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Using the Omaha System to Examine Outpatient Rehabilitation Problems, Interventions, and Outcomes Between Clients With and Without Cognitive Impairment
A retrospective cohort design was used to examine whether the Omaha System was useful in documenting differences in outpatient rehabilitation problems, interventions, and outcomes between clients with cognitive impairment and those with intact cognition. The sample included 201 clients who had been admitted to a comprehensive outpatient rehabilitation facility. The results showed no statistically significant differences in the prevalence of main Omaha problems, interventions, and outcomes between the two groups; however, clients with cognitive impairment experienced fewer changes in knowledge and behavior associated with neuromusculoskeletal function and pain than clients with intact cognition. These findings are consistent with an earlier report published by the authors that used standard instruments and indicate that the Omaha System can be valuable for rehabilitation clinical practice and research.
The Omaha System (OS) was developed between 1975 and 1992 by researchers and staff members of the Visiting Nurses Association of Omaha (Martin & Scheet, 1992). The OS was formulated inductively by analyzing the records of home healthcare patients and was modified after extensive field-testing. There are three components to the OS: the Problem Classification Scheme, the Intervention Scheme, and the Problem-Rating Scheme for Outcomes (Martin & Norris, 1996).
The Problem Classification Scheme addresses 42 client problems distributed among four domains (environmental, psychosocial, physiological, and health-related behaviors). After an Omaha problem has been identified, one or more of the four categories in the Intervention Scheme are used to appropriately address the problem. The first category of the Intervention Scheme—health teaching, guidance, and counseling—refers to activities that range from providing information, anticipating client problems, and encouraging client actions and responsibilities for self-care and coping, to assisting with decision making and problem solving. The second category—treatments and procedures—includes technical activities directed toward preventing signs and symptoms, identifying risk factors and early signs and symptoms, and decreasing or alleviating signs and symptoms. The third category—case management—encompasses activities of coordination, advocacy, and referral. The last category—surveillance—includes activities of detection, measurement, critical analysis, and monitoring a client’s status in relation to a given condition or phenomenon. Finally, the Problem-Rating Scheme for Outcomes is used to document three outcomes—knowledge, behavior, and status (K-B-S)—associated with each client problem. Knowledge refers to the client’s ability to remember and interpret health-related information. Behavior describes the client’s observable responses, actions, or activities that fit the occasion or purpose. Status is the client’s condition in relation to objective and subjective defining characteristics. K-B-S is rated on a 5-point Likert-type scale for each problem. An intervention’s effectiveness can then be evaluated based on the score changes for K-B-S (Martin & Norris, 1996).
Researchers have demonstrated that the OS is effective, highly reliable, valid, and easy to use for describing the types and frequencies of problems, interventions, and outcomes experienced by clients in acute care services, home care services, and primary care clinics (Bowles, 2000; Coenen, Marek, & Lundeen, 1996; Sampson & Doran, 1998). However, the OS has not been used to examine geriatric outpatient rehabilitation services. The purpose of this study was to determine the utility of the OS in documenting differences in rehabilitation problems, interventions, and outcomes between two groups: clients with cognitive impairment and those with intact cognition.
A retrospective cohort design was used to abstract relevant data from the healthcare records maintained by the Collaborative Assessment and Rehabilitation for Elders (CARE) Program, a nurse-managed, community-based comprehensive outpatient rehabilitation facility in Philadelphia, PA. Data pertinent to the study were converted into a Microsoft Excel dataset by the healthcare record manager of the CARE Program to ensure data consistency. The following research questions were tested:
The OS was adopted by the CARE Program in 1995 to establish a common language and taxonomy among clinicians as they documented assessments, treatments, and outcomes (Yu, Evans, & Sullivan-Marx, 2005; Yurkow, 1999). The introduction of the OS toThe CARE Program helped highlight the documentation redundancy that was occurring among different disciplines. As a result, each of the 42 Omaha problems was assigned to an appropriate discipline based on expertise. For example, social workers were responsible for assessing environmental problems, nurse practitioners assessed physiological and psychosocial problems, and physical and occupational therapists were assigned to evaluate musculoskeletal problems.
Clients who met the following criteria were included in the study: (1) client was admitted to The CARE Program between 1997 and 1999 when healthcare records were electronically documented using the OS; and (2) client completed the prescribed rehabilitation services (Evans, Yurkow, & Siegler, 1995). Two hundred and one clients were included in the study. Their primary rehabilitation diagnoses were degenerative joint disease (n = 45, 22.4%), gait disturbance (n = 34, 16.9%), difficulty walking (n = 31, 15.4%), muscle disuse atrophy (n = 27, 13.4%), arthritis (n = 19, 9.5%), and cerebral vascular accident (n = 14, 7%).
The CARE Program was located at a Medicare-certified and reimbursed comprehensive outpatient rehabilitation facility in inner-city Philadelphia. It was designed specifically for clients who needed more than simple outpatient rehabilitation services, but who were unable to tolerate the intense demands of inpatient rehabilitation services (Evans et al., 1995). An interdisciplinary team, including a geriatrician, gerontologic nurse practitioners (GNPs), physical therapists, occupational therapists, speech and language pathologists, geropsychiatric clinical nurse specialists, social workers, registered nurses, and therapy aides, provided comprehensive interdisciplinary rehabilitation care. A GNP served as the clinical director and interdisciplinary team leader. After a client was admitted to the facility, team members from each discipline assessed the client for a set of Omaha problems. An individualized interdisciplinary rehabilitation plan based on a standard practice protocol was then developed and implemented. This process was repeated until rehabilitation goals had been reached. After the client’s discharge, a team member from each discipline reassessed the client’s original set of problems. A client typically received rehabilitation services two to three times a week for 4–6 weeks (Evans et al.; Yu et al., 2005). The clinicians had been expertly trained to use the OS and there was very little staff turnover during the study period.
Cognitive impairment, which is the independent variable in this study, was determined by the score from a Mini-Mental State Examination (MMSE) administered by the GNPs. The MMSE screens for orientation, memory, attention, calculation, language, and visual construction domains with high validity (0.68 to 0.96) and reliability (0.80 to 0.95) (Folstein, Folstein, & McHugh, 1975; Tombaugh & McIntyre, 1992). MMSE scores range from 0 to 30 and a score ≤23 indicates cognitive impairment (Folstein et al.). Although using age- or education-adjusted MMSE scores was suggested for interpreting MMSE scores in clinical practice (Crum, Anthony, Bassett, & Folstein, 1993; Gallo, Fulmer, Paveza, & Reichel, 2000), a nonadjusted cutoff score of ≤23 has been widely used in rehabilitation and gerontology research (Agüero-Torres et al., 1998; Espiritu et al., 2001; Folstein et al.; Heruti, Lusky, Barell, Ohry, & Adunsky, 1999) and was, therefore, used in this study. Clients with MMSE scores ≤23 were assigned to the cognitively impaired group and those with MMSE scores >23 were assigned to the cognitively intact group.
Three dependent variables were examined in this study: Omaha problems, Omaha interventions, and Omaha outcomes. Omaha problems were operationalized as the total number of Omaha problems diagnosed for a client on admission. Omaha interventions included the percentage of clients receiving each of the four categories of Omaha interventions: health teaching, guidance, and counseling; case management; treatments and procedures; and surveillance. Omaha outcomes described the difference in each K-B-S subscale of the Problem-Rating Scheme for Outcomes for each Omaha problem from admission to discharge.
Descriptive statistical analyses were first computed. Fisher’s Exact Tests were performed to identify any differences in the percentage of clients who received each of the four categories of Omaha interventions for the six most prevalent Omaha problems. Wilcoxon rank sum tests were used to compare differences in the prevalence of Omaha problems and K-B-S outcomes. Wilcoxon rank sum tests are commonly used for comparing outcome differences between two groups when data are not normally distributed. The remainder of the Omaha problems were not analyzed because they rarely occurred (i.e., occurred in <20% of the study sample).
This study was approved by the Institutional Review Board of the University of Pennsylvania.
The average age of clients was 78 years, ranging from 56 to 95 years. Clients were predominantly female (n = 167, 83.1%) and African American (n = 154, 76.6%), with an average of 10.6 years of education. Their mean MMSE score on admission was 24, ranging from 2 to 29. Seventy-six clients (37.8%) were cognitively impaired (MMSE mean score 19.57 ± 4.27), and 125 clients (62.2%) had intact cognition (MMSE mean score 26.39 ± 1.68). There were no statistically significant differences in age and gender between the cognitively intact and the cognitively impaired groups; however, the cognitively impaired group was composed of more African Americans (n = 66, 86.8% versus n = 88, 70.4%, p = .008) and had fewer years of education (9.39 ± 3.96 versus 11.24 ± 3.18, p < .001).
Clients had an average of eight Omaha problems diagnosed when admitted to the facility. The average number of Omaha problems diagnosed for clients with cognitive impairment and those with intact cognition (7.75 versus 8.22, p = .491) was not different. The most frequently diagnosed Omaha problems were neuromusculoskeletal function (n = 173, 86.1%), pain (n = 128, 63.7%), emotional stability (n = 99, 49.3%), cognition (n = 90, 44.8%), circulation (n = 93, 46.3%), and genitourinary function (n = 92, 45.8%). Other Omaha problems were diagnosed at different frequencies ranging from 1% for consciousness to 32.8% for nutrition. Neuromusculoskeletal function was the most often diagnosed Omaha problem: 84.8% of clients had intact cognition and 88.2% had cognitive impairment. In addition, 71.1% of clients with cognitive impairment and 28.8% of those with intact cognition had the Omaha problem of cognition (see Table 1).
The difference in the prevalence of Omaha problems between the two groups—except for grief (p = .005), dentition (p = .011), and cognition (p < .001)—was not statistically significant. More clients with intact cognition had grief problems (n = 32, 25.6% versus n = 7, 19.4%), and fewer had problems with dentition (n = 18, 14.4% versus n = 23, 30.3%) and cognition (n = 36, 28.8% versus n = 54, 71.1%).
Omaha Interventions and Outcomes for the Six Prevalent Omaha Problems
Neuromusculoskeletal function. One hundred and six clients with intact cognition and 67 clients with cognitive impairment had the Omaha problem neuromusculoskeletal function. For this problem, health teaching, guidance, and counseling (category I) were provided to 80.2% of clients with intact cognition and 83.6% of those with cognitive impairment. Seventy-six percent of clients with intact cognition received treatments and procedures (category II) to improve their neuromusculoskeletal function; so did 64% of those with cognitive impairment. Case management (category III) was provided to approximately half of all clients, and surveillance (category IV) was initiated for one-third of clients in both groups. The percentage of clients who received each category of Omaha interventions did not differ between the two groups (see Table 2).
Both clients with intact cognition and cognitive impairment showed significant improvements from admission to discharge in their knowledge and behavior outcomes related to neuromusculoskeletal function. Clients with intact cognition also demonstrated significant improvement in status outcome related to neuromusculoskeletal function. There were, however, statistically significant differences in the magnitude of changes in knowledge and behavior outcomes between the two groups. Clients with intact cognition had lower admission knowledge Likert scores (2.17 versus 2.39) and status than those with cognitive impairment (3.06 versus 3.24); however, clients with intact cognition significantly improved their knowledge by more than one point after participating in the rehabilitation program. Although their admission behavior rating was similar to that of clients with cognitive impairment, clients with intact cognition achieved significantly greater behavior changes (1 point on average) than those with cognitive impairment. Clients with cognitive impairment had a higher level of neuromusculoskeletal status upon admission. Participation in rehabilitation services did not improve their status at discharge (see Table 2).
Pain. Eighty-three clients with intact cognition and 45 clients with cognitive impairment had pain. Health teaching, guidance, and counseling were provided to 88% of clients with intact cognition and 80% of those with cognitive impairment. Fifty-seven percent of clients with intact cognition received treatments and procedures to remedy their pain; so did 53.3% of those with cognitive impairment. Case management and surveillance were provided to approximately 40% of clients in both groups. The percentage of clients who received each category of Omaha interventions for pain did not differ between the two groups (see Table 3).
Regardless of their cognitive status, all clients exhibited statistically significant changes in K-B-S related to pain from admission to discharge. Even though knowledge levels were the same for both groups at admission, clients with intact cognition showed more improvement in knowledge by discharge (see Table 3).
Cognition. Thirty-six clients with intact cognition and 54 clients with cognitive impairment had the Omaha problem of cognition. For this problem, health teaching, guidance, and counseling; case management; and treatments and procedures were provided to more than two-thirds of the clients in both groups. The percentage of clients who received each category of Omaha intervention for cognition did not differ between the two groups (see Table 4).
Clients with intact cognition had significantly less knowledge about cognition when admitted to the facility, but no such difference was observed at the time of discharge. Clients with cognitive impairment exhibited statistically significant improvements in K-B-S related to cognition from admission to discharge. Similar improvements in K-B were also observed in those with intact cognition. The changes in K-B-S did not differ between the two groups (see Table 4).
Emotional stability. Sixty clients with intact cognition and 39 clients with cognitive impairment had the Omaha problem of emotional stability. For this problem, health teaching, guidance, and counseling were provided to approximately 85% of clients in both groups. Seventy-five percent of clients in both groups received case management and less than one-third were provided with treatments and procedures, and surveillance for their emotional problems. The percentage of clients who received each category of Omaha interventions for emotional stability did not differ between the two groups (see Table 5).
Regardless of their cognitive status, all clients exhibited significant changes in K-B-S related to emotional stability from admission to discharge. The changes in K-B-S did not differ between the two groups (see Table 5).
Circulation. Fifty-nine clients with intact cognition and 34 clients with cognitive impairment had the Omaha problem of circulation. Health teaching, guidance, and counseling were provided to 88.1% of clients with intact cognition and 70.6% of those with cognitive impairment. Approximately 40% of clients in both groups received case management, treatments, and procedures for their circulation problem. The percentage of clients who received each category of Omaha interventions for circulation did not differ between the two groups (see Table 6).
All clients experienced statistically significant gains in K-B-S regarding circulation from admission to discharge. These gains did not differ between clients with cognitive impairment and those with intact cognition; however, the discharge circulation status level was higher for those with intact cognition (see Table 6) .
Genitourinary function. Fifty-eight clients with intact cognition and 34 clients with cognitive impairment had the Omaha problem of genitourinary function. For this problem, health teaching, guidance, and counseling were provided to 79.3% of clients with intact cognition and 70.6% of those with cognitive impairment. Approximately 40% of clients in both groups received case management, treatments and procedures, and surveillance for their circulation problem. The percentage of clients who received each category of Omaha interventions did not differ between the two groups (see Table 7).
All clients showed statistically significant improvements in K-B-S regarding genitourinary function from admission to discharge. However, the K-B-S changes did not differ between the two groups (see Table 7).
The prevalence of Omaha problems, interventions, and outcomes did not differ between clients with cognitive impairment and those with intact cognition except that clients with cognitive impairment had a smaller change in their knowledge and behavior associated with neuromusculoskeletal function and in knowledge related to pain. Despite their impaired cognition, clients with cognitive impairment demonstrated significant improvements in their abilities to remember and interpret information and to appropriately respond and react to targeted rehabilitation services. The intervention that was used most often and was most successful in our client sample (with and without cognitive impairment) was health teaching, guidance, and counseling. Treatments and procedures, and case management were used only half of the time, while surveillance was the least used intervention. The findings from this study support the idea that certain information, when presented appropriately, can improve rehabilitation outcomes in clients with cognitive impairment, which is contrary to the commonly held belief that clients with cognitive impairment are unable to learn. For example, using multistrategies, such as effective communications, prompts, demonstration, and physical assistance, when working with clients with cognitive impairment has produced improved outcomes. Methods for successfully delivering healthcare interventions to this population should be investigated further.
Clients with cognitive impairment showed improvements similar to those with intact cognition without requiring special interventions. This finding from the OS is consistent with previous reports published by this study’s author that examined the effectiveness of outpatient rehabilitation for clients with cognitive impairment using standard research instruments (Yu et al., 2005; Yu & Richmond, 2005). In those studies, the motor subscale of the Functional Independence Measure was used to measure functional gain from admission to discharge and showed that clients with cognitive impairment achieved similar functional gain within comparable days of rehabilitation services to those with intact cognition, and cognitive impairment did not explain rehabilitation outcomes.
An interesting finding that emerged from the current study is that one-third of the clients with cognitive impairment were not diagnosed with the Omaha problem of cognition, and one-third of those with intact cognition were diagnosed with a cognition problem. This discrepancy might be explained by the different evaluation focuses of the OS and MMSE. Other than evaluating orientation, recall, and calculating skills, the Omaha problem of cognition emphasizes sequencing skills, reasoning and abstract thinking ability, impulsiveness, and repetitious language and behavior, which are factors not assessed by the MMSE (Folstein et al., 1975; Martin & Scheet, 1992). This finding suggests that future testing of the convergent validity of certain Omaha problems and standard clinical and research instruments might help the future modification and interpretation of the OS.
Despite the observed changes in almost all outcome ratings for the six prevalent Omaha problems, the clinical meaningfulness and significance of those changes demand further exploration. For instance, the changes in knowledge and behavior related to Omaha problem of neuromusculoskeletal function in clients with intact cognition, the changes in knowledge related to pain regardless of the clients’ cognitive function, and the changes in behavior associated with pain in clients with intact cognition are all one point or more, which clearly indicates that the improvements are clinically meaningful because these changes signal improvement one level. Albeit statistically significant, the rest of the changes are less than one point. Finding a way to clinically interpret outcome changes of less than one point needs to be addressed.
Although the researchers gained a number of insights about the OS from this study, four distinct issues remain open for future research. First, the OS is a useful and reliable classification system that can be used to direct practice and research in rehabilitation settings. It provides a rich array of information that is holistic and can inform individualized client care. For example, the OS not only measures the status changes related to each Omaha problem, it also identifies the effectiveness of healthcare education and any behavioral changes resulting from the interventions. Further testing of the OS’s utility in outpatient rehabilitation settings will help generalize its use and research applicability. Second, combining the OS with standard research and clinical instruments may enhance future research and clinical practice. For example, incorporating the MMSE into cognition assessment helps identify clients who may not otherwise exhibit cognitive problems. Third, because some components for the OS overlap and lack specificity, its value as a research tool is diminished. Under each of the four categories of the Intervention Scheme there are 62 fixed targets, such as physiology and behavior modification, that can be stated for each category. However, it remains unclear how to code and analyze the target data in a meaningful way. Similarly, the client-specific information might provide valuable information about the delivered interventions, but it cannot be easily integrated into the rest of the intervention data or manipulated for research. Finally, although the results showed few differences in Omaha status outcomes (which is consistent with the authors’ earlier report using standard instruments), it is unclear how Omaha interventions and outcomes are specifically connected. Are there direct relationships between Omaha interventions and outcomes, or are different combinations of interventions producing different outcomes?
The study also had limitations. First, a retrospective cohort design was used to abstract data from existing medical records, which were bound by history and time. Second, because there was no link between the OS outcomes and gold-standard research instruments, directly testing OS content validity was difficult. Third, Omaha problems uncommon in rehabilitation populations could not be evaluated. Last, the study sample represented an urban population living in close proximity to a university. Thus, the study findings might not be generalizable to broader populations.
This study provided evidence that the OS might be a valuable classification and documentation tool for outpatient rehabilitation programs despite its limitations. Future studies are needed to address those limitations to promote the use of OS in outpatient rehabilitation settings.
The authors thank Drs. Eilleen M. Sullivan-Marx, Lois K. Evans, Therese Richmond, and Lenore Kurlowicz for their support, and Jeff Gilbert for his help with data abstraction. Dr. Yu is supported by a NIH K12 Career Advancement Award.
Funding sources include Frank Morgan Jones Research Funds and Sigma Theta Tau International Xi Chapter at the University of Pennsylvania School of Nursing.
About the Authors
Fang Yu, PhD RN APRN BC-GNP, is assistant professor at the University of Minnesota School of Nursing in Minneapolis, MN. Address correspondence to email@example.com.
Norma M. Lang, PhD RN FAAN FRCN, is a professor emeritus at the University of Pennsylvania School of Nursing in Philadelphia, PA.
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