Factors Associated with Receiving Chaplaincy Care: - Findings from a Study of Patients with TBI George Fitchett, D.Min., Ph.D. Department of Religion, Health & Human Values george_fitchett@rush.edu James Risk, MDiv, BCC Executive Director (retired) Bishop Anderson House Hendrik Hutagaol, MA, BCC Chaplain Loma Linda University Medical Center

Framing our Research Sneak Preview Study Methods Study Findings Outline Framing our Research Sneak Preview Study Methods Study Findings Discussion Future Research form rehab research collaborative

No conflicts to declare Objectives At the conclusion of this activity: Participants will be able to critically reflect on the factors that shape which patients receive spiritual care and how much care they receive. Participants will be able to critically describe an instrument that was developed to collect data about the type and amount of chaplain care in 3 different institutions. Participants will be able to describe what is required to develop objective indicators for spiritual care in diverse clinical contexts, including acute rehabilitation. No conflicts to declare

Framing Our Research What information do you have, would you like to have, to answer these questions? 1. You are a spiritual care department manager. Your institution is about to acquire a 35 bed medical rehabilitation facility that has had no spiritual care. Your administrator asks you what level of chaplaincy staffing will be needed. What do you tell her?

Framing Our Research What information do you have, would you like to have, to answer these questions? 2. A new director of OT has come to your acute rehab unit and wants you to do an in-service on when OTs should make referrals to the chaplain. What do you tell them?

Framing Our Research What information do you have, would you like to have, to answer these questions? 3. You are the chaplain for your 25-bed acute medical rehab unit. You also cover 3 general med/surg units with a total of 90 beds. How do you decide which patients to see in each of these areas?

Sneak Preview – What We Found There was wide variation, across the 3 institutions in: percent of patients who received any chaplain care and, among those who received any chaplain care, the amount of chaplain care they received. Essentially none of the variables we tested (demographic, medical, psychological, religious) were consistent predictors of receiving any chaplain care or of the amount of chaplain care received.

in Acute Rehabilitation for TBI Using Practice-Based Evidence (PBE) Parent Study Improving Outcomes in Acute Rehabilitation for TBI Using Practice-Based Evidence (PBE) Susan Horn, PhD, PI, International Severity Information Systems, Salt Lake City (presently University of Utah School of Medicine) John D. Corrigan, PhD, Co-PI Ohio State University PBE is an alternative to RCTs for determining effectiveness of interventions.

Parent Study: Aims Aim 1: Identify patient characteristics (demographic, medical) that explain variation in the outcomes of acute rehabilitation for TBI. Aim 2: Identify specific procedures and interventions that are associated with better outcomes, controlling for patient characteristics. Aim 3: Determine whether specific impairment-by-treatment interactions are associated with better outcomes. TBI Mtg Overview and Design 11/5-6/07

Parent Study: Method Study Variables Patient characteristic variables Severity of the TBI and other medical conditions, demographics and psychosocial background Process variables All rehabilitation interventions (therapy, medical interventions, patient education, counseling, and activities involving all disciplines) Outcome variables Functional independence, length of stay, and discharge location Data Sources: Medical record Patient characteristics and medical procedures Point-of-care documentation

Multi-Center Study Rush University Medical Center Chicago, IL Loma Linda University Rehabilitation Institute Loma Linda, CA Toronto Rehabilitation Institute Toronto, ON, Canada Wexner Medical Center Columbus, OH Carolinas Rehabilitation, Carolinas HealthCare System Charlotte, NC Mount Sinai Medical Center New York, NY National Rehabilitation Hospital Washington, DC Shepherd Center Atlanta, GA Intermountain Medical Center Salt Lake City, UT Brooks Rehabilitation Hospital Jacksonville, FL N=2130 patients enrolled from October 2008 to September 2011 TBI Mtg Overview and Design 11/5-6/07

Chaplain Sub-Study: Aims Aim 1. To describe the spiritual care provided by the chaplains to the TBI patients in this study. Our goal in this aim was to describe the type and extent of the chaplains’ spiritual care for these patients and to explore a number of factors that might be associated with variations in the care that was provided. Aim 2. To examine the effect of chaplain care on patient outcomes. TBI Mtg Overview and Design 11/5-6/07

Chaplain POC Form

Chaplain POC Form

Study Participants Variable LLU (n = 112) RMC (n = 71) TRI (n = 149) Age - mean (range)* 39.8 (14-88) 67.6 (22-90) 48.1 (19-88) Gender: Female 30% 28% Race White* 48% 51% 71% Race Black 9% 41% 6% Race White Hispanic 38% 4% 0% Race Asian/Other/Unknown 5% 24% Marital Status Single (Never married)* 46% 11% 34% Marital Status Married/Common Law 36% 39% 44% Marital Status Previously married 13% 16% Marital Status Other/Unknown Education HS or less* 67% 59% Education More than HS 37% Education Unknown Employment Employed + Student* 7% Employment Employed only 49% 14% Employment Not Employed 23% Employment Retired 18% 63% 25% Employment Student only Employment Unknown 3% English is Primary Language 92% 86% 83% *significant differences between centers

Study Participants Variable LLU (n = 112) RMC (n = 71) TRI (n = 149) Injury Cause Fall* 18% 85% 42% Injury Cause Vehicle 66% 7% 46% Injury Cause Misc 4% 6% 2% Injury Cause Sports 5% 0% 1% Injury Cause Violence 8% 3% 9% Days injury to rehab admission* 27 (32.1) 11.6 (8.3) 64.8 (47.4) Admission brain injury CSI* 36.7 (16.2) 36.8 (16.1) 20.5 (12.4) Admission non-brain injury CSI* 18.5 (12.2) 19.0 (14.3) 4.2 (6.2) Admission adjusted FIM cognitive* 38.3 (16.7) 41.6 (17.1) 54.3 (11.3) Admission adjusted FIM motor* 33.9 (11.6) 35.6 (15.0) 62.8 (16.7) Admission anxiety 10% Admission depression* 11% 24% 12% Rehab length of stay* 22.3 (10.5) 15.9 (7.8) 46.1 (22.8) *significant differences between centers CSI=comprehensive severity index; FIM=function independence measure

Study Participants Variable LLU (n = 112) RMC (n = 71) TRI (n = 149) Faith Group: Catholic* 21% 28% 8% Faith Group: Protestant 39% 35% 7% Faith Group: Other 6% 4% 10% Faith Group: None/Atheist 9% 5% Faith Group: Missing 27% 24% 70% Deeply Religious or Spiritual*a 36% 34% 16% Fairly Religious or Spiritual 19% 40% Not at All Religious or Spiritual 25% How R/S missing or unable to determine 38% High R/S Distress*a 15% 0% 14% Moderate R/S Distress Slight or No R/S Distress 52% R/S Distress missing or unable to determine 37% 42% *significant differences between centers apercent for those with chaplain care

Who Receives Chaplain Care Total LLU RMC TRI Total patients in study 332 112 71 149 Patientsa with any chaplain care 58% 60% 90% 42% For patients who received any chaplain care (median + range) Number of chaplain visits per patient 4 (1-17) 4 (1-11) 3 (1-12) Total minutes of chaplain care per patient 100 (1-793) 125 (4-455) 63 (1-256) 83 (5-793) Minutes of chaplain care/week of rehab 28.7 (0.73 - 222) 42.0 (1.3-138.5) 31.7 (0.88-129.5) 13.5 (0.73-222) Minutes of OT/week of rehab 281.59 (105.25) 307.6 (95.3) 309.0 (91.9) 248.7 (109.6) Minutes of PT/week of rehab 301.39 (120.13) 364.6 (78.9) 357.3 (81.6) 226.9 (119.9) aIncludes cases with any care to patient, family or both What questions do you have when you see these data? Why do some patients get any spiritual care and others get none? Why do some patients get a lot of spiritual care and others get a little? There was no association between demographic factors, measures of severity of illness or measures of religion and chaplain care

Received Any Chaplain Care LLU (n=112) TRI (n=149) (yes=67, no=45) (yes=63, no=86) Variable OR (95% CI) p-value Age 1.02 (0.99,1.04) 0.16 1.0 (0.98,1.02) 0.95 Male (vs Female) 0.39 (0.15,1.03) 0.06 3.11 (1.35,7.16) 0.01 Days Injury to Rehab Admit 1.03 (1,1.06) 0.05 1.0 (0.99,1.01) 0.63 Adm Brain Injury CSI 1.05 (1,1.1) 0.03 1.0 (0.95,1.05) 0.91 Adm Non-Brain Injury CSI 1.03 (0.99,1.07) 0.11 0.99 (0.93,1.05) 0.66 Adm adjusted FIM Cognitive 1.04 (1,1.09) 1.02 (0.96,1.07) 0.55 Adm adjusted FIM Motor 1.03 (0.97,1.08) 0.36 0.99 (0.97,1.02) 0.72 Rehab Length of Stay 1.03 (0.98,1.1) 0.25 0.87 Rush omitted because there was little variation to explain; 90% of patients received some chaplain care. Models adjusted for all variables listed

Minutes of Care Received Total Sample (n = 180) Variable Estimate SE p-value Age -0.145 0.115 0.21 Gender: Male -7.512 5.354 0.16 Education More than HSa 2.862 5.126 0.58 Education unknowna -6.782 8.940 0.45 Days injury to rehab admit -0.089 0.060 0.14 Adm non-brain injury CSI -0.074 0.202 0.72 Adm adjusted FIM cognitive 0.19 0.198 0.34 Adm adjusted FIM motor -0.401 0.173 0.02 Fairly Religious or Spiritualb -3.465 6.378 0.59 Not at All Religious or Spiritualb -13.695 7.545 0.07 Unable to determine how R/Sb -17.709 11.175 0.12 High Level of R/S Distressc 7.886 8.210 Moderate Level of R/S Distressc -0.86 6.475 0.90 Unable to Determine Level of R/S Distressc -4.832 10.716 0.65 R2 = 0.1949, Adj R2 = 0.1266 aReference Group = Education Less than HS bReference group = Deeply Religious or Spiritual cReference Group = No R/S Distress

What about the variations in chaplain care? Discussion What about the variations in chaplain care? 2. What about no variables consistently predicting chaplain care? 3. Limitations Possible unmeasured predictors of chaplain care Other limitations

Advancing EB Screening & Assessment Research about spiritual needs can inform the development of EB models for screening and referrals for spiritual care This will increase the likelihood that patients who need spiritual care are offered the opportunity to receive it Form a rehab research collaborative?

Acknowledgments Parent study funding: NIH Chaplain sub-study funding: Bishop Anderson House Susan Horn, PhD (PI parent study), University of Utah School of Medicine Erin Emery-Tiburcio, PhD, Rush Medical Center Jim Huth, PhD, BCC, Sunnybrook Veterans Centre, Toronto

Bibliography Archives of Physical Medicine and Rehabilitation Vol 96, No 8, August 2015, Supplement 3 (special issue of reports on the parent study) Horn SD, Corrigan JD, Bogner J, Hammond FM, Seel RT, Smout RJ, Barrett RS, Dijkers MP, Whiteneck GG. Traumatic Brain Injury-Practice Based Evidence Study: Design and Patients, Centers, Treatments, and Outcomes. Arch Phys Med Rehabil. 2015 Aug;96(8 Suppl):S178-96.e15.