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University of Kentucky UKnowledge Theses and Dissertations--Rehabilitation Sciences Rehabilitation Sciences 2012 DEVELOPING A MODEL OF CLIENT SATISFACTION WITH A REHABILITATION CONTINUUM OF CARE Melba G. Custer University of Kentucky, melba.edu Recommended Citation Custer, Melba G., "DEVELOPING A MODEL OF CLIENT SATISFACTION WITH A REHABILITATION CONTINUUM OF CARE" (2012). Theses and Dissertations--Rehabilitation Sciences.edu/rehabsci_etds/7 This Doctoral Dissertation is brought to you for free and open access by the Rehabilitation Sciences at UKnowledge. It has been accepted for inclusion in Theses and Dissertations--Rehabilitation Sciences by an authorized administrator of UKnowledge.

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Custer, Student Dr. Huebner, Major Professor Dr. Anne Olson, Director of Graduate Studies DEVELOPING A MODEL OF CLIENT SATISFACTION WITH A REHABILITATION CONTINUUM OF CARE DISSERTATION A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the College of Health Sciences at the University of Kentucky By Melba G. Custer Lexington, Kentucky Director: Dr.

Huebner, Professor of Occupational Therapy Lexington, Kentucky Copyright © Melba G. Custer ABSTRACT OF THE DISSERTATION DEVELOPING A MODEL OF CLIENT SATISFACTION WITH A REHABILITATION CONTINUUM OF CARE Client satisfaction is an important outcome indicator because it measures multiple domains of the quality of healthcare and rehabilitation service delivery. It is especially important in occupational therapy because it is also client-centered. There are multiple domains of satisfaction and findings described in previous research; however, there is no single standard of measuring client satisfaction or any single working model describing the relationship among variables influencing satisfaction.

This research was designed to apply a measure of satisfaction in rehabilitation and to develop a working model of satisfaction. This study was an exploratory and predictive study using a large existing dataset to test a working logic model of client satisfaction, determine the best predictors of satisfaction, and then to revise the model for future research. After developing the Satisfaction with a Continuum of Care (SCC) in a pilot study, the SCC was completed by 1104 clients from a large Midwest rehabilitation hospital. The SCC results were paired with administrative data with client demographics, functional status, and measures of the` rehabilitation process.

Six research questions on the predictors of satisfaction with client- centeredness and clinical quality were answered using logistic regression. Significant predictors of satisfaction were having a neurological disorder, total rehabilitation hours, and admission to rehabilitation within 15 days of onset. The most robust and consistent predictors of satisfaction in this study were aspects of functional status as measured by the Functional Independence Measure especially improvement in overall and self-care functioning. The results in the study were consistent with some previous research and inconsistent with others.

The finding that improvements in functional status were highly predictive of satisfaction supports the worth that clients place on rehabilitation results including the self-care improvements focused on by occupational therapy. This study was a partnership involving occupational therapy and a rehabilitation hospital. The finding that changes in self-care function were predictive of satisfaction was intended to isolate the effects of OT. There is a need to demonstrate outcomes and link these to occupational therapy and other rehabilitation disciplines to continue to identify best practices and contribute to the rehabilitation literature.

KEYWORDS: Outcomes, Predictive Modeling, Occupational Therapy, Satisfaction Measures, Logistic Regression Melba G. Custer Student’s Signature June 19, 2012 Date DEVELOPING A MODEL OF CLIENT SATISFACTION WITH A REHABILITATION CONTINUUM OF CARE By Melba G. Huebner Director of Dissertation Dr. Anne Olson Director of Graduate Studies June 19, 2012 ACKNOWLEDGEMENTS Many individuals have contributed to the successful completion of this doctoral experience.

I am grateful for their efforts and commitment throughout its progress. I would like to thank my dissertation committee members, Dr. Judy Page, Dr. Terry Malone, Dr.

Kelly Bradley, and Dr. Their time, effort, support, and guidance during the development and progression of this process were invaluable to me. I would like to specifically convey my deepest feelings of gratitude to Dr. Huebner, whose patience, dedication, support, and mentorship has had a profound impact on my life, both professionally and personally.

I would also like to extend my gratitude to Dr. Susan Effgen and Dr. Carl Mattacola, whose support and leadership have always been an encouragement to me. I am grateful for their dedication and assistance.

In addition, this project would not have been possible without the support of many other individuals. Alberta Cramer has provided support and encouragement throughout this journey, a true understatement. My family in Tennessee (Margaret, Robert, Melissa, Margaret Lyle, Aunt Frances and Aunt Gene) have been solid and ever-present as cheerleaders. Shirley Peganoff O’Brien, Jessie Bollinger, Anne Harrison, and Kim Stacy have all played very supportive roles in this journey.

I have benefitted and appreciated the camaraderie of Hank White, Lori Bolgla and Lyn Tindall Covert “in the trenches.” My friends at EKU supported me greatly. Without the support of Lisa Tudor and Cardinal Hill Rehabilitation Hospital, this research would not have been possible. Lisa is a valued resource and friend. A special thanks to Gordon St.

Michel, the APA master. iii TABLE OF CONTENTS Acknowledgements. iii List of Tables. vii List of Figures.

viii Chapter One: Introduction. 1 Background and Need. 1 Statement of the Problem. 5 Statement of Purpose.

5 Research Questions and Design. 5 Contribution to the Field. 6 Chapter Two: Literature Review. 7 Conceptual Model for Client Satisfaction Outcomes Measurement.

7 Conceptual Model for Outcomes Measurement. 7 Literature Review on Client Satisfaction .12 Methodology for Literature Review .12 Evolution of Client Satisfaction and Outcomes Measurement .13 The foundations of outcomes measurement .13 Health care satisfaction and outcomes .15 Satisfaction scale development .17 Challenges in Measurement of Patient Satisfaction .22 Satisfaction Studies in Rehabilitation .27 Predictive Satisfaction Studies in Rehabilitation .31 Correlates of Patient Satisfaction .40 Improving Client Satisfaction .43 Methodology Literature Review .44 Instrument and Scale Development .44 Model Building and Data Analysis Concepts .51 Functional Independence Measure .55 Chapter Three: Methodology .59 Overall Research Design .59 Pilot Client Satisfaction Survey .60 Background and Design .69 Redesign of the SCC measure: Part 2 .69 Functional Independence Measure .70 iv Inpatient Rehabilitation Facility–Patient Assessment Instrument .73 Demographic and process variables.73 Research Question 1: How Do Client Demographic Variables Contribute to Models of Client Satisfaction in Rehabilitation? .74 Research Question 2: How Does Functional Status and Self-Care Functional Status at Admission and Discharge Contribute to Models of Client Satisfaction in Rehabilitation? .74 Research Question 3: How Does the Client’s Medical Status (e., How Sick They Are, Medical Complications) Contribute to Models of Client Satisfaction in Rehabilitation? .74 Research Question 4: How Does Variation in Rehabilitation Processes Contribute to Models of Client Satisfaction in Rehabilitation? .75 Research Question 5: How Do the Client’s Gains and Discharge Situation Relate to Models of Satisfaction in Rehabilitation? .75 Research Question 6: How Do Occupational Therapy Services Contribute to Models of Satisfaction in Rehabilitation? .75 Data Analysis Plan and Modeling Building.80 Chapter Four: Results .81 Psychometric Analysis of the SCC .87 Defining the Dependent Variable .87 Diagnostic Statistics for Logistic Regression .90 Answering the Research Questions .91 Research Question 1: How Do Client Demographic Variables Contribute to Models .92 Research Question 2: How Does Functional Status and Self- Care Functional Status at Admission and Discharge Contribute to Models of Client Satisfaction in Rehabilitation? .94 Research Question 3: How Does the Client’s Medical Status (e., How Sick They Are, Medical Complications) Contribute to Models of Client Satisfaction in Rehabilitation? .96 Research Question 4: How Does Variation in Rehabilitation Processes Contribute to Models of Client Satisfaction in Rehabilitation? .97 Research Question 5: How Do the Client’s Gains and Discharge Situation Relate to Models Of Satisfaction in Rehabilitation?. 100 v Research Question 6: How Do Occupational Therapy Services Contribute to Models of Satisfaction In Rehabilitation?. 101 Summary and Synthesis.

103 Chapter Five: Discussion. 106 Relationship of Findings to Previous Literature. 106 Implications for Practice. 113 Strengths and Limitations.

119 Appendices Appendix A: Cover Letter Quality Manager. 120 Appendix B: Satisfaction With Continuum Of Care. 121 Appendix C: Irf-Pai. 123 Appendix D: Uk Internal Review Board Office Of Research Integrity.

136 vi LIST OF TABLES Table 1.1, Predictive Studies of Client Satisfaction .2, Descriptive Statistics for Research Question 1 .3, Descriptive Statistics for Research Question 2 .4, Descriptive Statistics for Research Question 3 .5, Descriptive Statistics for Research Question 4 .6, Descriptive Statistics for Research Question 5 .7, Descriptive Statistics for Research Question 6 .1, Reliability Analysis for Each SCC Item or Statement .2, Factor Loadings for SCC Subscales .3, Client-Centeredness: Descriptive Statistics .4, Quality of Clinical Service Delivery: Descriptive Statistics .5, Client-Centered Subscale .6, Clinical Quality Subscale .7, Client Demographics: Predicting Satisfaction with Client Centeredness .8, FIM and FIM self-care: Predicting Satisfaction with Client Centeredness.9, FIM and FIM self-care: Predicting Satisfaction with Clinical Quality .10, Medical Status: Predicting Likelihood of Satisfaction with Client Centeredness .11, Rehabilitation Processes: Predicting Likelihood of Satisfaction with Client-Centeredness.12, Rehabilitation Processes: Predicting Likelihood of Satisfaction with Clinical Quality .13, Discharge Status and Gains: Predicting Satisfaction with Client Centeredness .14, Discharge Status and Gains: Predicting Satisfaction with Clinical Quality .15, OT Services: Predicting Satisfaction with Client Centeredness .16, OT Services: Predicting Satisfaction with Clinical Quality. 102 vii LIST OF FIGURES Figure 2.1, Dimensions of satisfaction based on previous research.1, Working model: Correlates of client satisfaction.1, Predictors of satisfaction with client-centeredness.2, Predictors of satisfaction with clinical quality.1, Revised overall model of predictors of satisfaction. 113 viii CHAPTER ONE: INTRODUCTION Background and Need Patient-centered or client-centered care has been an important focus in occupational therapy for a number of years and endorsed as a fundamental principle from the profession’s inception. Client-centered care as related to client satisfaction is now a term frequently used in health care service delivery as an emphasis or indicator of quality and used in accreditation.

In most medical or healthcare settings, patient satisfaction has become an important quality outcome indicator of services provided (Yellen, Davis, & Ricard, 2002). Satisfied clients are more likely to be compliant, have higher quality of life (QOL) and better outcomes and are more likely to return to the same provider or institution for future care (Keith, 1998). The increased emphasis on satisfaction in the literature may signal a new emphasis on the client as an active consumer rather than a passive recipient of healthcare (Speight, 2005). The American Nurses Association (1999) defined patient satisfaction as measuring patient/family opinion regarding care received from nursing staff (ANA, 1999).