| | The American Congress of Rehabilitation Medicine (ACRM) and Rehabilitation Research in a Changing Postacute Landscape. The 2007 ACRM Presidential AddressPresented in part to the American Congress of Rehabilitation Medicine, October 5, 2007, Washington, DC. Abstract DeJong G. The American Congress of Rehabilitation Medicine (ACRM) and rehabilitation research in a changing postacute landscape. The 2007 ACRM presidential address. Postacute rehabilitation is on the threshold of several major changes that have implications for rehabilitation practice and research. The most important of these is the desire of the Centers for Medicare & Medicaid Services to establish a uniform patient assessment method and implement a more setting-neutral prospective payment system across all major postacute settings. The proposed uniform patient assessment instrument will in all likelihood displace the FIM instrument as the industry standard. The rehabilitation research community needs to remain vigilant about the nature, scope, and measurement properties of the proposed uniform patient assessment instrument. A new instrument and setting-neutral payment system may provide new opportunities for service innovation and research. Neurorehabilitation has been one of the strengths of the American Congress of Rehabilitation Medicine (ACRM). ACRM needs to build on this strength and examine more earnestly the rehabilitation interventions and outcomes associated with the increasing prevalence of people with orthopedic and musculoskeletal conditions seen in rehabilitation centers today. ACRM’s ability to do so will depend in part on its ability to join forces with other professional and consumer organizations to increase research funding significantly for each of the major federal agencies that currently fund rehabilitation research. THE WORLD OF POSTACUTE rehabilitation is changing and promises to change even more dramatically in the years to come. In this address, I want to characterize these changes and then outline what they imply for rehabilitation research and what they mean for the American Congress of Rehabilitation Medicine (ACRM) as an organization. Several major changes are underway. To illustrate, I will mention only 3. First and most important is the passage of the Deficit Reduction Act of 20051 that launched a serious conversation about the future of American postacute care (PAC). Section 5008 of the Act provides for a 1-year ramp-up, starting in 2007, and a 3-year demonstration project, starting in January 2008, to develop and test a uniform patient assessment methodology that will lead to a site-neutral postacute prospective payment system (PPS). The new uniform postacute PPS would replace the 4 separate ones we have now—for (1) inpatient rehabilitation facilities (IRFs), (2) skilled nursing facilities (SNFs), (3) home health agencies, and (4) long-term care hospitals. The soon-to-be implemented demonstration project signals our government’s intent to reset the terms of how we assess patients for postacute placement and outcome and how we pay for this care—based more on the needs of the patient and less on the characteristics of the postacute setting in which the patient is placed. Second is the changing mix of patients coming to postacute rehabilitation across settings of care. Among hospital-based rehabilitation centers, for example, the signature impairment groups include people with stroke, spinal cord injury (SCI), and brain injury—all under the rubric of neurorehabilitation. Yet, up until recently, the fastest growing impairment groups were people with joint replacements and hip fracture—all under the rubric of orthopedic (ortho-) rehabilitation. This change reflects the aging of the population, the increasing numbers of people with joint disease, the rapidly increasing number of people acquiring a hip or knee replacement, and other trends. Third is the changing distribution of patients across settings of care. From all indications, the “75% rule” has shifted patients, particularly orthopedic, cardiac, and pulmonary patients, away from hospital-based rehabilitation settings to SNFs and other settings. Since 2004 when the Centers for Medicare & Medicaid Services (CMS) reinstituted the 75% rule, the number of rehabilitation units in acute care hospitals has begun to decline after decades of growth. These and other changes have had downstream consequences that affect choices that newly minted rehabilitation physicians make when choosing a practice setting or subspecialty. In recent years, proportionately fewer rehabilitation residents are choosing an institution-based practice setting doing neurorehabilitation and more are electing a community-based practice setting doing orthopedic rehabilitation, sports medicine, and pain management. A recent survey of graduating rehabilitation medicine residents conducted by the American Academy of Physical Medicine and Rehabilitation (AAPM&R) found that pain and musculoskeletal medicine were the most popular choices for fellowship training and future practice. There was much less interest in brain injury, stroke, and SCI among graduating residents.2 When asked to identify their top areas of practice, current AAPM&R members listed the following areas: electrodiagnostic medicine, pain medicine, orthopedic rehabilitation, stroke, spinal medicine (apart from SCI), and sports medicine (Tom Stautzenbach, American Academy of Physical Medicine and Rehabilitation, personal communication, August 30, 2007). The number of PM&R physicians practicing in neurorehabilitation has not necessarily declined, but newer entrants are selecting other areas of rehabilitation practice. Findings such as these affect the direction of our sister organization, AAPM&R, where increasing attention is being given to issues related to orthopedic and musculoskeletal rehabilitation and pain management in private practice settings. Some of the trends seen in the United States are not unique. They are seen in other nations that are coping with their own aging populations and postacute systems. They all struggle with the issues of how to assess and place patients and how to pay for their PAC. However unique some of their systems may be, they watch with an eye on how we are trying to sort out these issues. My advice to our international colleagues is not to take us too seriously. Our systems of care can be quite dysfunctional. Take only the best of what we have to offer and forget the rest. More importantly, we need to learn from you. ACRM and Hospital-Based Rehabilitation  For better or worse, ACRM has been linked closely with the academic and hospital-based segments of the rehabilitation industry. ACRM’s members come disproportionately from such settings. If you look closely at the institutional affiliations of ACRM board members and leaders, you will note that they come disproportionately from the top 20 rehabilitation facilities ranked in US News & World Report Best Hospitals in 2007.3 As a matter of fact, of the 10 highest ACRM member–contributing facilities, 7 are also in the Top 10 US News & World Report list. In short, the more members a facility contributes to ACRM membership, the more likely the facility is to be ranked in the top 10, 20, or 25 facilities. As every researcher knows, association is not causation—and most know well the weaknesses of the US News & World Report Best Hospitals list (and there are other facilities that should be on this list and are not)—but I do believe that participation in the scientific endeavors of a national organization such as ACRM does contribute to a facility’s reputational score in rehabilitation. The more highly ranked facilities also tend to be sponsors at our annual meetings. They are also more likely to have residency and other training programs. This is no coincidence. These institutions are deeply committed to advancing the field. They bring a deep sense of public service that extends well beyond excellence in patient care. Our nation owes these facilities and others like them a real debt for the spirit of public service and commitment to research and education. Without this commitment, our field cannot advance. Many of the listed institutions are brand-name legacy institutions and bring a distinct institutional culture to American PAC. Their existence depends in part on a postacute payment system that has recognized this legacy as an important segment of the American postacute landscape. As we move toward a more setting-neutral patient assessment and payment system, some of the boundaries that distinguish this group of facilities from other settings of care may begin to blur, although hospital licensure, accreditation standards, and other criteria will maintain some of the system’s distinct features. Implications for Rehabilitation Research Frankly, I see enormous opportunities in a more site-neutral patient assessment and payment system. Placing patients in narrowly defined PAC boxes never made sense to me when their needs and capacities shift over the course of their rehabilitation. If implemented, I believe a more site-neutral system can begin a new era of service experimentation and innovation that is more tailored to the natural history of the recovery process. I hope that such a system will unleash a quest for best practice based on sound research. Whether we get there will depend greatly on how the federal government and other payers structure the payment system to incentivize providers to advance the state of care. If we develop a payment system that is based on patient needs at admission and risk-adjusted outcomes at discharge and follow-up (pay for performance)—along with a full risk-adjusted outcome disclosure system, providers will scramble to figure out how best to achieve these outcomes to be the best in their class. A well-structured payment and outcome disclosure system is worth a thousand randomized trials, much like a picture is worth a thousand words. Today’s research questions, such as whether SNF- or IRF-level care is better, will become moot. Instead, we will seek to determine what combinations of resources over time lead to better outcomes. These kinds of questions are not easily answered by randomized trials in a changing practice environment but by research methods that can identify practice patterns that are most strongly associated with patient outcomes. The linchpin for a new postacute system is the uniform patient assessment instrument. It will drive all other downstream changes in PAC—payment systems, information systems, referral systems, quality monitoring, and outcome systems—to name just a few. Getting there is a huge lift. Each of today’s main postacute settings is deeply vested in its own patient assessment tool. Each tool represents years of development, arises from a distinct professional and institutional culture, and reflects additional years of investment in information systems technology, database development, training, and quality monitoring systems. Retooling all of this is no easy task. There is much to be said for building on the best of what each system of care provides now. My fear, however, is that in doing so, CMS will try to please all and satisfy none. The great risk is that we will develop an unwieldy one-size-fits-all tool that tries to cover all the bases. CMS needs to avoid the mistake it made in 2000 when it developed the Minimum Data Set (MDS) for PAC care based on a single legacy tool—namely, the MDS for skilled nursing. This instrument had limited relevance to other settings of care where nursing home “residents” were never a part of its traditional patient mix. The field wisely rejected this alternative. Once a new instrument is designed and implemented, we may have to live with the new tool for the next 2 decades or more. And once instituted, this is not a piece of postacute infrastructure that many will want to revisit anytime soon. We may be stuck with it—unless CMS makes a real commitment to update and refine the tool as we gain experience with it and as new information technologies enable us to achieve new economies of use. The developers of the instrument assure me that the instrument will be modular, robust, and amenable to change as new measurement technologies evolve. By simply building on current tools, I am concerned that we are not taking full advantage of computer-adaptive testing technologies that can assist us in developing instruments that are more comprehensive but also more efficient to administer and thus more generalizable to the wide range of patients seen across PAC settings including outpatient care. I wish that CMS had taken this route—although I am told that many postacute facilities remain paper-based and simply lack the information technology platforms needed to support such advances in measurement. By aiming our measurement tools to the lowest common denominator, however, I fear that we will carry forward vestiges of older systems that we will later live to regret. The new postacute patient assessment instrument promises to displace the FIM instrument that is incorporated in much of rehabilitation outcomes research. This, I believe is a good thing. The FIM is now badly outdated given the changing mix of patients seen in rehabilitation today. It is largely a retooled Barthel Index—an instrument that dates back to the 1960s, with 5 cognitive items added on. The FIM has served rehabilitation well for 2 decades, but several of its features have frustrated researchers for years. It is time to move on and to shake it loose of the proprietary claims that have stymied research and policy development. The proposed uniform patient assessment instrument offers us an opportunity to move on to a new generation of more robust functional assessment tools. Implications for ACRM Patient Assessment ACRM and its members have a large stake in the future of patient assessment. ACRM and AAPM&R were the sponsors of the joint task force that developed the FIM in the mid 1980s. In short, ACRM was one of the FIM’s initial investors and its members, who are frequent users of the FIM, are among its many stakeholders. Given the far-reaching implications of the proposed uniform patient assessment instrument, I have appointed an ad hoc committee whose task is to develop public commentary and advise the board of governors as to how ACRM—possibly in collaboration with other organizations—can best respond to these developments. Unfortunately, CMS and its contractors are moving with such speed that much of its work will be cast in stone before various stakeholders can make adequate comment on all of its moving parts. Given the instrument’s far-reaching and long-term implications, CMS would be wise to undertake a more deliberate approach. To its credit, though, CMS and its contractor have done an admirable job of reaching out to as many stakeholders as possible in the short time available. Need to Expand Portfolio of Interests ACRM is strongly focused on neurorehabilitation. It has a strong and vigorous brain injury special interest group and an emerging spinal injury network. Much of its annual program is oriented toward neurorehabilitation issues, and ACRM shares its annual meeting with the American Society for Neurorehabilitation. Much of ACRM’s leadership has had careers in neurorehabilitation practice and research. This has been one of the organization’s real strengths. I believe, however, as our American society and those of other countries age, ortho-rehabilitation will become a proportionately larger share of what we do because of the increased prevalence of osteoarthritis, hip fracture, bone and joint disease, and the increased prevalence of obesity that affect all body systems. Rehabilitation science related to these conditions is not as well developed as is the science of neurorehabilitation, in part because our research funding agencies have funded more neurorehabilitation relative to ortho-rehabilitation. The National Institute on Disability and Rehabilitation Research (NIDRR), for example, sponsors model system centers in brain and spinal injuries but does not fund corresponding centers in orthopedic rehabilitation nor can it within the scope of current funding levels. Likewise, the National Center for Medical Rehabilitation Research (NCMRR) is headed by a neurorehabilitation physician, and the Center has sponsored a strong portfolio of research in neurorehabilitation topics such as activity-induced neuroplasticity. These are all strengths; but they are not enough. ACRM needs to have a conversation about whether and how best to expand its portfolio of rehabilitation interests. Its relative neglect of orthopedic and musculoskeletal rehabilitation is not by design but by default. We need not engage in any self-flagellation on this matter. We simply need to ask ourselves whether we are keeping pace with the changes in society at large, in PAC, and with the practice mix of physicians, therapists, and nurses in rehabilitation today. This is also important in thinking about the future direction of our trademark journal, Archives of Physical Medicine and Rehabilitation. ACRM also needs to reach out beyond its base in the hospital-based portion of the rehabilitation industry. Many ACRM members already practice and do research in nonhospital settings. I believe that with the upcoming changes in PAC, ACRM and its members will have new opportunities to reach out across today’s postacute boundaries. Its members have much to offer—and much to learn from—other segments of PAC. Change is opportunity, and we need to embrace it. Need for Additional Research Funding Ultimately, our ability to strengthen and expand our neuro- and ortho-rehabilitation research portfolios will depend in part on our ability to secure additional research funding for the federal agencies that sponsor our research. In this regard, the results of the last few years have been disappointing. NCMRR funding growth has leveled off in the last few years after several years of increases in the wake of Congress’s willingness to nearly double the National Institutes of Health (NIH) annual budget over a 5-year period. That growth has now ceased, and last year the “pay line” declined to 10%. Sadly, NIDRR has experienced level funding for several years in a row, not to mention the erosion of its purchasing power through annual “recisions” made by the current administration and by the 3% to 4% annual rate of inflation. NIDRR’s peer review and grant administration processes have improved significantly in recent years, and NIDRR now has better staff than at any time in its history—although it remains significantly short-staffed. NIDRR is deeply buried in a federal department for whom NIDRR is not a priority. It lacks a well-organized constituency to advocate for its budget. Whether we like it or not, it falls to organizations like ACRM and like-minded groups to advocate for NIDRR. Although ACRM is stronger financially than at any time in the last decade, it does not have deep pockets to support a well-oiled advocacy and lobbying effort, except in conjunction with other stakeholders. People will continue to look to ACRM to take a lead role in mobilizing organizations that share its commitment to NIDRR. NIDRR’s funding has to remain a top priority for ACRM for the foreseeable future. There appears to be greater shared interest across associations with respect to NCMRR. The agency’s future development will depend on its ability to spring from its childhood home at the National Institute for Child Health and Human Development, where it has been since its inception in 1990. Now 17 years later, it has become a young adult ready for more independent status within NIH. About 2.5 years ago, ACRM joined forces with AAPM&R and the Association of Academic Physiatry to be the lead trio in advancing NCMRR’s NIH status. Last year, with the unexpected end-of-session passage of NIH’s reauthorization legislation, we were unsuccessful in elevating NCMRR to more independent status. The reauthorization legislation does, however, require the NIH director to address rehabilitation research as one of several cross-cutting topics in his/her biannual report to Congress. Since last year’s development, the Institute of Medicine (IOM), in its newly released report, the Future of Disability in America, has joined the call for “elevating NCMRR to the status of full institute or free standing center within NIH with its own budget.”4 The IOM report also underscores the important role that other agencies have had in disability and rehabilitation–related research, such as the U.S. Centers for Disease Control and Prevention and especially the U.S. Department of Veterans Affairs Rehabilitation Research and Development Service (VA RR&D), which now funds nearly $60 million in rehabilitation research. Like NIDRR and NCMRR, the VA RR&D funding has also leveled off. The VA’s program is largely intramural, and its lead investigators must be VA employees. Its future funding also needs to be a priority, but more importantly for ACRM, VA researchers need to become a more integral part of the ACRM family of rehabilitation researchers. Relative to its size, the VA is underrepresented in ACRM membership and program activities. I believe that the VA RR&D remains an undertapped intellectual resource for ACRM growth and development. Conclusions In looking to its future, ACRM is organizationally and financially more secure than in recent memory. It is the co-owner and soon will be the sole owner of the field’s signature rehabilitation research journal—an important intellectual asset for the field’s future development. Its single greatest challenge in coming years will be its ability to bring together the diaspora of rehabilitation researchers across settings of care, from within the VA, and from the many networks of rehabilitation researchers in other countries. We need a rehabilitation research community that can collaborate across institutional and agency-funding walls and across international boundaries. ACRM is singularly well positioned to foster such a research environment and has committed itself to do so in its vision and mission. I invite all of you to be a part of this vision for our organization. References Center for Post-acute Studies, National Rehabilitation Hospital, Washington (DC).  Correspondence to Gerben DeJong, PhD, Center for Post-acute Studies, National Rehabilitation Hospital, 102 Irving St NW, Washington, DC 20010. Reprints are not available from the author.
No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. PII: S0003-9993(07)01813-8 doi:10.1016/j.apmr.2007.11.020 © 2008 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved. | |
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