]]

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.

[[email protected]]

1. Telerehabilitation is defined by ReLAB-HS as, “the delivery of rehabilitation services using information and communication technologies and is proposed as an alternative to in person consultation to provide rehabilitation.” Furthermore, it “encompasses a range of rehabilitation services that include assessment, monitoring, therapy, prevention, supervision, education, consultation, and counseling.”
This proposed intervention supports the priorities to increase access to rehabilitation services for those with unmet needs in an equitable and resource-efficient way. It recognizes that in LMICs rehabilitation services are limited in scale and scope of practice leaving many without access to rehabilitation care. Additionally, as an evidenced-based practice driven organization, telerehab is promising because promising evidence is emerging to support it’s impact and cost-effectiveness. Importantly, telerehab can also be used for professional development of local staff to increase the strength of the local health system, and perhaps ultimately decrease the initial significant need for remote services.
Regarding it’s fit with community values, I would need to study the intended group as there is no “one-size fits all” approach to rehabilitation in general, but in particular regard to community values. For example, some communities may have gender preferences for clinicians. Other communities may have community concerns over the use of technology, particularly on religious holy days. Engaging all stakeholders can help develop a telerehab program that is suitable to the intended community, and ultimately avoid culturally insensitive words or actions.

2. For a stakeholder analysis I would use the pre-implementation strategies of qualitative, in-depth research, including key informant interviews and surveys to assess true stakeholder engagement and staff/organizational readiness, needs and capacity. I would use information from other implementation efforts to contextualize the current situation and help inform changes at this pre-implementation stage. I could use dissemination strategies such as developing intervention advertising to targeted participants. Project Last Mile, supported by the CocaCola Foundation, Gates Foundation, USAID and PEPFAR has had tremendous success in this area. They’ve been able to leverage Coca-Cola’s distribution expertise to help navigate supply chain management issues in African LMICs while also using their branding expertise. (www.projectlastmile.com) In this way, they support both the supply and the demand for healthcare services. I would closely examine the guideposts they have used, and shared, to help promote uptake of services – and to ensure that those services are unique and intentional to the community at hand.

Integration strategies which optimize intervention accessibility and success include reminder systems, staff coaching, regular review of staff roles, process and procedures. I have worked at NYP-Cornell Weill Medical Center in NYC and over the years I have seen meetings such as these transform from a top-down to a blend of bottom-up feedback. Now, they are referred to as “Town Hall Meetings” giving staff a chance to voice what is working and what isn’t. This allows training sessions to be more informative as they can be tailored to areas of need, rather than rudimentary review of areas already successfully adopted.
Capacity building strategies aim to improve the motivation and capability of organizations, offering technical assistance and opportunities for peer working and developing. Leadership offers individuals the opportunity to grow their professional and leadership skills. By fostering a a learning and networking environment, the organization, and our intervention of telerehab, has the best chance of success. Again, I refer to Project Last Mile – an organization I studied in a supply chain management class. Specifically, I am thinking of the “Girl Champ” brand that was developed in eSwatini to support adolescent girls and young women decrease their risk of HIV infection. (1). Networking allows transfer and development of thought and experience leading to broader and more encompassing outcomes for the organization than a linear, top down approach.

(1) Brault, M. A., Christie, S., Aquino, S., Rendin, A., Manchia, A., Curry, L. A., & Linnander, E. L. (2021). Project Last Mile and the development of the Girl Champ brand in eSwatini: engaging the private sector to promote uptake of health services among adolescent girls and young women. SAHARA-J: Journal of Social Aspects of HIV/AIDS, 18(1), 52–63. https://doi.org/10.1080/17290376.2021.1894224

[[email protected]]

In order to gather useful information about the current rehabilitation needs and the current status of the health system, I would examine both quantitative and qualitative data from various sources. These sources would range from the household and community level up through the national or regional level. I would explore global levels for reference as I assess the needs of the current local situation. Data sources include patient surveys at the micro – household level, patient charts, facility registers and logbooks, district and national summary reports. Patient surveys at the household level will give a more granular, personalized look at needs, as the scope of surveillance zooms out to facility, district and national levels the data can provide information on trends, or geographic needs. This may assist in understanding equitable distribution of resources to meet the needs of the entire population, and to identify resource gaps where vulnerable populations may have increased need for services. The WHO categorizes data resources into three groups: user level, facility or program level, andpopulation level. These different groups support outcome evaluation, service and quality assurance, and policy respectively. I would also want to explore more specific data bases such as military, education data bases, NGO reports that may not be engaged in local ministry of health, social security and socia registries.
There are different data bases that indicate rigor of current health system These each have their own unique advantages and disadvantages. The WHO Global Health Observatory provides population level indicators in the dementia and post stroke populations. Multiple Indicators Cluster Surveys (MICS) by UNICEF is an international household health survey canvassing 130 indicators. This is useful to compare data across different countries but does not identify rehab specific needs – perhaps as rehab grows in importance in the health industry, this survey can be adapted to assist rehabilitation in health systems. DHS – or Demographic and Health Surveys by USAID is also commonly used for population level data but not yet specific to rehab needs. That said, it can offer insight into resource allocation as it provides indicators into public health levels across regions. I think I would utilize the MICS because it seems to have robust data that is comparable across the world. It would need adaptations that shed light on rehab specific needs. I do not have much experience in developing surveys but feel this is a key priority as we learn about assessing and strengthening the role of rehabilitation in health systems.
To assess an intervention, I would use the CFIR – or consolidated Framework for Implementation Research. This focuses on 5 areas: intervention, outer setting, inner setting, the individual and process. Monitoring is a continuous process required the reliance on the following indicators: SMART objectives, goals, key informant interviews, cost, surveys. To ensure adequate monitoring an evaluation, I would have personnel dedicated to this aspect, structure a uniform way to capture and disseminate information so the entire multidisciplinary team is aware of overall progress, or lack thereof.

[[email protected]]

1. Leadership behavior can be taught vs leaders are born. What do you think? Provide your rationale and an example of a born and made leader.

I think that while some people have inherent traits that predispose them to leadership, ultimately leaders can be taught versus being born. The primary reason for my belief is that the idea that leaders are born implies far too much bias on behalf of the judge. I think that pursuing a leader that is born risks the oversight of so many who may not fit the mold of a “leader.” Just like there are different ways to lead, there are different ways to learn and thus a leader isn’t a “one-size fits all” category.Mahatma Gandhi is an example of a born leader.
Dr. Anthony Fauci is an example of made leader, influenced by circumstance.

2. Post your reflections on your strengths, areas that need attention, and development priorities as identified by the emotional intelligence questionnaire on the discussion board.

Overall, I scored highly on the Emotional Intelligence Questionnaire (SA 44, ME 38, MO 40, E 44, SS 44). However, my lowest score was in managing emotion, and then motivating oneself. This is no surprise to me, I wrestle with emotions regularly. On the one hand, it makes me a very empathetic clinician. I pride myself on treating every patient as if they were my family, but it can sometimes distract me from task and make me less efficient. I understand that in leadership roles, working with team members I will need to keep my emotions in check.

3. Research some vision statements of various organizations. Post at least two such statements on the discussion forum and explain how these may have evolved.

Mission and Visions are different. According to our coursework, “The mission identifies the “how” and “what” of the organization’s operations, whereas a vision describes the “why” behind what the organization is working toward.”

Life Is Good is a popular t-shirt and merchandise company. Their vision is “to spread the power of optimism.” The company’s website (www.lifeisgood.com) explains that optimism is a practice, a choice that supports emotional well-being and resilience. Their products have evolved from t shirts to hats, coffee mugs, household wares. Their vision has evolved to further their product placement, and it’s message in it’s overarching goal to spread optimism.

Ikea’s (www.ikea.com) vision is “to create a better everyday life for many people.” They achieve this vision through their mission which is to “offer a wide range of well-designed, functional home furnishing products at prices so low that as many people as possible will be able to afford them.”

4. Post your reflections on building strong leadership and increasing political support for rehabilitation of your country on the discussion board.

Professional organizations such as the APTA , the American Physical Therapy Association, are vital in developing leaders within physical therapy with the goal of advocating for rehabilitation support in the United States. While the US seemingly has resources, they are not accessible to all people. Medicare reimbursement decreases make therapy less affordable to patients. Clinicians are pressed to provide lower quality care given the time constraints of decreased reimbursement. Some clinicians are leaning towards fee-for-service where they do not take any insurance at all. It is imperative in the United States to advocate for rehabilitation equity to all populations.

[[email protected]]

PTForall is an NGO serving the Southern California region of the United States. It has connected individuals who have completed an application for services, with clinics willing to provide the services at no cost. This is a small scale organization meeting the niche population in a specific location with the potential to scale up to wider populations. The United States has services, but it also has people without access to them and more needs to be done to bridge that gap.

The US is not using the WHO Guide to Action.

As a health care provider, I advocate regularly for my patients to get access to health care, rehab and AT. One case that I distinctly remember was the result of the events of 9/11. On that day, I was working as a PT in lower Manhattan. One of my inpatient rehab patients in the week following sustained a leg amputation when she was a pedestrian hit by a car leaving the chaos, pinned against a bus stop for a period of time. The first responders in the area were all heading further downtown to the World Trade Center and it took her longer to receive pre-hospital care. Perhaps this influence the outcome of her leg being amputated. Regardless, she had very little financial means and insurance. She was not “eligible” for the prosthesis that the team recommended for her. During her weeks of rehab, I advocated that she benefit from the multitude of funds that were set up to assist 9/11 survivors. Ultimately, we prevailed and she had her prosthesis financed through one of these funds. The take home lesson was that health care providers need to be engaged with the patient and access all resources possible to help someone in shock from injury and perhaps less fluent in resources available.

[[email protected]]

In the United States:
129 million people live with at least one major chronic disease. (CDC)
42.5 million people have a disability (US Census.gov)
Incidence of road safety injuries is decreasing – it fell by 4.6% in 2021 (2.5 million people) to 2.38 million people in 2022. Concomitantly, the injury rate per 100 million vehicle miles traveled (VMT) fell from 80 in 2021 to 75 in 2022.

[[email protected]]

In my experience in the United States, I see a blend of the medical and social models of disability. I see the medical model mostly in acute onset of disability, particularly one with high rehabilitation potential. For example, a child who has an arterio-venous malformation in the brain, presenting as a stroke patient, is very much treated through a medical lens. Children have high levels of neural plasticity and often make robust improvement. The underlying “problem list” impacting the patient’s status would be specifically addressed, and rehab goals formed to meet each “deficit.” A good rehab program would recognize the child as an individual with unique home environment – do they live in a one story building? An elevator building? A 3 story walk up building? Do they have siblings? Parents at home who can help? Etc… But the underlying rehab plan is based on the medical model. I tend to see more social models in application of long term rehab needs, chronic or even degenerative conditions. Examples that come to mind are fully cognitively intact, employed adults with professional and family responsibilities who also have rehab needs such as adults with lasting side effects from polio, or spinal cord injuries, or long term diseases such as multiple sclerosis. These individuals may have maximized the rehab potential that can be derived through the medical model and must have social model applications to minimize barriers to society and allow them to exercise their best potential.
It’s a difficult question to ask what I think of when I see someone with a disability. I’d like to believe my impression and thoughts are purely altruistic, but I have taken classes addressing bias in health care and am aware that I need to check my biases and privileges as an able bodied person before engaging in any judgemental thoughts. That said, working in NYC, when I see someone with disabilities I usually scan the environment to be sure it is safe. There are a lot of uneven surfaces to manage, potholes in the street, curbs of varying heights. Sometimes the elevator in the subway can be broken. I try my best to be aware of the environment. I think I was raised in a combination of the medical and social models. I come from a very large extended family, and as such have loved ones with varying degrees of ability – disability. I was raised with the attitude of “there but for the Grace of God, go I”, suggesting it’s somewhat the luck of the draw who has what body and capability, to maintain humility, empathy and try to even the playing field for all.

[[email protected]]

I work in a busy, NYC hospital as a physical therapist. A huge part of our job is doing an initial evaluation of a patient in the hospital and assessing their rehabilitation needs upon discharge from the medical hospital. Patients can be discharged anywhere on the continuum of care from no rehab needs at all, up to inpatient acute care rehabilitation. Acute rehab is loosely defined as a multidisciplinary needs (PT,OT &/or SLP), ability to tolerate at least 3 hours of therapy a day, and achievable goals within a short time frame (~5-21 days). In between these two endpoints are home service, going home and attending community – or “outpatient” services, or “subacute” rehab which is inpatient rehab for those unable to tolerate a full three hours a day and/or have rehab goals/expectations spanning longer than 2-3 weeks.
In short, there are ample services available in NYC. The frustrating part is ACCESS to, and payment for services. For the small minority of patients who can afford the best services, they have it all at their fingertips. For most, they are restricted by what their insurance covers. There are patients who go home and require outpatient services but have a co-payment for each visit. Some patients have co-pays as high as $50 a visit. That cost, times multiple visits a week is prohibitive and discourages patients from fully utilizing services available.
I am interested in how to firstly ensure that these services are available in other countries, but also that they are accessible.

[[email protected]]

To be very honest, rehabilitation services coverage is very complicated in the United States. Where you live and what insurance you have influence coverage of care. Furthermore, coverage in the United States has many qualifiers – meaning, a patient can be a good candidate for inpatient rehab services, including physical, occupation and speech therapy, but only if they have rehab goals that can be met in a short time frame. Further complicating the matter – health care providers may charge more for services than insurance companies allow, leaving patients with bills.

[[email protected]]

The first thing that comes to mind with “rehabilitation” is restoring normal function. Assessing a person’s functional mobility and identifying underlying causes that contribute to anything less than full function. Identofying the problem list that contributes to any decreased function, and then goals and a plan to improve, restore and adapt to maximize rehabilitation potential

[Author]

Posts