Associations of SW/CM time and activities with outcomes
The 1-year post-injury interview was completed with 91% of the 1032 enrolled patients; 12.5% of these were conducted with a proxy rather than the patient. Interview questions were asked in a sequential manner. Some participants may not have had an answer for each question, some may have fatigued prior to the end of the interview, and, if the interview was conducted with a proxy, some questions were not asked (e.g. satisfaction with life and PHQ-9); therefore, we see variation in sample sizes for specific outcomes.
Most patients (89%) were discharged to home and 11% went to a location other than home (Table ). Patient characteristics explained some of the variation (c statistic = 0.77, Max R2 = 0.20). Older age, greater medical severity (CSI), and race other than White (Black, Hispanic, other minority) were associated with smaller likelihood of discharge to home and higher admission motor FIM score with greater likelihood. The addition of SW/CM treatments increased the c statistic to 0.91 and Max R2 to 0.50. More total hours spent in SW/CM community/in-house services (see Table for topics included) and financial planning and more SW/CM sessions involving planning for a home discharge and arranging for supplies and medications were associated with greater likelihood of discharge to home. More time spent providing information and making referrals for peer/advocacy groups and more SW/CM sessions involving planning for discharge to a nursing home or alternative living environment were negative. Adding rehabilitation center to the model increased the c statistic by only 0.01.
Regression models for residential location at discharge and one-year anniversary and work/school status at one-year anniversary
Residential location at 1-year injury anniversary
Patient characteristics were associated weakly with residential location at the 1-year injury anniversary (c statistic = 0.55); the only significant variable was speaking English. SW/CM treatment variables added a moderate increase; c statistic = 0.77. More SW/CM sessions dedicated to planning a nursing home discharge was associated with less home residence and more sessions focused on arranging for supplies and medications was associated with more. Adding rehabilitation center to the model increased the c statistic by only 0.01 (see Table ).
Patient characteristics were associated with patients being employed or in school at the time of the 1-year injury anniversary. Students (prior to injury) were about 4.5 times as likely to be working or in school and patients with a college education were almost three times as likely (<12 years/other/unknown was the reference group). Other significant patient variables include injury group, etiology of injury, age, and payer. The c statistic for patient variables alone was 0.81; it increased only slightly with the addition of SW/CM treatments (to 0.82); the only significant variable was more SW/CM sessions focused on discharge planning to a nursing home (negative) (see Table ). The addition of rehabilitation center increased the c statistic by only 0.01.
Table contains regression models with patient characteristics and SW/CM treatments as the independent variables for the four dimensions of the CHART: Physical Independence (R2 = 0.43), Social Integration (R2 = 0.16), Occupation (R2 = 0.26), and Mobility (R2 = 0.29). Various patient variables were significant in one or more of these four dimensions. Older age was associated with lower scores in all models. Higher admission motor FIM was associated with higher Physical Independence, Occupation, and Mobility scores. Neurological injury group was also significant: high tetraplegia ABC with lower scores on three dimensions, low tetraplegia with lower Physical Independence and Mobility scores and paraplegia with lower Occupation and Mobility scores as compared to AIS D injuries. Persons who were married at the time of injury have higher Social Integration, Occupation, and Mobility scores. Black race was associated with lower Mobility scores. Level of education achieved prior to injury was significant in each model: having a college education was associated with higher scores (<12 years combined with other was the reference group). Payer also was significant: Medicaid was associated with lower Social Integration and Mobility scores (private insurance was the reference group). Several SW/CM treatment activities also were significant. More total time spent in classes provided by social workers/case managers was associated with higher Physical Independence and Social Integration scores. More time spent providing supportive counseling and doing assessments was associated with lower Occupation scores. More SW/CM sessions dedicated to planning discharge to an alternative living environment was associated with higher scores in all dimensions except for Physical Independence, which has a negative association. More sessions dedicated to planning discharge to a nursing home were associated with lower Social Integration, Occupation, and Mobility scores. More sessions dedicated to arranging personal care services were associated with lower Social Integration scores. The addition of center variables added only 0.01 or 0.02 to the adjusted R2 for each model.
Regression models for societal participation (CHART)
Mood state and life satisfaction
Together, patient characteristics, SW/CM treatments, and rehabilitation center were associated weakly with depressive symptomology, as measured by the PHQ-9 (adjusted R2 = 0.08); more SW/CM sessions focused on addressing barriers to discharge were associated with more depressive symptomatology (Table ). SW/CM interventions had no significant associations with life satisfaction.
Regression models for mood state (PHQ-9) and satisfaction with life (SWLS)
SW/CM treatments, along with patient characteristics also were not strongly associated with rehospitalization after rehabilitation discharge (c statistic = 0.70, Max R2 = 0.16) (see Table ). Higher medical severity during rehabilitation and longer time from injury to rehabilitation admission were associated with greater likelihood of rehospitalization. Payer was also significant – payers of Medicare, Medicaid, and workers compensation were associated with higher likelihood (as compared to private insurance), along with more SW/CM sessions dedicated to addressing barriers to discharge. Higher admission motor FIM, longer rehabilitation LOS, male gender, student status prior to injury, and more time spent in classes led by social workers/case managers were associated with a smaller likelihood of rehospitalization. The addition of rehabilitation center as an independent variable improved the explanatory power by only 0.01.
Regression model for rehospitalization between rehabilitation discharge and one-year post injury and pressure sore(s) at 1-year post injury
Pressure sore at the anniversary
Persons with paraplegia were four times more likely to report a pressure sore at the time of the 1-year anniversary (OR = 4.2) than persons with AIS D injuries. Other patient characteristics associated with greater likelihood of reporting a pressure sore at the anniversary included greater medical severity during rehabilitation, longer duration from injury to rehabilitation admission, being unemployed or retired at the time of injury, and having Medicare as the payer type. Variables associated with a smaller likelihood of reporting pressure sores included: higher admission motor FIM scores, being retired at the time of injury, and longer rehabilitation LOS (see Table ). Adding rehabilitation center to the model increased the explanatory power by only 0.02.
Linear regression models that validated well (relative shrinkage <0.1) include CHART Physical Independence and Social Integration. The models for CHART Occupation validated moderately well (relative shrinkage 0.1–0.2). Three models validated poorly (relative shrinkage >0.2): CHART Mobility, PHQ-9, and SWLS. For dichotomous outcomes, the models for working or being in school at the anniversary, rehospitalization, and pressure ulcer at the time of the anniversary validated well (HL P value >0.1 for both), the model for residential location at the anniversary showed some lack of fit (HL P value was 0.05 to 0.1 for one or both models) and the model for discharge location showed lack of fit (HL P value <0.05 for one or both models).
A major goal of all SW/CM programs is to work with the patient and family toward a safe discharge back to the home environment. Efforts are put forth to optimize living environments, ensure adequate availability and training of caregivers, obtain equipment, and secure necessary financing for needed services. For some patients, especially those with stable family situations, developing and implementing the plan for a home discharge generally goes smoothly. For other patients, the plan may become more tenuous as the rehabilitation course progresses and the patient may end up not being discharged to home.
Of all activities included in the SW/CM taxonomy, the two that were delivered to almost all patients and in which most time was spent, were discharge planning and discharge services.6
Time spent in these activities was associated significantly with multiple outcomes. Because the topics contained within these two activities were numerous and diverse (Table ), we identified the mean duration and number of sessions in which each sub-topic was addressed. In the discharge planning activity, the most common services were planning for a home discharge and addressing barriers; less common services included planning for discharge to locations other than home. Topics included in the discharge services activity were more similar, but still identified different areas of need. Thus, we allowed the number of sessions in which each topic of the discharge planning and discharge services activities to serve as additional independent variables in regression models.
Discharge to home after SCI is highly complex with needs including accessible housing, home modifications, equipment, supplies, medications, and therapy services. Successful home discharge requires the social worker/case manager to educate the patient and family about accessible transportation, housing options, waiver programs to fund services such as homecare or home modifications, and local and government financial resources; the social worker/case manager also assists with completing appropriate applications. The association of SW/CM time spent on financial planning and community services with home discharge is indicative of how important such planning is to discharging patients to home as opposed to alternative settings. When the need for discharge to a location other than home, typically a nursing home, is determined, discharge efforts are expanded to include planning for this alternative type of discharge, and indeed, we see associations of more time spent on planning for discharge to a nursing home or alternative living environment to be associated with less likelihood of discharge to home. The association of the number of sessions dedicated to discharge planning and services with discharge to home and other outcomes is probably due to the fact that most of these services are addressed with all patients while time is spent on planning for a discharge to a location other than home only after home discharge has been explored and determined to be unsafe or otherwise not feasible.
More sessions focused on planning for discharge to a location other than home, along with other SW/CM interventions had many associations with societal participation. The association of more sessions spent on planning for personal care services and discharging to alternative environments with lower social integration scores may signal a need for greater intervention to improve societal participation, or we could infer that when patients do not live at home or require much personal care services in the home, their ability to spend time with family, business associates, or friends is diminished. Other negative associations were also seen, for example, more time spent addressing barriers to discharge was associated with greater likelihood of rehospitalization. It may be that these interventions provide benefits to the patients and families who need them. Typically, patients who need more assistance with addressing barriers and improving accessibility would be those patients with limited mobility, which could be associated with greater likelihood of rehospitalization. Thus, negative associations should be interpreted with caution, and not necessarily as ‘bad’ but rather may be an indicator of patient need.
It is astonishing to see positive associations between more time spent in classes led by SW/CM with several outcomes (higher CHART physical and social integration and less rehospitalization). Perhaps the learning that occurs in these classes can be used by the patient and family to manage low-risk medical situations for which care may otherwise be sought in a hospital setting. Further research is needed to determine benefits of SW/CM classes and other forms of education as well as the most effective ways to deliver such information.
In addition to examining the associations of SW/CM interventions with outcomes, it is also interesting to discuss the influence of primary payer. Medicaid as a payer was associated with lower CHART Social Integration and Mobility scores, a smaller likelihood of working or being in school at the 1-year anniversary, reporting lower life satisfaction, and greater likelihood of rehospitalization after discharge. Medicare was associated with more rehospitalization and reporting of pressure sore at the time of the anniversary. Thus, Medicaid and Medicare as a primary payer source appear to be a marker for worse outcomes. Persons who qualify for Medicaid benefits have limited income and assets, and thus, may have limited access to resources and may live in an environment less conducive to satisfying their needs. Persons with Medicare tend to be of an older age and/or have more complex medical conditions (co-morbidities). Payer type is indicative of socioeconomic status and age, which may influence educational and employment opportunities, as well as access to high-level technological devices (environmental controls, computer technology), personal transportation (accessible van), leisure pursuits involving costly high-tech equipment or additional costs, and travel. While a majority of third-party payers provide benefits for skilled services in the home (intermittent nursing visits and therapy services), both Medicaid and Medicare recently have begun imposing limits on the amount of services provided. There also may be access to care issues for patients covered by Medicaid or Medicare as some health care providers may not accept the lower Medicare or Medicaid reimbursement for services.
The SCIRehab sites are highly specialized centers for SCI rehabilitation, and thus, findings may not be generalizable to all rehabilitation facilities that provide care for patients with SCI. Data are only as complete as the data entered by each social worker/case manager; some intervention time may not have been included. Additionally, potentially meaningful service may have been lost by not capturing interventions that occurred during interventions lasting 5 minutes or less, as it is common for SW/CM to conduct interventions in small periods of time. This study assessed associations of treatment variables with outcomes and is not designed to answer questions of cause and effect, but provides information that can inform future clinicians and researchers in their future work.
Insurance information was available for the time of admission to rehabilitation but not at the time of the 1-year injury anniversary. Thus, while insurance payer is significantly associated with several outcomes 1 year post-injury, the insurance may have been different at that time.