Advancing Rehabilitation Practice Through Improved Specification of Interventions

doi:10.1016/j.apmr.2018.09.110

Archives of Physical Medicine and Rehabilitation

Volume 100, Issue 1, January 2019, Pages 164-171

https://doi.org/10.1016/j.apmr.2018.09.110 Get rights and content

Abstract

Rehabilitation clinicians strive to provide cost-effective, patient-centered care that optimizes outcomes. A barrier to this ideal is the lack of a universal system for describing, or specifying, rehabilitation interventions. Current methods of description vary across disciplines and settings, creating barriers to collaboration, and tend to focus mostly on functional deficits and anticipated outcomes, obscuring connections between clinician behaviors and changes in functioning. The Rehabilitation Treatment Specification System (RTSS) is the result of more than a decade of effort by a multidisciplinary group of rehabilitation clinicians and researchers to develop a theory-based framework to specify rehabilitation interventions. The RTSS describes interventions for treatment components, which consist of a target (functional change brought about as a direct result of treatment), ingredients (actions taken by clinicians to change the target), and a hypothesized mechanism of action, as stated in a treatment theory. The RTSS makes explicit the connections between functional change and clinician behavior, and recognizes the role of patient effort in treatment implementation. In so doing, the RTSS supports clinicians’ efforts to work with their patients to set achievable goals, select appropriate treatments, adjust treatment plans as needed, encourage patient participation in the treatment process, communicate with team members, and translate research findings to clinical care. The RTSS may help both expert and novice clinicians articulate their clinical reasoning processes in ways that benefit treatment planning and clinical education, and may improve the design of clinical documentation systems, leading to more effective justification and reimbursement for services. Interested clinicians are invited to apply the RTSS in their local settings.

Section snippets

The current state of treatment specification

Current approaches to naming and describing treatments are problematic for several reasons. Existing systems are fragmented across disciplines and diagnostic groups, reinforcing divisions rather than highlighting the many similarities in treatment approaches across disciplines and diagnostic specialties. Examples of discipline-specific frameworks for naming and describing rehabilitation treatments include the Guide to Physical Therapist Practice,³ the Occupational Therapy Practice Framework,⁴

A new way forward

For the past decade, a multidisciplinary group of rehabilitation clinicians and researchers has worked to develop a theory-based framework to specify and classify rehabilitation interventions across all domains of rehabilitation practice. The effort began with an attempt to create a rehabilitation treatment taxonomy,^∗,13, 14 and has evolved into a manualized system for specifying interventions, the RTSS, which is described in detail elsewhere in this issue.² The RTSS is intended not only to

Benefits of the RTSS for clinical practice

Clinicians endeavor to develop plans of care that address the needs and priorities of their patients with the resources available. The goals of patients and families may range from achieving relatively simple functional tasks (eg, walking independently in the house) to complex tasks that involve multiple functions (eg, living in my own home without help). The RTSS, with its emphasis on specific targets of treatment and specific ingredients associated with each, and its distinction between

Benefits of the RTSS for clinical education

Clinician training is meant to teach trainees the specific skills and knowledge to accurately and effectively implement treatments. Although accreditation requirements dictate that programs provide certain core elements such as an evidence-based curriculum, basic science content (eg, anatomy, kinesiology, neurosciences, pathophysiology), and clinical courses (eg, evaluation and treatment of different conditions and different age groups), the extent and nature of training in accurate and

Benefits of the RTSS for documentation and reimbursement

Although a significant portion of clinicians’ time is devoted to documenting treatment in EMRs, the current design of EMRs does not serve clinicians’ purposes well. EMR menu structure varies widely across facilities and is designed primarily to capture information needed to justify reimbursement (eg, assessment findings, progress toward goals, units of time spent in treatment activities) and protect against liability (eg, by documenting actions taken to preserve safety in the hospital, or the

Benefits of the RTSS for knowledge translation

There has been a proliferation of rehabilitation treatment studies, meta-analyses, and evidence-based practice guidelines in recent years. These documents identify types of treatments that are or may be effective, and characteristics of patients who may benefit from those treatments, but often fail to provide sufficient detail to allow replication of the treatments; that is, they tell clinicians what to do, but not how to do it.¹³ Researchers may publish their treatment manuals, but these often

Further development and implementation of the RTSS

Implementation of the RTSS is expected to take several forms, ranging from efforts to educate rehabilitation professionals about its concepts in order to influence treatment planning and performance, to implementation projects that employ the RTSS as a means of prospectively specifying treatment protocols or retrospectively documenting treatment delivered. At present, the RTSS is embodied in the Manual for Rehabilitation Treatment Specification that is publicly available for download.²⁶

Conclusion

The RTSS provides a common framework and language for specifying rehabilitation interventions that can be used across all disciplines, diagnostic specialties, and interventions. The framework of the RTSS encourages clinicians to think through and articulate the rationale for their choices by requiring them to state explicitly, in the form of a treatment theory, how the ingredients they are delivering are expected to create change in the target of treatment.

We recognize that the reasoning

Acknowledgment

All statements in this report, including its findings and conclusions, are solely those of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors, or Methodology Committee. We thank the members of our Advisory Board, who provided valuable feedback on the concepts presented here.

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The RLVT paradigm is a theoretically driven approach for optimizing speech breathing patterns to increase efficient voice production in people with primary MTD. By applying a standardized, systematic treatment taxonomy system to specify the components of RLVT, future researchers and clinicians can implement RLVT with improved fidelity and consistency to optimize treatment outcomes.
Rehabilitation Treatment Specification System: Identifying Barriers, Facilitators, and Strategies for Implementation in Research, Education, and Clinical Care
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To explore rehabilitation professionals' experiences and perspectives of barriers and facilitators to implementing the Rehabilitation Treatment Specification System (RTSS) in research, education, and clinical care.
A cross-sectional survey with free text and binary responses was completed by rehabilitation professionals. Survey data were analyzed with a deductive approach of directed content analysis using 2 implementation science frameworks: Consolidated Framework for Implementation Research (CFIR) and the Expert Recommendations for Implementing Change (ERIC).
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The barriers and facilitating strategies differed according to the end-users’ intended use, that is, research, education, or clinical. Overall, the 4 most frequently encountered CFIR barriers were the RTSS's complexity, a lack of available RTSS resources, reduced access to knowledge and information about the RTSS, and limited knowledge and beliefs about the RTSS. The ERIC-CFIR matching tool identified 7 ERIC strategies to address these barriers, which include conducting educational meetings, developing and distributing educational materials, accessing new funding, capturing and sharing local knowledge, identifying and preparing champions, and promoting adaptability.
When attempting to use the RTSS, rehabilitation professionals commonly encountered barriers to understanding and skillfully using the framework. Theory-driven implementation strategies have been identified that have potential for addressing the RTSS's complexity and lack of educational and skill-building resources. Future work can develop the identified implementation strategies and evaluate their effects on RTSS implementation.
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Citation Excerpt :
Although studies have compared the costs and patient outcomes by type of PAC setting or by rehabilitation treatment intensity, these observational studies had several limitations.13-26 Furthermore, research to identify the costs and effectiveness of specific rehabilitation interventions with dosing recommendations has been limited.27 Given the limited amount of evidence in the literature showing the value of PAC or specific rehabilitation interventions for specific patients, it is not surprising to see that implementation of alternative payment models has led to decreases in Medicare spending through reductions in PAC utilization and spending.
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A significant proportion of Service Members and Veterans (SMVs) experience at least 1 mild traumatic brain injury during military activities (mil-mTBI), which can result in enduring cognitive symptoms. Although multiple cognitive rehabilitation (CR) interventions have been developed for this population, patient psychoeducation focusing on biopsychosocial relationships and health behaviors is often cited as the first line of defense for mil-mTBI sequelae. However, theoretical and conceptual foundations of these psychoeducational techniques are not well articulated. This raises questions about the potency of attempts to boost health literacy in affected SMVs, who represent a highly heterogeneous patient population within a special cultural milieu. To elucidate the significance of this problem and identify opportunities for improvement, we view the psychoeducation of SMVs through the lens of educational principles described in serious mental illness, where “psychoeducation” was first formally defined, as well as contextual and phenomenological aspects of mil-mTBI that may complicate treatment efforts. To advance psychoeducation research and practice in mil-mTBI, we discuss how treatment theory, which seeks to link active treatment ingredients with specific therapeutic targets, and an associated conceptual framework for medical rehabilitation—the Rehabilitation Treatment Specification System—can be leveraged to personalize educational content, integrate it into multicomponent CR interventions, and evaluate its effectiveness.
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In the United States, approximately 400,000 patients with acute stroke are discharged annually to inpatient rehabilitation facilities (IRFs) or skilled nursing facilities (SNFs). Typically, IRFs provide time-intensive therapy for an average of 2-3 weeks, whereas SNFs provide more moderately intensive therapy for 4-5 weeks. The factors that influence discharge to an IRF or SNF are multifactorial and poorly understood. The complexity of these factors in combination with subjective clinical indications contributes to large variations in the use of IRFs and SNFs. This has significant financial implications for health care expenditure, given that stroke rehabilitation at IRFs costs approximately double that at SNFs. To control health care spending without compromising outcomes, the Institute of Medicine has stated that policy reforms that promote more efficient use of IRFs and SNFs are critically needed. A major barrier to the formulation of such policies is the highly variable and low-quality evidence for the comparative effectiveness of IRF- vs SNF-based stroke rehabilitation. The current evidence is limited by the inability of observational data to control for residual confounding, which contributes to substantial uncertainty around any magnitude of benefit for IRF- vs SNF-based care. Furthermore, it is unclear which specific patients would receive the most benefit from each setting. A randomized controlled trial addresses these issues, because random treatment allocation facilitates an equitable distribution of measured and unmeasured confounders. We discuss several measurement, practical, and ethical issues of a trial and provide our rationale for design suggestions that overcome some of these issues.
Applying the Rehabilitation Treatment Specification System to Functional Communication Treatment Approaches for Aphasia
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: Supported by Patient-Centered Outcomes Research Institute (contract number ME-1403-14083).

: Disclosures: none.

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Special communicationAdvancing Rehabilitation Practice Through Improved Specification of Interventions

Abstract

Section snippets

The current state of treatment specification

A new way forward

Benefits of the RTSS for clinical practice

Benefits of the RTSS for clinical education

Benefits of the RTSS for documentation and reimbursement

Benefits of the RTSS for knowledge translation

Further development and implementation of the RTSS

Conclusion

Acknowledgment

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Cogn Sci

Neuron

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Coming to terms with the IMPACT Act of 2014

Am J Occup Ther

Guide to physical therapist practice 3.0

Occupational therapy practice framework: domain and process (3rd ed.)

Am J Occup Ther

Special communication
Advancing Rehabilitation Practice Through Improved Specification of Interventions