Vol.1, No.2, 52-61 (2013) Open Journal of Therapy and Rehabilitation
http://dx.doi.org/10.4236/ojtr.2013.12009
Inpatient rehabilitation outcomes in solid
organ transplantation: Results of a unique
partnership between the rehabilitation hospital and
the multi-organ transplant unit in an acute hospital
John T. Patcai1,2,3*, Marie P. Disotto-Monastero3, Manuel Gomez1,3,
Lesley E. Adcock1,2
1Faculty of Medicine, University of Toronto, Toronto, Canada; *Corresponding Author:
2University Health Network (UHN), Toronto General Hospital, Toronto, Canada
3Sunnybrook Health Sciences Centre, Toronto, Canada
Received 30 July 2013; revised 1 September 2013; accepted 10 September 2013
Copyright © 2013 John T. Patcai et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Objective: To determine the outcomes in solid
organ transplant recipients following inpatient
rehabilit ation, as a result of a unique p artnership
between the rehabilitation hospital and the m ult i-
organ transplant program in an acute hospital.
Design: Retrospective observational study. Set-
ting: Community rehabilitation hospital affiliated
with a university. Participants: A cohort of 173
organ transplant patients admitted consecuti vel y
over a four-year period (2004-2008) was com-
pared to a cohort of all rehabilitation patients (n
= 9762) admitted to the same inpatient rehab
facility during the same period. Interventions:
Inpatient rehab program to all participants. Main
Outcome Measures: Length of hospital stay,
Functional Independence Measure (FIM™) change
(admission-discharge), and rate o f discharges to
home. Results: Outcomes w ere measured using
components of the FIM™ instrument, admission
and discharge dat a. Chi-square and indepen dent
tw o -s a mp l e t-tests were used for statistical
analysis. Compared to a general rehabilitation
inpatient population, transplant rehabilitation
inpatients had: more immediate (<3 days)
transfers to an acu te hospital (5.2% vs. 1.9%, p <
0.001); a higher rate of readmission to an acute
hospit al af ter the first 3 day s (19.1% vs. 1.9%, p <
0.001); a longer mean length of stay (27 ± 19 vs.
20 ± 18 days, p < 0.001); a lower total FIM™ change
(8.9 vs. 20.9, p < 0.001); a lower FIM™ efficiency
(1.1 vs. 1.4, p < 0.001); and a higher rate of dis-
charges to home in patients not readmitted to
acute care (98.5% vs. 94.5% p < 0.001). Conclu-
sion: Outcomes of rehabilitation in solid organ
transplant patients are comparable but not iden-
tical to those in other patient groups. Inpatient
rehabilitation for transplant patients is therefore
fully justifiable and necessary. The ten times
higher rate of transplant patient readmission to
acute hospital must be communicated, facili-
tated, accepted and managed within a partner-
ship strategy.
Keywords: Rehabilitation; Outcome s Assessment;
Transplants; Pat ien t Re admission; Health Planning
Guidelines
1. INTRODUCTION
Different studies have shown some effects of trans-
plantation on quality of life (QoL). QoL improves post
liver transplant [1], primarily in areas affected by physi-
cal functioning with improvement in psychological func-
tion. QoL also may improve after renal transplant [2,3],
pancreas-kidney transplant [4,5], heart and heart-lung
transplant [6], heart, liver and lung transplant [7], and
post solid organ (liver, heart, kidney and lung) transplant
[8]. It is not known how much of the improvement in
QoL is attributable to any rehabilitation process.
The literature provides some indications that physical
function can be improved in transplantation with reha-
bilitation treatment. It is possible to find some data on
outpatient rehabilitation post-transplant. Physical per-
formance can be improved on an outpatient basis post

J. T. Patcai et al. / Open Journal of Therapy and Rehabilitation 1 (2013) 52-61 53
liver transplant [9], lung transplant [10], kidney trans-
plant [11,12], pancreas-kidney [13] transplant and car-
diac transplant [14-18].
On an inpatient basis, there are little data. There is, for
instance, a report of a single case of complicated inpa-
tient rehabilitation post liver transplant [19]. Providing
occupational therapy services post-transplant in an acute
hospital is effective in improving function [20]. The larg-
est study of inpatient rehabilitation published to date re-
ported on 55 patients [21], all of whom were liver trans-
plants. They noted significant functional gains, but
warned of complications. Another study [22] of twelve
patients, reported on inpatient rehabilitation stays post
cardiac rehab, with improvements in their degree of in-
dependence measured by the Barthel Activities of Daily
Living index. A study of inpatient rehabilitation [23] of
45 patients with end-stage renal disease (ESRD) con-
cluded that “ESRD patients on hemodialysis had similar
FIM™ scores to patients with renal transplantation”, and
“In particular, ESRD patients with stroke achieved lower
motor and cognitive FIM™ scores than other ESRD pa-
tients and made fewer gains in motor FIM™ scores than
stroke patients w i thout E SR D”.
Organ transplant patients develop a number of im-
pairments during the pre-transplant, and peri-transplant
phases. Most patients are much deconditioned [24], and
some may be nutritionally depleted [25], anaemic, in
respiratory or in cardiac failure. They are likely to suffer
some of the complications of bed rest [26,27]. Complica-
tions such as neuropathy and myopathy are associated
with ICU stays in general [28-31], and specifically in
liver transplants [32-34]. Uremic patients [35] may have
myopathies, and many patients may be taking some
medications such as colchicine or cyclosporine [36]. Cog-
nitive impairments may occur on the basis of the disease
(e.g. organ failure such as liver [37], heart or lung [38]),
treatment with some medications (even less toxic medi-
cations such as corticosteroids [39]), or as a complication
of cardio-pulmonary by-pass (at least during coronary
artery by-pass grafting [40]). Cognitive impairments
from liver disease may improve post-transplant [34].
Impairments such as those listed are in fact routinely
treated in the inpatient rehabilitation setting in other pa-
tient groups. This raises the question of whether inpatient
rehabilitation can improve physical function in the post-
transplant group.
A rehabilitation program was established by a Rehab
Hospital (RH) in partnership with a Multi-Organ Trans-
plant (MOT) program in an acute hospital. A formal,
written partnership was created between the RH and the
MOT. The RH was the provider of choice for MOT pa-
tients requiring inpatient rehabilitation. Up to six rehab
beds could be available for these patients. The RH had
clear admission criteria and processed admission re-
quests rapidly in order to clear the MOT beds expedi-
tiously. Original diagnosis and type of transplanted solid
organ were not considerations. The only real considera-
tion was whether the patient had goals that could be
achieved in an inpatient rehab program. The MOT pro-
vided medical support by offering education sessions to
medical and pharmacy staff, and day to day support via
telephone, pager, follow-up clinics and by telehealth.
Both partners worked to convince the ambulance ser-
vices to repatriate acutely ill patients from the RH di-
rectly to the MOT, when otherwise their policy was to
take patients to the nearest emergency department. The
MOT ensured that beds and/or resources would be
available for repatriation if needed.
The purpose of this study was to report the outcomes
of 173 post solid organ transplant patients who came to
the inpatient rehab program, and reviewed the features of
the unique partnership (RH-MOT) which allowed it to
succeed.
2. METHODS
This was a retrospective observational cohort study of
all solid organ transplant patients from the MOT (n =
173) consecutively admitted to the RH in the first four
fiscal years after the creation of the partnership (April 1,
2004 to March 31, 2008). The control cohort was the
entire patient population admitted to the RH during this
same time period (n = 9762). The RH had eight inpatient
rehab programs—amputee, burn, cardiac, musculoskele-
tal, neurological, oncological, transplant, and trauma.
Over half of the entire population of the RH consisted of
postoperative orthopaedic patients, mostly total joint
arthroplasties. No patients were excluded from the study.
Specific Rehabilitation Program for Organ
Transplant Patients
There were no specific components of the rehabilita-
tion program usually adjusted by patient diagnosis, or by
type of organ transplanted. Nor in fact was the disease
that caused the need for transplant considered unless the
disease caused specific changes in Body Functions,
Structure, Activities or Participation that required reha-
bilitation considerations. Each rehabilitation program
was specifically tailored to the individual patient with
their individual list of problems with Body Functions,
Structure, Activities and Participation as identified by the
patient and the rehabilitation team, in the context of
which abilities were most needed by the patient. As
noted in the introduction above, the most common prob-
lems were extreme fatigue, severe deconditioning, nutri-
tional depletion, metabolic toxicity, myopathy, neuropa-
thy, cognitive loss secondary to disease or its treatment,
and depression. In fact, this list is more a list of problems

J. T. Patcai et al. / Open Journal of Therapy and Rehabilitation 1 (2013) 52-61
54
of long standing, chronic, and severe illness than a list of
problems with specific organs or specific diseases. As
such, the rehabilitation program for the transplant pa-
tients had much in common with many of the other pro-
grams at the RH. The problems experienced by trans-
plant program patients compared to those in the cardiac,
severe trauma, severe medical illness, burn, and oncol-
ogy programs usually had many more similarities than
differences.
Medical complications included rejection of the trans-
planted organ, anemia, cardiac failure, respiratory failure
and infections. Medical complications were sometimes
treated in the RH, but more often in the MOT.
The electronic data collected was part of the routine
operation of the RH. Basic demographic information, ad-
mission and discharge information, including the Func-
tional Independence Measure (FIM™) are routinely col-
lected and entered into the RH electronic database.
The FIM™ instrument was developed in 1983 by a na-
tional task force in the United States to meet a long
standing need for an outcome measure that documents
the severity of patient disability and outcomes of medical
rehabilitation [41]. The FIM™ instrument is the most
widely used standardized functional outcome measure in
medical rehabilitation. The FIM™ instrument has been
recognized as an indicator of burden of care and has the
ability to predict the need for rehabilitation services
[42-46]. The FIM™ instrument consists of 18 items with
2 subscales: motor (13 items) and cognitive (5 items).
Each item is given a rating of 1 - 7, the lower the rating
the more dependent, the higher the rating the more inde-
pendent. The ratings are tallied up for a maximum total
rating of 126 and a minimum rating of 18 [47].
The FIM™ instrument has demonstrated reliability and
validity in a number of different patient populations
(multiple sclerosis, stroke [43,45,48-50], spinal cord in-
jury [42,51,52], traumatic brain injury [42,46], and in the
burn population) [53-55], as a general measure of func-
tional independence [56]. The FIM™ gain is the differ-
ence between the discharge and admission FIM™ scores
and higher values indicate greater functional independ-
ence during hospitalization. The FIM™ efficiency is the
FIM™ gain divided by the length of stay, and measures
rate of functional improvement [57].
All planned discharges have a discharge FIM™ rating
on file. Planned discharges occur when all established
goals are completed—either achieved or abandoned.
Discharge FIM™ rating is not measured if the rehab pro-
gram is interrupted (i.e. an unplanned discharge). For
reasons of mandated reporting, unplanned discharges are
separated into discharges soon after admission (<3 days)
and discharges after 3 days.
The RH Research Ethics Board approved the research
protocol. The data was retrospectively analyzed for the
two described cohorts. The outcomes of the organ trans-
plant group were compared by fiscal year (2004, 2005,
2006, 2007, 2008) to determine if there were differences
overtime. Chi-square and one sample t-tests were used
for statistical analysis, with a p < 0.05 considered sig-
nificant.
3. RESULTS
Table 1 shows the demographics of the 173 organ
transplant patients who underwent inpatient rehabilita-
tion. The majority were men (56.6%), post liver (43.4%),
followed by lung (24.9%), and organ transplants with
more than 1 year post transplant (16.8%). Compared to
the general rehabilitation population, transplant patients
were more likely to be male (56.6% vs. 36.0%, p < 0.001)
and younger (54.9 vs. 69.5 years, p < 0.001). Unplanned
discharges soon after admission (transfers to acute care
MOT within three days of rehab admission) were more
likely to occur in transplants than the general rehabilita-
tion population (5.2 % vs. 1.9%, p < 0.002). Readmission
to an acute care facility after the first 3 days was greater
for the transplant population (19.1% vs. 1.9%, p < 0.001).
Transplant patients had longer mean length of stay (27 ±
19 vs. 20 ± 18 days, p < 0.001) and slightly lower FIM™
efficiency scores (1.1 vs. 1.4, p < 0.001) than did the
general rehabilitation population. Mean motor (13.1 vs.
20.4), cognitive (−4.9 vs. 0.5) and total FIM™ (8.9 vs.
20.9) rating changes were significantly lower in the
transplant population than the general rehabilitation
population (Table 2).
Of the transplant patients who were not readmitted to
Table 1. Demographics of transplant patients.
Patients 173
Age (Years) 54.9 ± 12.0 (range 18 - 83)
Gender
Males (%) 98 (56.6)
Females (%) 75 (43.4)
Organ Transplant Groups
Liver (%) 75 (43.4)
Lung (%) 43 (24.9)
Heart (%) 10 (5.8)
Heart-Lung (%) 3 (1.7)
Kidney (%) 3 (1.7)
Combined (%) 10 (5.8)
Old transplants (%) 29 (16.8)
Combined = several organs transplanted in the same operation; Old trans-
plants = with more than 1 year post-transplant.

J. T. Patcai et al. / Open Journal of Therapy and Rehabilitation 1 (2013) 52-61 55
an acute care hospital, 98.5% were able to successfully
meet their rehabilitation goals and were discharged home
directly from the RH, compared to 94.5% (p < 0.001) of
the general rehab patients (Table 2).
3.1. Outcomes by Organ Transplant Group
Patients post-kidney transplant were significantly
older (64 years), patients post-combined transplants (who
had several organs transplanted in the same operation)
had more immediate (<3 days) transfers to an acute hos-
pital (10%), and a higher rate of readmission to an acute
hospital after the first 3 days (20%), and patients who
received a heart-lung transplant had greater FIM™ effi-
ciency (1.2) than the other organ transplant groups (Ta-
ble 3).
3.2. Outcomes of Organ Transplant Group
by Year
The greater improvements in outcomes were seen in
last two years of the study. In 2007, there were more
transplant patients admitted to the RH (61%, 35.3%). and
there was a significantly reduced waiting time for RH
admission (1.6 days). In 2008, there were no immediate
(<3 days) transfers to an acute hospital, no readmission
to an acute hospital after the first 3 days, and all patients
met the rehab goals and were discharged to their homes
(Table 4).
Table 2. Demographics and outcomes by patient groups.
Transplant All Rehabp Value*
Patients (%) 173 (1.7) 9762 (98.3)<0.001
Age (Years) 54.9 ± 12.0 69.5 ± 13.1<0.001
Gender
Males (%) 98 (56.6) 3514 (36.0)<0.001
Females (%) 75 (43.4) 6248 (64.0)<0.001
Unplanned Discharges (%) 9 (5.2) 189 (1.9)<0.002
Acute Care Readmissions (%)33 (19.1) 185 (1.9)<0.001
LOS (Days ± SD) 27.1 ± 19.2 20.3 ± 18.2<0.001
Motor FIM™ Gain (±SD) 13.1 ± 31.5 20.4 ± 9.3<0.001
Cognitive FIM™ Gain (±SD) −4.9 ± 12.9 0.5 ± 9.8<0.001
Total FIM™ Gain (±SD) 8.9 ± 43.4 20.9 ± 9.8<0.001
FIM™ Efficiency (Points/Day ± SD)1.1 ± 0.6 1.4 ± 0.9<0.001
Met Rehab Goals (%) 129 (74.6) 9225 (94.5)<0.001
Discharged Home (%) 129 (74.6) 9225 (94.5)<0.001
Discharged Home 2 (%) 129 (98.5) 9225 (94.5)<0.001
*Chi-square test or Student’s t-test between Transplant and All Rehab values;
Unplanned Discharges = inpatient stay that lasts 3 days or less, including the
admission day; LOS = length of stay; FIM = functional independence
measure; FIM gain = difference between discharge FIM and admission FIM
scores; FIM efficiency = FIM gain divided by the length of stay; Discharged
Home 2 = in patients not readmitted to acute care (n = 131).
Table 3. Demographics and outcomes by organ transplant group.
Liver Lung Heart He art-LungKidney Combined Old Transplants p Value*
Patients (%) 75 (43.3) 43 (24.9) 10 (5.8) 3 (1.7) 3 (1.7) 10 (5.8) 29 (16.8) 0.001b
Age (Years) 54.6 ± 10.3 53.6 ± 11.949.8 ± 9.844.0 ± 19.264.0 ± 6.650.8 ± 12.0 60.6 ± 14.6 0.024a
Gender
Males (%) 41 (54.7) 23 (53.5) 7 (70.0) 1 (33.3) 2 (66.7) 4 (40.0) 20 (69.0) 0.579
Females (%) 34 (45.3) 20 (46.5) 3 (30.0) 2 (66.7) 1 (33.3) 6 (60.0) 9 (31.0) 0.579
Unplanned Discharges (%) 6 (8.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (10.0) 2 (6.9) 0.006b
Acute Care Readmission (%) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (20.0) 1 (3.4) 0.006b
LOS (Days ± SD) 25.7 ± 18.2 32.3 ± 21.123.4 ± 21.818.7 ± 8.526.7 ± 10.617.6 ± 10.1 28.8 ± 20.0 0.308
Motor FIM™ Gain (±SD) 9.8 ± 34.6 23.4 ± 23.5−4.4 ± 44.523.3 ± 17.619.7 ± 6.71.3 ± 38.4 13.6 ± 25.1 0.114
Cognitive FIM™ Gain (±SD) −5.6 ± 14.6 −2.4 ± 9.7−11.8 ± 15.80.7 ± 1.2 0.3 ± 0.6−9.9 ± 16.6 −4.1 ± 11.0 0.306
Total FIM™ Gain (±SD) 4.2 ± 47.8 21.0 ± 32.2−16.0 ± 60.024.0 ± 18.720.0 ± 7.0−8.6 ± 54.7 9.5 ± 35.4 0.145
FIM™ Efficiency (Points/Day ± SD)−0.8 ± 4.4 0.8 ± 1.7 −3.9 ± 7.31.2 ± 0.5 0.9 ± 0.5−2.3 ± 7.0 −0.1 ± 2.4 0.018a
Met Rehab Goals (%) 50 (66.7) 38 (88.4) 6 (60.0) 3 (100.0) 3 (100.0)6 (60.0) 23 (79.3) 0.076
Discharge Home (%) 50 (66.7) 38 (88.4) 6 (60.0) 3 (100.0) 3 (100.0)6 (60.0) 23 (79.3) 0.076
Combined = several organs transplanted in the same operation; Old Transplants = with more than 1 year post transplant; *Chi-square test or Student’s t-test be-
tween Transplant and All Rehab values; ap < 0.05, bp < 0.01; Unplanned Discharges = inpatient stay that lasts 3 days or less, including the admission day; LOS =
length of stay; FIM = functional independence measure; FIM gain = difference between discharge FIM and admission FIM scores; FIM efficiency = FIM gain
divided by the length of stay.

J. T. Patcai et al. / Open Journal of Therapy and Rehabilitation 1 (2013) 52-61
56
Table 4. Demographics and outcomes of organ transplant group by year.
2004 2005 2006 2007 2008 p Value*
Patients (%) 9 (5.2) 48 (27.7) 47 (27.2) 61 (35.3) 8 (4.6) 0.0.01
Age (years) 56.4 ± 6.8 53.8 ± 12.0 51.9 ± 12.1 57.7 ± 12.4 54.6 ± 10.1 0.145
Gender
Males (%) 8 (88.9) 27 (56.2) 24 (51.1) 35 (57.4) 4 (50.0) 0.335
Females (%) 1 (11.1) 21 (43.8) 23 (48.9) 26 (42.6) 4 (50.0) 0.335
Waiting for Rehab Admission (Days ± SD) 2.4 ± 1.6 2.8 ± 3.1 3.5 ± 3.1 1.6 ± 1.9 2.5 ± 1.6 0.007
Unplanned Discharges (%) 0 (0.0) 2 (4.2) 1 (2.1) 6 (9.8) 0 (0.0) 0.472
Acute Care Readmission (%) 1 (3.0) 11 (23.9) 12 (26.1) 9 (16.4) 0 (0.0) 0.785
LOS (Days ± SD) 24.7 ± 11.9 24.2 ± 16.7 27.8 ± 18.1 28.1 ± 21.7 36.8 ± 24.2 0.477
Motor FIM™ Gain (± SD) 24.4 ± 13.7 8.5 ± 33.8 10.4 ± 32.4 15.3 ± 32.3 26.6 ± 8.9 0.379
Cognitive FIM™ Gain (± SD) −3.9 ± 11.7 −5.7 ± 14.0 −6.3 ± 14.0 −4.0 ± 12.2 0.9 ± 1.5 0.615
Total FIM™ Gain (± SD) 20.6 ± 22.0 2.8 ± 47.2 4.1 ± 45.3 11.3 ± 43.6 27.5 ± 9.3 0.447
FIM™ Efficiency (Points/Day ± SD) 1.1 ± 1.0 −1.0 ± 4.6 −0.4 ± 4.1 −0.6 ± 4.1 1.0 ± 0.5 0.558
Met Rehab Goals (%) 8 (88.9) 35 (72.9) 33 (70.2) 45 (73.8) 8 (100.0) 0.378
Discharge Home (%) 8 (88.9) 35 (72.9) 33 (70.2) 45 (73.8) 8 (100.0) 0.378
*Chi-square test or Student’s t-test between Transplant and All Rehab values; Unplanned Discharges = inpatient stay that lasts 3 days or less, including the
admission day; LOS = length of stay; FIM = functional independence measure; FIM gain = difference between discharge FIM and admission FIM scores; FIM
efficiency = FIM gain divided by the length of stay.
3.3. Outcomes of the Partnership RH-MOT
The waiting time from the moment an organ transplant
patient was ready for discharge from the MOT and ad-
mission to the RH was on average 2.4 days in April 2004,
compared to an average of 1.6 days in 2007, representing
a 66.7% reduction of waiting time to be transferred to the
alternative level of care (ALC), in this case the RH. This
reduction represented that more beds at the MOT were
available for new solid organ transplant patients, im-
proving bed utilization at the MOT.
4. DISCUSSION
Evaluating the, outcomes of 173 patients over four
years in our RH program, we found a number of statisti-
cally significant differences between the outcomes of
transplant rehab patients and general rehab patients.
Transplant rehab patients were younger, had a longer
length of stay, decreased FIM™ efficiency, and reduced
FIM™ gain, compared to general rehab patients. But a
higher proportion of transplant patients who were not
readmitted to an acute care hospital went back into their
home settings, compared to general rehab patients. One
could also consider that over half of the total general
rehabilitation patients were admitted to the muscu-
loskeletal program. These consisted mostly of postopera-
tive total joint arthroplasties who required a short length
of stay and had a higher FIM™ efficiency. However,
even including those less complex musculoskeletal pa-
tients, the comparable transplant rehab outcomes are
acceptable. Patients post-combined transplants had more
immediate (<3 days) transfers to an acute hospital, and a
higher rate of readmission to an acute hospital after the
first 3 days, and patients who received a heart-lung
transplant had greater FIM™ efficiency than the other
organ transplant groups. Overall, these results are con-
vincing to demonstrate that an inpatient rehab program,
assuming identified achievable rehab goals, can achieve
acceptable outcomes in a manner that is as effective and
efficient as the other programs in the RH.
There are however very significant differences be-
tween transplant rehab patients and other rehab patients
in one area—unplanned discharges. Within the first three
days, the rate of sending patients back to the acute hos-
pital is almost three times higher in transplant patients.
During the rest of their admission, transplant rehab pa-
tients were about ten times more likely to be sent to the
acute hospital (19.1%) than were general rehab patients
(1.9%). This is comparable to the rates reported else-
where for transplant rehab (15% [21]), or even transfer
rates for a similar medically fragile and complex rehab
group—oncology patients (21% [58], 35% [59]).

J. T. Patcai et al. / Open Journal of Therapy and Rehabilitation 1 (2013) 52-61 57
The partnership program between the RH and the
MOT was established for two reasons. One was to im-
prove organ transplant patients physical functioning,
which is discussed above, and the other reason was re-
garding the logistics of the health care of these patients.
Regarding logistics, there are clear advantages to
sending patients post-transplant to an inpatient rehabili-
tation program. The efficiency is increased because more
beds in the transplant unit are cleared faster to be avail-
able for new organ transplant patients. Post-transplant
patients no longer recuperate in high-cost transplant pro-
gram beds in the MOT program (approximately CAN
$700 per day, not including costs for housekeeping, die-
tary, allied health services, corporate overhead, lab &
diagnostic testing). The rehabilitation is better in a rehab
unit at lower cost (approximately CAN $594 per day,
including direct and indirect costs), because the unit is
appropriately staffed for rehab, has appropriate expertise,
and has the equipment and space necessary for rehab.
The rehab program focuses on maximum efficiency in
recovery of function, meeting goals regarding safety, ac-
tivities of daily living (both basic and instrumental), mo-
bility, strength, endurance etc. The RH-MOT program
has been a success in logistics, in helping patients to
move along the continuum of care while remaining in the
setting most appropriate to their needs at any given mo-
ment.
Therefore, there exists a patient group (post-operative
organ transplants) for whom the acute hospital does not
meet their needs well. There exist rehabilitation pro-
grams which can improve their impairments efficiently
and cost effectively. Why do most transplant patients
stay in acute hospital beds until discharge, following
which some outpatient rehabilitation may or may not be
instituted? There are a number of possible reasons. One
might be that inpatient rehabilitation is just not part of
the culture of the transplant team. This was answered by
our partnership process, because the signed agreement
served as an indicator of a cultural change, and focussed
the communication strategy RH-MOT. A second reason
might be that rehabilitation facilities are not comfortable
with the complexity and possible instability of these pa-
tients and just do not routinely accept them. Again, the
RH-MOT partnership was the answer to this. The MOT
promised to maintain their medical accountability for
these patients during complications, and they did in fact
readmit sick patients as needed. A third reason might be
that the rehab hospital might feel that they are unfamiliar
with transplant impairments and treatment programs for
them. With our partnership, the RH developed a formal
program, and has acquired considerable expertise. It
turns out that most of the impairments are not specific to
the transplant patients. Nevertheless, this is now a high
profile program for the RH. A fourth reason might be
that the costs of converting RH beds to treat complex
transplant patients might increase the costs of running
each bed without necessarily having the ability to recoup
those costs. This could be a significant disincentive in
the Canadian health care system with a government
funded hospital global budget model (where hospitals re-
ceive a fixed amount of money for operating costs, based
upon historic experience [60]), in particular the phar-
macy budget would suffer a major impact. This would be
a weaker disincentive in a case-costing funding model
where a fee-for-service payment is billed to payers by the
institutions [60]. A fifth reason might be that the initial
barriers for the RH to overcome are large, and the initial
cost of entry is high-essential factors include a minimum
volume of cohorted patients, a team with identified mem-
bers who acquire expertise, and aggressive RH medical
treatment partnered with a full Transplant service back-
up—a large investment for the RH.
The last reason is that there may have been insufficient
published literature to date to persuasively demonstrate
that a rehab program will accomplish valued outcomes.
Our data supports the pre-existing publications, and con-
vincingly shows that transplant patients, regardless of
organ group, improve their function at a rate and to an
extent similar to other complex rehabilitation patient
groups.
Study Limitations
While our results are substantial, one should consider
the following: this is a retrospective study, which limits
certain aspects of information gathering like patients’
data, which depends on the accuracy of electronic data
entry and the correct rehabilitation patient group (RPG)
coding of these inpatients as organ transplant patients.
Notably, the current study was conducted in Canada’s
only dedicated organ transplant rehabilitation program.
Consequently, these results may not be representative of
the general organ transplant population.
5. CONCLUSIONS
A written partnership agreement between a high vol-
ume multi-organ transplant service and a specialized
rehabilitation hospital produced a program that over four
years cleared 173 acute transplant beds expeditiously.
The transplant patients had a significantly longer length
of stay, decreased FIM™ efficiency, larger FIM™ gain,
and a higher proportion of them went back into their
home settings, compared to general rehabilitation pa-
tients. Although statistically significant, these results
were not clinically significant because they all remain
within the expected range of outcomes that would justify
a course of rehabilitation. The rehab program improved
patient function (as measured by FIM™ efficiency) at an

J. T. Patcai et al. / Open Journal of Therapy and Rehabilitation 1 (2013) 52-61
58
acceptable rate (1.1 vs. 1.4) compared to the general re-
habilitation population in the same rehabilitation hospital
(of whom close to half were short stay orthopaedic pa-
tients). It is known that for medically very complex pa-
tients (e.g., oncology patients), there will be a high rate
of transfer back to acute hospital for treatment of com-
plications and intercurrent illness, and this is as true for
organ transplant patients in our study. There were greater
outcome improvements in organ transplant patients dur-
ing the last two years of the study (2007 and 2008).
We are planning to conduct a larger retrospective
study where we will compare the functional outcomes of
patients admitted to the RH organ transplant program
with those of organ transplant patients who are not ad-
mitted to the RH program, matched by age, gender, and
severity of physical function measured by the FIM™ rat-
ings. We will also stratify the patients in three compari-
son groups: the organ transplants, the orthopaedic pa-
tients, and the other groups in rehab. In addition, we will
compare the rehabilitation outcomes of transplant pa-
tients by the organ transplanted to determine if their out-
comes are the same or different.
6. ACKNOWLEDGEMENTS
The contribution of Arash Kashfi MD in assisting with the statistical
analysis is gratefully acknowledged.
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LIST OF ABBREVIATIONS
QoL = Quality of Life
ESRD = End-Stage Renal Disease
FIM™ = Functional Independence Measure
ICU = Intensive Care Unit
RH = Rehabilitation Hospital
MOT = Multi-Organ Transplant program
ALC = Alternative Level of Care
CAN$ = Canadian Dollar
RPG = Rehabilitation Patient Group