Focusing on rehabilitation trajectories

I worked once in an inpatient post-acute rehabilitation service that had developed an excellent model of staggered discharge. As people receiving rehabilitation progressed through the program they were increasingly supported to move back into the community. This would start with short trips, followed as appropriate by whole days, gradually moving to overnight stays and then more than one day at a time, until eventually they were ready for full discharge. Their rehabilitation support would then be fully handed over to the community based team, who had begun to work with them as well during this process. At the time I joined this service, the funders had noted that bed occupancy rates were below their target. Pressure was being applied to the service to increase occupancy rates, which primarily required us to pull back from this best practice approach, to focus on providing rehabilitation that resulted in our patients being back in their hospital beds at the end of the day. (Yes, I did revert to patients deliberately.) As a result, we were back to actually delivering "what we were paid for". And that analysis wasn't wrong. We were paid to provide a certain number of "beds". But why? Leaving aside the obvious aspects of simplicity of billing and continuation of historical practices, why were we being paid to deliver "beds", or for those in other services not lucky enough to be paid for the empty ones as well, "bed days"?

These and related questions have captured much of my thinking in recent times, because there's no question that the way we fund services cannot help but drive, or at least constrain, the way we provide services. That could be fine, if our funding models could be tuned to directly reward best practice. I've had the opportunity to see a how the specifics of funding arrangements differ across funders and countries, though many have similarities. What is most typical, however, particularly for post-acute rehabilitation, is that they do not tend to enable, let alone reward, innovation and flexibility in the way services are delivered to clients.

In last month's editorial in Archives of Physical Medicine and Rehabilitation, Dr Gerben de Jong queries, Are we asking the right question about post-acute settings of care? He suggests that most of our current funding arrangements and research are focussed on the input and outcomes of contact with single rehabilitation providers at single points in a person's recovery journey, when we should instead be focussing on entire rehabilitation trajectories. I entirely agree. This is a topic that is of considerable interest me, to colleagues at Auckland University of Technology and elsewhere, and to our clinical partners. We continue to work through how we might evolve our models of service delivery and research to place the focus squarely on a person's full rehabilitation trajectory. The ideal would be to align funding models to ensure that the contingencies are in place to reward practice that supports a person's best long-term outcomes.

If you'd like to hear further about this topic, there's a podcast episode you might want to listen to. As Senior Media Editor of Archives, I interviewed Dr de Jong in the February podcast (11 minutes | podcast collection | podcast feed | mp3 file). And note that while the paper requires subscription access to the journal, the podcast episodes are always free.

DeJong, G. (2014). Are we asking the right question about postacute settings of care? Archives of Physical Medicine and Rehabilitation, 95(2), 218-221.

DeJong, G. (Interviewee), & Babbage, D. R. (Interviewer/Producer). (2014, February). Are we asking the right question about post-acute settings of care? Archives of Physical Medicine and Rehabilitation. [Audio podcast]. Retrieved from