Debra Braunling-McMorrow, Ph.D.
Shannon Tompkins, M.B.A.
Tony Neumann B.S.
Below you will find information on the Functional Area Outcome Menu; developed at CCS for assessing the outcomes of the services provided in the NeuroRehabilitation, NeuroBehavioral Rehabilitation, and Adolescent Integration programs.
If you would like a copy of the menu; right click this link and "save as" on your hard drive.
While the importance of measuring outcomes in post-acute rehabilitation for persons with traumatic brain injury (TBI) is well recognized, the development of models for assessing outcomes significantly lags behind clinical practice. The purpose of this monograph is to review a comprehensive model for evaluating outcomes as discussed in a previous monograph, as well as to present the Functional Area Outcome Menu developed at the Center for Comprehensive Services, Inc.
In establishing a comprehensive model for evaluating the performance and functional gains in post-acute rehabilitation it is important to include components of the following:
- consumer satisfaction ratings for the individual, the family and the funding source
- measurements of goal attainment
- a system for classifying client characteristics which allows for comparison of similar clients
- a measure of overall levels of functioning or impact of rehabilitation on individuals lives which can be used to compare functioning prior to and following rehabilitation
- a means for analyzing the durability of outcomes at specified follow-up intervals
- and calculations of the cost of rehabilitation.
In addition, standardized outcome measurements should be incorporated where feasible to facilitate comparisons of outcomes across individuals and programs.
In our effort to establish a valid measure of levels of functioning we extensively reviewed applicable literature and attended numerous and recent conferences on establishing outcomes in rehabilitation. In addition, we contacted peers in other post-acute rehabilitation programs to corroborate our experiences. Unfortunately, we discovered that an industry-wide acceptable dependent measure for persons in post-acute rehabilitation does not exist. Those standard measures that do exist, in general, are targeted toward acute populations and lack sensitivity to the functional skills gained in a post-acute setting. Most post-acute rehabilitation programs have therefor created, or are in the process of creating measures of outcomes unique to their program. There does exist however, a relative consensus that measurement of outcomes for post-acute programs that focus on functional gains/skills training must include measurements of change in the following:
- residential status
- level of independence or assistance
- level of community inclusion
- and level of participation in educational, vocational, or productive activity pursuits.
Nevertheless, there remains considerable variability across programs regarding the method by which each of these areas are measured, the definitions of the dependent measures such as the definition of level of supervision or assistance individuals require, and differences in the interpretation of data. For example. Cope, Cole, Hall and Barkan3 measured level of assistance by the hours of attendant care per day in four-hour blocks (i.e. one to four hours, five to eight hours). Ashley, Persel, and Krych4 measured levels of function using the Disability Rating Scale criteria of "completely dependent," "mildly dependent," "moderately dependent," or "totally dependent." In a study by Evans and Jones5, living assistance status was measured as "independent" or "dependent." "Dependent" was then divided into levels of one to two hours per day of assistance in Activities of Daily Living (ADL's) or 24-hours per day of assistance/availability for ADL's. Comparisons of data across programs and across measurement tools is therefor a challenge.
In developing the Functional Area Outcome Menu, we analyzed the types of outcomes typically expected or promised by industry consensus as well as those we have found in our 16 year history which most significantly impact individuals' lives following participation in each of our specialty programs:
- the NeuroRehabilitation Program
- the Neurobehavioral Personal Intervention Program
- the Adolescent Integration Program
- the Day Treatment and Out Patient Programs
- and the Long-Term Supported Living Program
The areas of outcomes include:
- Residential Status
- Level of Independence/Assistance
- Behavioral/Emotional Status
- Level of Community Participation
- Level of Awareness
- and Level and type of involvement in Vocational, Educational, or Productive Activity pursuits.
These areas were identified to reflect the expected outcomes in post-acute rehabilitation by clients, family, and funding sources.
The Residential Status functional area assesses whether individuals reside in homes or apartments with or without residential assistance, reside in congregate group living arrangements, reside in residential rehabilitation programs, or reside in institutional environments. Residential status is one of the most common functional outcome areas assessed across post-acute rehabilitation programs. There exists an obvious desire by individuals, family, friends, and providers to attain individuals' most autonomous and least restrictive living arrangements.
The Level of Independence/Assistance functional area assesses the abilities of individuals to safely remain alone or independent of assistance for various lengths of time. This measure is designed to reflect caretakers' capacities to attend to external commitments. Measurement levels in this area are divided into four hour blocks of independence to parallel parents' or partners' abilities to work outside the home full- or part-time.
The Behavioral/Emotional Status functional area is a measure of individuals' abilities to self-regulate behavioral or emotional factors in contrast to dependence on externally managed systems. This assessment is critical in neurobehavioral programming for evaluating individuals' levels of autonomy or self-regulation, maintenance and generalization of self-management skills, ultimate environment of functioning, and degrees of support or assistance needed.
The Level of Community Participation functional area is adapted from Willer, Rosenthal, Dreutzer, Gordon and Rempel6 as a measure of community inclusion independent of whether or not individuals require assistance. This distinction is critical for assessing community involvement outcomes since individuals may be very involved in their community yet require assistance or support due to physical or cognitive difficulties.
The Level of Awareness functional area is often cited as a factor in rehabilitation success. This scale attempts to define awareness by actual observable behaviors that can be easily measured, such as initiation and utilization of compensatory strategies as well as verbalization of strengths and difficulties. By defining awareness as observable behaviors, it is apparent that maintenance and generalization of skills following rehabilitation may depend upon individuals' abilities to understand and predict their own levels of performance.
The Vocation/Higher Education/Productive Activity Status functional area assess adult individuals' abilities to participate in competitive placements, higher educational endeavors, homemaker responsibilities, supported placements, productive activities, and avocational activities. The ability to work or participate in vocational or related activities is also very commonly assessed across post-acute rehabilitation programs as it generally correlates positively with quality of life issues for persons with TBI, but the way we group these categories may differ from other measures. For example, individuals' abilities to be competitively employed, enroll in competitive degree-oriented academic programs, or assume independent homemaker tasks are considered equivalent in the Functional Area Outcomes Menu.
The Educational Status functional area was specifically designed to measure academic mobility in children and adolescents. Educational Status assesses incremental changes in children's and adolescents' levels of participation in educational pursuits throughout the rehabilitation process, including participation in specialized instruction as well as active reception of formal or informal tutorial assistance.
The Level of Involvement in Vocation/Education/Productive Activity functional area measures the actual amount of participation that all individuals, regardless of age (i.e., adult, child, adolescent), contribute to their vocational, educational, or productive activity endeavors. This measure was designed to complement the other vocational and educational or related measures by assessing more sensitive temporal advancements in endeavors, such as advancements from half-time to full-time employment, rather than less sensitive categorical advancements, such as advancements from supported to competitive employment.
Recently added to the menu are : Managed Health, Relationships, and Quality of Life
Information about these additional menu areas will be added in the near future.
Within each of these outcome areas, a five-point hierarchical scale of specific observable behaviors was developed to obtain valid, reliable levels of measurement. The Functional Area Outcomes Menu was piloted in each program to ensure sensitivity to change across programs, to determine reliability of consensus ratings by teams and to further refine the definitions and the assessment tool. The following is the revised Functional Area Outcomes Menu which is completed at the time of individuals' pre-admission screening, at the time of admission into a CCS rehabilitation program, at the time of discharge, and at designated follow-up intervals following discharge.
It is our goal in sharing our measurement system to encourage other programs to do the same and to thereby encourage adoption of a common language and set of parameters by which to measure outcomes across programs which will allow for standardization and a means by which to compare post-acute rehabilitation programs.
1. Braunling-McMorrow, D. (1994). Creating Useful Performance Measures in Post-Acute Rehabilitation. Center for Comprehensive Services Monograph, 1(2), Carbondale, IL.
2. DeJong, G. (1987). Medical rehabilitation outcome measurement in a changing health care market. In Fuhrer, M. (ed.), Rehabilitation Outcomes Analysis and Measurement, P.H. Brookes, Baltimore.
3. Cope, D. N., Cole, J., Hall, K., & Barkan, H. (1991). Brain Injury: Analysis of outcome in post-acute rehabilitation systems. Part 1: General Analysis. Brain Injury, 15(2), 111-125.
4. Ashley, M., Persel, C., & Krych, D. (1993). Change in reimbursement climate: Relationship among outcome, cost, and payor type in post-acute rehabilitation environment. Journal of Head Trauma Rehabilitation, 8(4), 30-47.
5. Evans, R. & Jones, M. (1991). Integrating outcomes, value and quality: An outcome validation system for post-acute rehabilitation programs. Journal of Insurance Medicine, 23(3), 192-196.
6. Willer, B., Rosenthal, M., Kruetzer, J., GOrson, W., & Rempel, R., (1993). Assessment of community integration following rehabilitation for traumatic brain injury. Journal of Head Trauma Rehabilitation, 8(2), 75-87.