Question #1: P: For adults who receive acute (inpatient) rehabilitation for new or worsening disability resulting from injury or medical event I: Does providing case management services as part of an interdisciplinary acute rehabilitation program C: versus not providing case management services

O: lead to better outcomes in terms of:

functional outcomes at acute rehabilitation care discharge

functional outcomes, return to home, independent living, and life quality in the months or years following acute rehabilitation care discharge

number of services and/or total hours of outpatient/community rehabilitation received after acute rehabilitation care discharge

rehospitalizations in the months or years following acute rehabilitation care discharge

survival/mortality in the months or years following acute rehabilitation care discharge

costs to patients/families, third party payers or federal government related to health care or social services

To what extent does case management during the acute rehabilitation stay produce differential outcomes based on:

rehabilitation diagnostic group (stroke, traumatic brain injury, other brain injury, spinal cord injury, and cancer)

severity of the physical, cognitive or behavioral impairments of patients in these groups

age

scope/duration/intensity of case management services

Question #2: P: For adults who are discharged from acute rehabilitation for new or worsening disability resulting from injury or medical event I: Does providing case management as part of transition, home and community based, or long-term support service programs C: versus not providing case management O: lead to better outcomes in terms of:

functional outcomes, return to home, independent living, employment, and life quality in the months or years following acute rehabilitation care discharge

number of services and/or total hours of outpatient/community rehabilitation received after acute rehabilitation care discharge

rehospitalizations in the months or years following acute rehabilitation care discharge

survival/mortality in the months or years following acute rehabilitation care discharge

costs to patients/families, third party payers or federal government related to health care or social services

To what extent does case management produce differential outcomes based on:

rehabilitation diagnostic group (stroke, traumatic brain injury, other brain injury, spinal cord injury, and cancer)

severity of the physical, cognitive or behavioral impairments of patients in these groups

age

time post-acute rehabilitation discharge that case management services begin

scope/duration/intensity of case management model used, e.g., service coordination model, rehabilitation model, assertive community treatment team

• Relevant patients, group(s) or subgroups of people Primary rehabilitation diagnostic groups of interest include stroke, traumatic brain injury, other brain injury, spinal cord injury, and cancer.
• Important health-related benefits/harms

Include:

functional outcomes, return to home, independent living, employment, and life quality

number of services and/or total hours of outpatient/community rehabilitation needed after discharge from the acute rehabilitation care program

rehospitalizations in the months or years following discharge from the acute rehabilitation care program

survival/mortality in the months or years following discharge from the acute rehabilitation care program

costs to patients/families, third party payers or federal governments related to health care or social services

Case management services have been a standard component in behavioral health systems for decades. The primary goal of case management is to facilitate the individual s long-term recovery and ability to function independently in the community. There is significant evidence of case management service effectiveness for persons with severe, chronic mental illness and substance use disorders. Persons with severe disabilities due to traumatic injury or disease often have multiple severe, chronic conditions that require on-going post-acute care. They have significant difficulty transitioning from medical to community settings and living independently in the community. In the U.S. (and other countries) there have been substantially different approaches to the provision of case management services for this group of medical rehabilitation recipients (i.e., stroke, traumatic brain injury, other brain injury, spinal cord injury, and cancer) in terms of its general use, timing, scope, and intensity. The identification of optimal use of case management service models for rehabilitation populations across the recovery continuum, ideally stratified by severity, will provide the U.S. healthcare system with valuable information for improving short- and long-term outcomes and decreasing long-term costs. This information is particularly valuable as payer systems transition to bundled payments and population-based capitation payment models.

Systematic review findings will provide educational information to key stakeholders including patients, their families, clinicians, administrators, payers, and policy makers on the effectiveness of case management services along the recovery continuum including acute rehabilitation and in the community. If the strength of the evidence exists, we will create formal practice recommendations for using specific case management models for specific diagnostic groups stratified by severity.

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

Chair, Evidence and Practice Committee

If you are you making a suggestion on behalf of an organization, please state the name of the organization

American Congress of Rehabilitation Medicine

Please tell us how you heard about the Effective Health Care Program