Kristen L. Mauk


“Rehabilitation refers to services and programs designed to assist individuals who have experienced a trauma or illness that results in impairment that creates a loss of function (physical, psychological, social, or vocational)” (Remsburg & Carson, 2006, p. 579). Rehabilitation is also an approach to care in which persons with chronic illness and disability are “made able” again (Pryor, 2002).

Rehabilitation assists individuals with longterm health alterations to regain independence and adapt to changes that have occurred as a result of deviations in their health status. A popular rehabilitation saying is that “rehabilitation begins day one” and thus should be considered as part of the overall plan of care for most acute illness episodes and throughout the duration of most chronic illnesses.

The primary goal of rehabilitation is to achieve the highest level of independence possible for the client. This goal is highly individualized. For example, a person with a mild stroke may have the goal to walk again and resume gainful employment at the same job he held previously. Another person with a high-level spinal injury may realistically have a different goal of being able to be mobile independently with the use of a mechanically adapted wheelchair such as a Sip-N-Puff chair. Both persons have achievable goals that are based upon their capacity and functional limitations that have resulted from illness or injury.

The goals of rehabilitation may be summarized with a few concepts: restoring or maximizing the level of function, facilitating independence, preventing complications, and promoting quality of life. Rehabilitation typically involves an interdisciplinary team of professionals working toward a common goal. The client and family are considered the most important team members. Professional team members may include physicians, nurses, therapists, social workers, vocational counselors, nutritionists, orthotists, prosthetists, and chaplains. Additional professionals may be consulted to help meet the unique needs of the individual.

Rehabilitation is commonly associated with certain disorders or illnesses in which therapeutic interventions have been shown to be effective. These include health alterations such as stroke, spinal cord injury, traumatic or other brain injury; neurologic diseases such as Parkinson’s disease, multiple sclerosis (MS), Guillain-Barré syndrome; orthopedic problems such as arthritis, fractures, or joint replacements; and less commonly, burns, cancer, or respiratory
disorders. In each of these conditions, persons can be assisted to regain maximal functioning that may have been altered because of a disease process, injury, or congenital defect.

One of the foci of the rehabilitation process is community reintegration or re-entry, sometimes referred to as resocialization. This is a process by which individuals are reintegrated into society after a life-altering health condition or situation changes their previous roles and abilities. Within a rehabilitation setting, reintegration is an ongoing goal. Rehabilitation professionals work with disabled clients or individuals with chronic illness and their families to help them re-enter their communities; they may have to accomplish significant adjustments to adapt to changes that have occurred in every area of their lives. Often this process involves the client relearning how to do self-care with activities of daily living (ADLs) such as bathing, grooming, toileting, eating, and dressing. Rehabilitation is a hopeful process that encourages individuals to maximize their strengths while making positive adaptations to their limitations.

Rehabilitation Models and Classification Systems

Models are used to help explain, guide, or direct practice or processes. Rehabilitation models can aid in understanding how chronic conditions and disability develop and progress, or how they can be managed. There are several major classification systems used to document rehabilitation processes and outcomes (Brandt & Pope, 1997; World Health Organization [WHO], 1980; WHO, 2002). These include the Functional Limitations System (FLS), the Enabling-Disabling Model, and the WHO International Classification of Functioning, Disability, and Health (ICF).

The IOM recommends the use of the Enabling-Disabling Process Model, whereas the WHO recommends the use of the ICF to help standardize and effectively communicate information about diagnoses, care, and treatment. The model used may depend largely on the facility and its preferences and choices. The use of standard terminology within these models can help facilitate communication, but rehabilitation professionals must be thoroughly familiar with the chosen model and understand the terminology within it.

The Enabling-Disabling Process

The Enabling-Disabling Process was developed at the IOM in 1997 as a framework for professional rehabilitation practice. It emphasizes the uniqueness of each individual client by revising the original Disability in America model generated by the IOM (Pope & Tarlov, 1991). A committee of professionals enhanced the 1991 IOM model “to show more clearly how biological, environmental (physical and social), and lifestyle/behavioral factors are involved in reversing
the disabling process, i.e., rehabilitation, or the enabling process” (Brandt & Pope, 1997, p. 13). In the new Enabling-Disabling Process, “disability does not appear in this model since it is not inherent in the individual but, rather, a function of the interaction of the individual and the environment” (Brandt & Pope, 1997, p. 11). Disability is seen as a product of the interaction of an individual with the environment. The model posits that rehabilitation depends largely upon the individual and his or her unique characteristics, and that the disabling process may even be reversed with appropriate rehabilitation interventions (Lutz & Bowers, 2003). The basic concepts of the model include pathology, impairment, functional limitation, disability, and society limitation (Brandt & Pope, 1997). Table 24-1 provides a summary of the concepts of the Enabling-Disabling Process.

Enabling America (Brandt & Pope, 1997) urged rehabilitation professionals to adopt a framework that better described the rehabilitation process. Since its introduction, however, the Enabling-Disabling Model has not received the recognition or use within healthcare professions that was probably hoped for by the IOM. A search of several notable scholarly databases over the last 10 years revealed few articles written by rehabilitation professionals in healthcare professions that mentioned this process or used it as a framework for research.

International Classification of Functioning, Disability, and Health

In 1980, the WHO developed a classification system that was widely used for years internationally. The WHO originally defined impairment as a loss related to structure and function; a disability was related to a loss of ability to perform an activity, and a handicap was a disadvantage for a person related to the environment.

The ICF is the WHO’s framework for measuring health and disability at both individual and population levels: “ICF is a classification of health and health related domains that describe body functions and structures, activities and participation. The domains are classified from body, individual and societal perspectives” (WHO, 2007, p. 1). The ICF provides a shift in viewing disability as gradually becoming a part of the majority of person’s lives over time. It provides a holistic look at the process of disability related to health, considering all aspects, not just the medical or physical (WHO, 2007). The four major sections of the classification document are body functions (by system and including mental health), body structures (by system), activities and participation (such as learning, communication, self-care, community involvement), and environmental factors (such as products, technology, attitudes, service, and policy) (WHO, 2007). Table 24-2 provides an overview of ICF.

Other models that can guide rehabilitation practice have emerged from rehabilitation nurse scientists. These middle-range theories are not classification systems for general rehabilitation, but provide insight and direction about specific processes or phenomena. An example of an area in which several new frameworks or models have arisen is in stroke rehabilitation and recovery. Secrest and colleagues (Secrest & Zeller, 2007; Secrest & Thomas, 1999) have explored the relationship of continuity and discontinuity following stroke. They continue to publish about the relationship of this phenomenon with
functional ability, depression, and quality of life. Their work resulted in the development of a tool to measure themes common to the post-stroke experience such as control, connection with others, and independence (Secrest & Zeller, 2003).

Table 24-1 Concepts of the Enabling-Disabling Process



Functional Limitation


Societal Limitation

Interruption of or interference with normal physiologic and developmental processes or structures

Loss and/or abnormality of cognition, and emotional, physiologic, or anatomic structure or function, including all losses or abnormalities, not just those attributable to the initial pathophysiology

Restriction or lack of ability to perform an action in the manner or within a range consistent with the purpose of an organ or organ system

Inability or limitation in performing tasks, activities, and roles to levels expected within physical and social contexts

Restriction, attributable to social policy or barriers (structural or attitudinal), that limits fulfillment of roles or denies access to services and opportunities that are associated with full participation in society

Level of Impact

Cells and Tissues

Organs and Organ Systems

Function of the Organ and Organ System



Structural or functional

Structural or functional

Action or activity performance or organ or organ system

Task performance by person in physical, social contexts

Societal attributes relevant to individuals with disabilities

Patient Examples

Lacunar infarct of the cerebellum (right hemisphere) related to microvascular changes associated with chronic hypertension

Neuromotor function of the brain

Left hemiparesis or difficulty with spatial-perceptual tasks, difficulty sequencing, memory deficits

Deficits in ambulation, self-care, shopping, work

Lack of adaptations in the work environment that would enable the person to continue employment

Source: Whyte, J. (1998). Enabling America: A report from the Institute of Medicine on rehabilitation science and engineering. Archives of Physical Medicine and Rehabilitation, 79(11), 1477-1480. Reprinted with permission from Elsevier.

Mauk (Easton, 2001; Mauk, 2006) developed a model from grounded theory that
identified six phases of post-stroke recovery that may help guide practice and interventions. She found that stroke survivors journey through a predictable pattern, with certain variables influencing the ease of adaptation after stroke. Other rehabilitation nurse scientists have explored the experience of caregivers of stroke survivors (Hartke & King, 2002; Pierce, Steiner, Govani, et al., 2004; Pierce, Steiner, Hicks, & Holzaepfel, 2006). Each of these examples suggest that although large, general models and classification systems are necessary and helpful, more manageable models, frameworks, and instruments are also needed to better reflect the unique experiences in rehabilitation and to guide practice.

Table 24-2 Concepts of the International Classification of Functioning, Disability, and Health

Major Concepts

Health Condition


Activity Limitation

Participation Restriction

Diseases, disorders, and injuries, e.g., leprosy, diabetes, spinal cord injury

Problems in body function or structure such as a significant deviation or loss, e.g., anxiety, paralysis, loss of sensation of extremities

Problems in body function or structure such as a significant deviation or loss, e.g., anxiety, paralysis, loss of sensation of extremities

Problems an individual may experience in involvement in life situations, e.g., unable to attend social events, unable to use public transportation to get to church, unable to perform job functions


Spinal cord injury


Incapable of using public transportation

Unable to attend religious activities

Source: World Health Organization. (2002). Towards a common language for functioning, disability and health ICF. Retrieved September 21, 2011, from:

Historical Perspectives

Rehabilitation as a specialty within medicine, and later nursing, was slow to develop (see Table 24-3). A general apathy toward the poor, disabled, disenfranchised, and elderly prevailed in European countries and the United States. England was the first developed country to pass legislation in The Poor Relief Act of 1662 to provide assistance to the poor and disabled (Edwards, 2007).

There was some interest in rehabilitation in the 1800s, mainly with regard to helping “crippled” children (Edwards, 1992). In the first half of the 1900s, society began to focus more on the needs of persons with physical limitations. Susan Tracy, a nurse and teacher, helped to develop the discipline of occupational therapy. The first medical social service department was established at Bellevue Hospital in New York City, and Lillian Wald began the first visiting nursing service (Easton, 1999).

The World Wars provided an impetus for the growth of rehabilitation. The number of American soldiers wounded in World War I led to the establishment of a national rehabilitation
program for veterans. It is interesting to note that rehabilitation services at this time were not generally available to the public. With the discovery of sulfa drugs and antibiotics, those injured in World War II had a much greater chance of survival. So, the numerous veterans of World War II coming home with multiple trauma, amputations, traumatic brain injuries, and spinal cord injuries necessitated a more comprehensive rehabilitation program. During this time, Dr. Howard Rusk (1965) emerged as both a pioneer and champion for rehabilitation, believing that these therapeutic services should be available not just to veterans, but to the entire world population. He demonstrated to the military powers through his personal assistance with the rehabilitation of those whom other medical professionals deemed a lost cause, that rather than convalescence, rehabilitation could promote recovery (Kottke, Stillwell, & Lehmann, 1982). Rusk showed that disabled persons could still be productive members of society and enjoy a good quality of life. As technology continued to explode in the 1940s, the number of civilians with industry and motor vehicle injuries increased, leading to a need for rehabilitation to address continuing disability. In 1947, Dr. Rusk established the first hospital-based medical rehabilitation services for civilians (Edwards, 2007).

Table 24-3 Historical Events and Legislative Initiatives Affecting Rehabilitation





“Studies of Invalid Occupation”

Published by nurse Susan Tracy; beginning of occupational therapy


American Red Cross

Institute for Crippled and Disabled Men personnel

Created to provide vocational training for wounded military


Smith-Sears Legislation (PL 65-178)

Authorized Federal Board for Vocational Education to administer a national vocational rehabilitation service to disabled veterans of World War I


Smith-Fess Legislation (PL 66-236)

Provided vocational rehabilitation services to people disabled in industry and otherwise


Veteran’s Administration (VA)

Created by Executive Order 5398 to care for those with service-related disabilities, signed by President Herbert Hoover. At this time there were 54 hospitals and 4.7 million living veterans.


Social Security Act (PL 74-271)

Provided permanent authorization for the civilian vocational rehabilitation program


American Academy of Physical Medicine

Organization formed; physical medicine and rehabilitation emerges as a specialty


First comprehensive book on physical medicine and rehabilitation

Krusen’s Handbook of Physical Medicine and Rehabilitation, written by Frank Krusen, MD


Sister Kenny Institute

Institute and Sister Kenny’s research led to the development of the profession of physical therapy and provided support for physiatry as a specialty


Welsh-Clark Legislation (PL 78-16)

Provided vocational rehabilitation for disabled veterans of World War II


United Nations



Organization established with representatives from 44 countries to plan care for disabled WWII veterans


Department of Medicine and Surgery

A department within the VA established to provide medical care for veterans; succeeded in 1989 by the Veterans Health Services and Research Administration, renamed the Veterans Health Administration in 1991


Bellevue Medical

Rehabilitation Services

First U.S. rehabilitation program, established by Howard Rusk, MD


American Board of Physical

Medicine and Rehabilitation

Board formed, and rehabilitation becomes a board-certified specialty


Hill-Burton Act (PL 83-565)

Provided greater financial support, research and demonstration grants, state agency expansion, and grants to expand rehabilitation facilities


Rehabilitation Medicine

H. Rusk and colleagues publish a rehabilitation text


Vocational Rehabilitation Act (PL 89-333)

Expanded and improved vocational rehabilitation services


Rehabilitation Act (PL 93-112)

Expanded services to the more severely handicapped by giving them priority; affirmative action in employment and nondiscrimination in facilities


Association of Rehabilitation Nurses

Organization formed; rehabilitation nursing emerges as a specialty


Education for All Handicapped Act (PL 94-142)

Provided for a free appropriate education for handicapped children in the least restrictive setting possible


National Housing Act Amendments (PL 94-173)

Provided for the removal of barriers in federally supported housing; established Office of Independent Living for disabled people in Department of Housing and Urban Development


Rehabilitation Nursing

First issue published


Rehabilitation Nursing: Concepts and Practice—A Core Curriculum

First core curriculum of rehabilitation nursing published


Tax Equity and Fiscal Responsibility Act (TEFRA)

Originally designed to be a bridge from the old fee-for-service system to the DRG system; free-standing rehabilitation hospitals reimbursed based on reasonable costs (with limits)


Diagnosis-Related Groupings (DRGs)

Established to decrease Medicare payments through the establishment of a prospective payment system for acute care


Omnibus Budget Reconciliation Act (OBRA)

Contained legislation on nursing home reform; required standards for nursing assistant education and certification; required Health Care Financing Administration (HCFA) to develop a standardized assessment instrument and move from a fee-for-service system to a prospective payment system


Department of Veterans Affairs

VA becomes the 14th department in the President’s Cabinet.


Americans with Disabilities Act (PL 101-336)

Established a clear discrimination on the basis of disability


Balanced Budget Act (BBA)

Enacted to restructure Medicare Part A reimbursement methods; mandated a prospective payment reimbursement system for rehabilitation hospitals and units


Balanced Budget Act Amendment

Provided adjustments to PPS for skilled nursing facilities


PPS for Inpatient

Rehabilitation Facilities

PPS mandated by the 1997 BBA phase-in begins


New Freedom Initiative

President George W. Bush launches a nationwide effort to remove barriers to community living for people of all ages with disabilities and long-term illnesses; goals of the initiative include increasing access to assistive technologies, expanding educational opportunities, and promoting full access to community life.


PPS for Inpatient

Rehabilitation Facilities

Phase-in complete; case-mix groups (CMGs) are used as the basis for reimbursement.


CMS modifies criteria used to classify inpatient rehabilitation facilities (IRF)

Phase-in begins for “75% rule.” By 2007, 75% of population treated in the facility must match one or more specified medical conditions.

Sources: Adapted from Larsen, P. (1998). “Rehabilitation.” In I. Lubkin & P. Larsen (Eds.), Chronic illness: Impact and interventions (4th ed., p. 534); Easton, K. (1999). Gerontological rehabilitation nursing (pp. 32, 41). Philadelphia: W.B. Saunders; Kelly, P. (1999). Reimbursement mechanisms. In A. S. Luggen & S. Meiner (Eds.), NGNA core curriculum for gerontological nursing (pp. 185-186). St. Louis: Mosby; Blake, D., & Scott, D. (1996). Employment of persons with disabilities. Physical Medicine and Rehabilitation (p. 182). Philadelphia: W.B. Saunders; Department of Veterans Affairs. (2000). Facts about the Department of Veterans Affairs. Retrieved from:

The American Academy of Physical Medicine and Rehabilitation was established in 1938, and rehabilitation medicine was recognized as a board-certified medical specialty in 1947. In 1974, the ARN was created, recognizing rehabilitation as a nursing specialty.

As societies continue to pursue medical and technologic advances that allow persons with extreme levels of physical disability to live longer, rehabilitation has become a specialty in demand. In the civilian population, more persons are living with disabilities, as first responders are better equipped to aid survival of serious injury. However, the need to address continuing adjustment to disability remains. In addition, as life expectancy in developed countries increases, chronic illness rates also rise, providing additional opportunities for rehabilitation professionals to enhance quality of life for those aging with disability or acquiring it with age.

For soldiers, the types of weapons used in the wars in Iraq and Afghanistan have resulted in polytraumatic injuries never seen before. Rehabilitation professionals are being called upon to address multiple injuries that may include a combination of multiple traumatic amputations, burns, internal organ and soft-tissue damage from explosive forces, brain and spinal injuries, as well as post-traumatic stress.

Public Policy and Rehabilitation

There are several ways in which rehabilitation services may be paid for. These include Medicare, Medicaid, workers’ compensation, private insurance, and social security disability benefits. Rehabilitation professionals should be familiar with these types of reimbursement and what is covered under the client’s insurance provider. Case managers and social workers are team members who may be excellent resources regarding payment for rehabilitation.


Medicare is a federal social insurance program that provides care for persons over the age of 65 and for certain younger persons with disabilities. The coverage and costs for Medicare change each year, so clients need to be aware of significant changes annually. Medicare Part A is the hospital insurance, providing funds for hospital care, skilled nursing, hospice, and home health care. Medicare Part B covers medically necessary services as well as some preventive services, with a monthly charge. Part B covers 80% of the costs of physician services, and other services including physical and occupational therapy, durable medical equipment, cardiac rehabilitation, pulmonary rehabilitation (for those with moderate to severe chronic obstructive pulmonary disease [COPD] within certain parameters), and prosthetics and orthotics (Centers for Medicare & Medicaid Services [CMS], 2011b). Many services that a rehabilitation client may need are not covered under Medicare. For example, Medicare has limited coverage for eye or hearing exams in special cases, but it does not cover routine foot care or nursing home care. Medicare Part C, referred to as the Medicare Advantage Plan, is a combination of Parts A and B, and functions much like a preferred provider organization or health maintenance organization using managed care (Doherty, 2004; Emmer & Allendorf, 2004; Stuart, 2006). Medicare Part D (CMS, 2011b) is a prescription drug plan in which private companies issue plans through Medicare. Part D is available for anyone with Medicare regardless of income. Costs vary greatly within this plan and clients would be wise to compare and review various plans each year prior to re-enrollment or plan changes.

The major changes in Medicare for 2011 were summarized in the CMS (2011b) publication Medicare and You and include: 1) no coinsurance or deductible for most preventive services, 2) a paid yearly wellness exam, 3) having to use certain suppliers for durable medical equipment, and 4) specific dates for making changes to health and prescription drug coverage.

Rehabilitation facilities and hospitals, collectively called inpatient rehabilitation facilities (IRFs), currently receive reimbursement using a Prospective Payment System (PPS) through the Social Security Act (CMS, 2011a). The IRF PPS uses information from the Uniform Data System for Medical Rehabilitation (UDSMR), better known as the Functional Independence Measure (FIM) tool, “to classify patients into distinct groups based on clinical characteristics and expected resource needs. Separate payments are calculated for each group, including the application of case and facility level adjustments” (CMS, 2011a, paragraph 2). Codes are assigned to casemix groups (CMGs), and Medicare pays a specific amount per discharge.

Since 2004, Medicare has been phasing in new rules for IRFs. The case-mix classifications for 2008 used the same as those for 2007. Common medical conditions covered under the IRF rule include stroke, brain injury, spinal cord injury, amputation, multiple trauma, neurologic disorders, cardiac and pulmonary conditions, osteoarthritis, rheumatoid arthritis, pain syndrome, and certain joint replacements (Federal Register, 2007).

Medicare limits the amount it pays for physical, occupational, and speech therapy services. There is a deductible for Part B Medicare, after which Medicare pays 80% and the individual pays 20% up to the set limits for medically necessary therapies. There are some allowable exceptions to this rule, and appropriate documentation by the provider is essential.


Medicaid is a state-run program in concert with the federal government that is the largest source of medical care payments for persons with low income and limited resources. In 2007, President Bush introduced a plan to place new restrictions on the rehabilitative services (called the rehab option) allowed through Medicaid to save the federal budget $2.29 billion over 5 years. Nearly 75% of persons receiving rehab services under Medicaid were those with mental health needs, and they were responsible for 79% of the rehab option spending (Kaiser Commission, 2007). Currently 47 states provide some type of mental or physical health services under the rehab option.

Establishing Medicaid is a complex process that varies among states (Santerre, 2002). Although each state sets standards for its own programs, the federal government provides broad guidelines for those who may qualify under categorically needy, medically needy, and special groups (such as some persons with disabilities). States must provide long-term care for persons who are Medicaid eligible. State Medicaid programs offer a variety of services within a variety of settings. Services that are provided relative to rehabilitation for the categorically needy include: hospitalization, lab and X-rays, nursing facilities for those age 21 and older, physician and some nurse practitioner services, medical-surgical dental needs, and home health (CMS, 2005).

Workers’ Compensation

Workers’ compensation is a state income-support program. To be eligible, the injury or condition must be work related. Benefits are usually calculated as a percentage of the employee’s weekly earnings at the time the injury occurred. There are restrictions placed by each state on the maximum amount of benefits, often two-thirds of the gross salary (Deutsch & Dean-Baar, 2007). The types of benefits may range from temporary partial or total disability to permanent partial or total disability, or death. Some states have a maximum benefit period and some may require a waiting period. Disabled workers may be compensated
through spousal benefits (in case of death), medical and rehabilitation expense coverage, and lost wages (Kiselica, Sibson, & Green-McKenzie, 2004). Current workers’ compensation programs are more restrictive than they once were; they limit physician choice and eligibility, provide lower benefits, and use managed care for cost containment (D’Andrea & Meyer, 2004).

Private Insurance

Most private insurances pay for at least some rehabilitative services. There is generally a deductible and often a co-pay, which may be higher if the provider is not within the network of providers supplied by the insurance company. In the case where the person has private insurance and Medicare as a secondary payer, much of the therapy services may be covered, provided there is sufficient and ongoing documentation of medical necessity and progress toward goals. Private insurance may also provide disability income insurance, accidental death and dismemberment insurance, or other benefits.

Social Security Disability Income

Social Security Disability Income (SSDI) was established in 1956 as part of the Social Security Disability Act of 1954. This is a federally administered disability insurance program for those who meet the strict definition of disability under Social Security. The criteria for disability is threefold: 1) the person cannot do the same work he or she did before; 2) it is determined that the person cannot adapt to other work because of the existing medical condition; and 3) the disability has lasted for at least 1 year, or is expected to result in death (Social Security Online, 2007). The person must also have worked and paid into the Social Security program before the disability. SSDI is paid as a monthly benefit.

Supplemental Security Income (SSI) may provide disability benefits for persons who have not worked long enough to receive SSDI. The SSI program pays benefits to disabled adults and children with limited income and resources, or certain older persons with severely limited income. Persons may receive a monthly check, and the SSI program also helps individuals to access Medicare benefits and take advantage of other possible assistance through the federal government. Qualifying for the program is based on income and resources (Social Security Online, 2007).

Disability Benefits for Veterans

The Department of Veterans Affairs, often called the VA, provides a number of benefits for veterans: “Disability compensation is a benefit paid to a veteran because of injuries or diseases that happened while on active duty, or were made worse by active military service. It is also paid to certain veterans disabled from VA health care” (VA, 2011). These benefits are tax free and may include a monthly stipend (ranging from $123 to $2673), priority medical care through the VA, clothing and housing allowances (to make accommodations), adaptive equipment, and various grants as needed (VA, 2010). The VA also provides vocational rehabilitation by maintaining working relationships with many businesses to employ veterans with physical and mental or emotional disabilities. Consultation is available in many areas including employment, assistive technology, case management, work site and job analysis, and help in addressing Americans with Disabilities Act (ADA) compliance issues (VA, 2010).

Vocational Rehabilitation

Vocational rehabilitation is an important part of the rehabilitation process, carrying heavier weight for those of working age and certain racial-ethnic groups for whom work is part of personal identify and reputation. In 1918, Congress passed the Smith-Sears Act to assist with national vocational rehabilitation services to veterans who served in World War I. In 1920, The Smith-Fess Act made vocational rehabilitation services available for all persons with disabilities, not just those with war-related injuries (Buchanan, 1996). More significant legislation was enacted when The Rehabilitation Act of 1973 provided funds to support state vocational rehabilitation programs. The Rehabilitation Services Administration (RSA) of the U.S. Department of Education (2005) coordinates vocational rehabilitation services. The RSA (2007) states that it “oversees grant programs that help individuals with physical or mental disabilities to obtain employment and live more independently through the provision of such supports as counseling, medical and psychological services, job training and other individualized services” (p. 1). This is accomplished through dispensing funds to state grant programs to assist them with finding work-related services or programs for persons with disabilities, particularly the severely disabled. The RSA is the Congressionally appointed federal agency charged with implementing the various titles associated with The Rehabilitation Act of 1973. This agency acts as a resource for information and a leader in advocating at all levels for national programs that help to remove barriers for persons with disabilities (RSA, 2007).

The services provided in vocational rehabilitation are many, but generally include personal counseling, mental and physical health services, and assistance with vocational placement and job training (Kielhofner et al., 2004; Lysaght, 2004; O’Neill et al., 2004; Targett et al., 2004). In addition, the RSA helps administer projects with specific groups of persons such as migrant and seasonal farm workers, American Indians, older adults, and the visually impaired. One principle of vocational rehabilitation is that informed consumer choice promotes enhanced employment outcomes. For vocational rehabilitation to be effective and enhance quality of life for the person with mental disabilities, the agency and counselors must work closely with the employer and the client to find the working environment suited to that individual (Inman, McGurk, & Chadwick, 2007; Morgan, 2007). Employment outcomes are most frequently used as the measure of the success of vocational rehabilitation for those with disabilities (Kosciulek, 2007). More research is needed to explore the factors related to positive outcomes of vocational rehabilitation.

Vocational rehabilitation may not be a goal for all rehabilitation clients. Many older adults requiring rehabilitation services are retired, and employment is not a goal. However, for those younger persons with functional limitations or mental health impairments, work may be directly related to their sense of self and identify within their culture. For these persons, vocational rehabilitation plays an important part in the comprehensive rehabilitation process, and the vocational rehabilitation counselor will be an essential team member.

Americans with Disabilities Act

The ADA enacted in 1990 guarantees individuals with physical disabilities equal access to
public accommodations related to transportation, education, and employment. Employment discrimination of qualified applicants because of disabilities is prohibited by this law (U.S. Equal Employment Opportunity Commission, 2008). Although the Rehabilitation Act of 1973 and its amendments covered accessibility to buildings of organizations that received federal financial assistance, the ADA also requires private organizations to comply with accessibility and employment laws. The concept of reasonable accommodation was introduced, requiring employers to make those accommodations within reason that may be necessary for a person with disability. Table 24-4 provides a summary of the ADA related to the four major areas it addresses: employment, public services, public accommodations services by practice entities, and telecommunications relay.

Table 24-4 Americans with Disabilities Act

Title 1: Employment

Employers cannot discriminate against a qualified disabled job applicant or employee in any manner related to employment and benefits.

Employers must make their existing facilities accessible and usable by individuals with disabilities.

Accommodations in all aspects of job attainment and performance are required in order to place individuals on an equal plane with the nondisabled.

Title 2: Public Services

Qualified disabled individuals must have access to all services and programs provided by state or local governments. Public rail transportation must be made accessible to disabled individuals and supplemented with paratransit.

Title 3: Public Accommodations Services Operated by Private Entities

Virtually every entity open to the public must now be made accessible to the disabled. A study is to be conducted concerning accessibility of the over-the-road transportation.

Title 4: Telecommunications Relay

Telephone companies are required to furnish telecommunication devices to enable hearing- and speech-impaired individuals to communicate by wire or radio.

Source: Reprinted from Watson, P. (1990). The Americans with Disabilities Act: More rights for people with disabilities. Rehabilitation Nursing, 15, 326. Published by the Association of Rehabilitation Nurses, 4700 W. Lake Avenue, Glenview, IL 60025-1485. Copyright © 1990 by the Association of Rehabilitation Nurses. Used with permission.


Rehabilitation services provided by an interdisciplinary team within a variety of settings suggest several possible challenges for providers. These include the rising costs of care, caregiver burden, inequities among those with disabilities, the negative image of disability, the changing composition of the disabled population, ethical issues, providing culturally competent
care, and professional and informal caregiver issues.

Rising Care Costs

It is estimated that 133 million Americans have at least one chronic illness, with 25% of those individuals having one or more daily activity limitation (Centers for Disease Control and Prevention [CDC], 2009). Forty-two million persons (17% of the U.S. population) were uninsured and 32 million (13%) received Medicaid assistance. Of those uninsured, the major reason cited was cost. About 10.7 million (5%) adults were unable to work because of health-related problems. Persons with less education and who were poor were less likely to be able to work because of health problems (Adams, Dey, & Vickerie, 2007). The American government spends about $200 billion per year on assistance for persons with disabilities (Council of State Administrators of Vocational Rehabilitation, 2004-2005). Given these statistics, major challenges for rehabilitation professionals are to assist persons to attain and regain their health and become productive, working members of society, and to explore other means of providing access to health care.

Caregiver Burden

Because an event requiring rehabilitation happens to the entire family and community, not just the client, it is important to address the needs of caregivers throughout the rehabilitation process and/or chronic illness trajectory. Family members comprise the vast majority (72%) of paid and unpaid caregivers of older persons with functional limitations from chronic disease, with adult children caregivers (42%) and spouses (25%) bearing the largest burden of care (Shirey & Summer, 2000). The caregiver’s ability to cope with the care demands is influenced by a variety of factors including the type and severity of illness, the length of quality of recovery, social support, inherent caregiver factors, and coping ability. This may hold true for both formal and informal caregivers (Bushnik, Wright, & Brudsall, 2007). For example, the caregiver spouse of a person with uncomplicated coronary bypass surgery may be able to meet care demands over a limited period of rehabilitation, whereas the older spouse caregiver of a stroke survivor with severe aphasia and functional deficits may be facing years of caregiving—a burden that is often overwhelming.

Caregiver burden, the effects of caregiving-related stress on family members or other care providers, has been associated with a number of health problems in the caregiver. Emotional distress, anxiety, depression, decreased quality of life, hypertension, lowered immune function, and increased mortality are among the concerns noted by researchers of caregivers (Anderson, Linto, & Stewart-Wynne, 1995; Brouwer et al., 2004; Canam & Acorn, 1999; das Chagas Medeiros, Ferraz, & Quaresma, 2000; Grunfeld et al., 2004; Hughes et al., 1999; King, Hartke, & Denby, 2007; Kolanowski, Fick, Waller, & Shea, 2004; Lieberman & Fisher, 1995; Mills, Yu, Ziegler, Patterson, & Grant, 1999; Schulz & Beach, 1999; Shaw et al., 1999; Ski & O’Connell, 2007; Weitzenkamp, Gerhart, Charlifue, Whiteneck, & Savic, 1997; Wu et al., 1999). There is sufficient research since 1995 to demonstrate that the burden of caregiving over time can have a deleterious effect on the health of the family caregiver.

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