RIWC_PARA_A074 the german recommendations for post discharge neuro-rehabilitation aiming at inclusion in all areas of society
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A074 the german recommendations for post discharge neuro-rehabilitation aiming at inclusion in all areas of society
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RIWC_PARA_A074 the german recommendations for post discharge neuro-rehabilitation aiming at inclusion in all areas of society
- 1. The German recommendations for post-discharge neuro-rehabiliation: aiming at inclusion in all areas of society Maren Bredehorst, MPH, PhD Bundesarbeitsgemeinschaft für Rehabilitation (BAR) e.V. German Federal Rehabilitation Council RI World Congress, 25-27 October 2016, Edinburgh Parallel Session C: The future of rehabilitation, recent advances
- 2. Rehabilitation goals for brain injured persons Source: Transferred from en.wikipedia to Commons. Author: The original uploader was Nunh-huh at English Wikipedia. Paris as seen with full visual fields What do I want to reach after discharge from in-patient (medical) rehabilitation? Is this a realistic goal? How can I get there?
- 3. Rehabilitation goals for brain injured persons Paris as seen with left homonymous hemianopsia. What do I want to reach after discharge from in-patient (medical) rehabilitation? Is this a realistic goal? How can I get there? Source: Transferred from en.wikipedia to Commons. Author: The original uploader was Nunh-huh at English Wikipedia.
- 4. Phase E in neuro-rehabilitation Neurological-neurosurgical rehab model: defines phases A – F in terms of medical entry and exit criteria for patients and of respective treatment requirements (VDR 1995) → issued by funders, to trigger new services (mainly in-patient facilities or day clinics) Phase E: describes the transition from medical rehab into a stable arrangement with best possible participation in society → various services from various sectors are potentially relevant!
- 5. Three groups of persons described Impairment regarding functioning, activities and participation (see ICF): Non-visible deviation of functions: e.g. difficulties with speech, seeing, hearing; reduced psycho-physical or cognitive capacity; changes of personality… Visible deviation of functions: gross motor skills, fine motor skills 1. Mild impairment→ good chance to return to work /school with specific support (primary job market) 2. Medium impairment → major efforts in occupational rehabilitation /schooling required (possibly secondary job market) 3. Considerable impairment → constantly high level of care required (possibly day care centre) Source: BAR (2013) Empfehlungen für die Phase E der neurologischen Rehabilitation
- 6. Services for participation in the educational sphere Combining different services and assistance Services securing the results of medical rehabilitation Services for participation in the social sphere Services for participation in the occupational sphere Information, counselling, planning, initiation, coordination Income support and supplementary assistance
- 7. Framing individualised transition What remains to be done at the individual (case) level? Both funders and providers need to develop their staff in terms of: neuro-competency - information, counselling, coordination, case management - different kinds of therapies, care and other aspects of service participatory goal setting - empowering the client - involving relatives and others (e.g. employer, colleagues) in planning and the rehabilitation process
- 8. Framing individualised transition What remains to be done at the intra-organisational level? Providers to come forward with concepts and cooperations for rehabilitative services in the community/in residential care Funders to further clarify which kind and scope of services are required and will be refunded on which legal basis
- 9. 1665 steps … Inclusion +individual participation greater coverage, more flexible delivery better integration of services from / within different sectors develop local / regional solutions adapt and extend available structures, involve people with acquired brain injury (& their families) in the planning processes Image: Benh LIEU SONG - https://commons.wikimedia.org/wiki/File:Tour_Eiffel_Wikimedia_Commons.jpg … or 7 lifts to get up !
- 10. Thank you for your attention! References: Bundesarbeitsgemeinschaft für Rehabilitation, BAR (2013): Empfehlungen zur Phase E der neurologischen Rehabilitation. Frankfurt/M. Bundesministerium für Arbeit und Soziales, BMAS (2015) Rehabilitation and integration of people with disabilities. Bonn. Deutsche Vereinigung für Rehabilitation, DVfR (2014): Phase E der Neuro- Rehabiliation als Brücke zur Inklusion. Heidelberg. Verband Deutscher Renten- versicherungsträger , VDR (1995): Phasenmodell in der neurologisch- neurochirurgischen Rehabilitation
Editor's Notes
- The Eiffel Tower as a possible goal (in a metaphorical sense): Maybe I used to climb it once a year, or this is what I have always wanted to do and worked towards. After an episode of (chronic) disease or severe injury and a longer stay in hospital/rehabilitation clinics, many people simply want things to be „back to normal“ and take up their habitual activities again. Rehabilitation goals are often not formulated in a very concrete way. Considering their health problems and reduced functions, they also often need professional appraisal and advice about what could be realistic goals within a set time frame. Also, planning the way to get there (and implementing the plan) might require some support and/or supervision.
- In having to cope with their illness, people with acquired brain injury are often confronted with an additional challenge: Their central organ for perception, planning, acting and regulation has suffered. Not only sensory reception might be affected, but also the perception and awareness of (internal or external) objects or processes. The resulting impairments are not immediately visible to outsiders or seizable by ‘common sense’. They require very careful and specific medical and neuropsychological assessment. Setting and pursuing rehabilitation goals therefore might require a very different and individual approach – to be provided by neuro-competent professionals and counsillors. From Wikipedia: Hemianopsia, or hemianopia, is a decreased vision or blindness (anopsia) in half the visual field, usually on one side of the vertical midline. The most common causes of this damage are stroke, brain tumor, and trauma.[1] A homonymous hemianopsia is the loss of half of the visual field on the same side in both eyes. The visual images that we see to the right side travel from both eyes to the left side of the brain, while the visual images we see to the left side in each eye travel to the right side of the brain. Therefore, damage to the right side of the posterior portion of the brain or right optic tract can cause a loss of the left field of view in both eyes. Likewise, damage to the left posterior brain or left optic radiation can cause a loss of the right field of vision.[2] Visual neglect (also called hemispatial neglect or unilateral spatial neglect) differs from hemianopia in that it is a perceptual deficit rather than a visual one. Unlike patients with hemianopia who actually don't see, those with visual neglect have no trouble seeing but are impaired in attending to and processing the visual information they receive. Whereas hemianopia can be assuaged by allowing patients to move their eyes around a visual scene (ensuring that the entire scene makes it into their intact visual field), neglect cannot. Neglect can also apply to auditory or tactile stimuli and can even leave a patient unaware of one side of his or her own body. [5]
- The publication of the neurological-neurosurgical rehabilitation model (phase A to E) developed by major public funding bodies of rehabilitation in Germany recently had its 20th anniversary. For each phase, medical entry and exit criteria, goals and measures of treatment have been defined in subsequent negotiations hosted by the Federal Rehabilitation Council (BAR). Negotiations of this kind are part of the self-regulation mechanism within the German rehabilitation system, which is characterized by its large variety of funding bodies. Phase A – D: mostly medical treatment with increasingly rehabilitative focus. Phase D: occupational aspects increasing, ambulatory rehab possible Phase E: the recommendations reflect a shift from medical and occupational focus to participation at large (care and independent living, long-term health care). (Phase F: long-term care at high dependency level) Various services from various sectors are potentially relevant in Phase E (medical and nursing care, social care, assistive technology, occupation, education, leisure) -> combination and coordination of assistance and services: Professionals/counsillors need to know the options! Phase E recommendations reflect a shift from medical and occupational focus to participation at large.
- Prognosis is very difficult! Careful assessments and continuous supervision are needed, to make adjustments when possible or necessary. Many impairments only manifest themselves when people with acquired brain injury leave the in-patient setting and are confronted either with their ‚normal‘ or with their new environment. However, rehabilitation does not end here; therepeutic interventions need to facilitate the transition (and if the environment changes after some time, they might have to be taken up again) From BMAS (2015) Rehabilitation and integration of people with disabilities, pp.29-31: According to section 4(1) of Book IX of the Social Code of 2001, integration assistance includes social assistance that, regardless of the cause of a person‘s disability, is necessary: To avert, eliminate, or alleviate a disability, to prevent its aggravation or to reduce its effects to avoid, overcome or alleviate reductions in earning capacty or the need for long-term care or prevent an aggravation and to avoid other social benefits being claimed prematurely or to reduce amounts claimed To secure permanent participation in working life in accordance with a person‘s leanings and abilities To promote an individual‘s personal development in a holistic approach, enable their participation in the life of society and facilitate a life as autonomous and self-determined as possible Section 10 of Book I of the Social Code stipulates a ‚general right of integration‘ to be observed in all social assistance areas (twelve Books altogether).
- The phase E-recommendations help to make responsibilities and competencies of funding bodies more transparent, so that people with acquired brain injury and their supporters know who to address. Hence they are also a good tool for case management. The „flower of assistance“ required is highly individual (type and level of services) The centre piece (overarching different funders and providers) is indispensible! From BMAS (2015) Rehabilitation and integration of people with disabilities, pp.37-39: Integration assistance is provided in the following categories: -medical rehabilitation assistance -occupational integration assistance -social integration assistance to aid participation in community life -Income support and other supplementary assistance There is no single independent social assistance fund responsible for integration assistance as a whole or for specific assistance categories. Instead it is part of the other responsibilities of various assistance funds which, where integration assistance is concerned, are referred to as rehabilitation funds. - Occupational accident insurance Social compensation Health insurance Pesion insurance Federal Employment Agency Income support for job seekers Youth welfare Social assistance (Integration offices)
- What are the necessary steps to implement the Phase E recommendations? The central task „information, counselling, planning, initiation, coordination“ has to be fulfilled by both funders and providers of rehabilitation services. As the Social Code is primarily addressed at the funders, they are obliged to coordinate and cooperate among each other – also at the individual case level. In large organisations dealing with clients with a wide range of disabilities, one option is to create competence hubs for persons with acquired brain injury. Service providersespecially in the field of mental health or mental or multiple disability already offer a number of relevant services for people with acquired brain injury. However, they must be made aware of the differences between these groups an diversify their programmes respectivel (e.g. special departments or groups).
- During the negotiation of the phase E recommendations 2011-2013 (multi-statkeholder negotiations hosted by the Federal Rehabiliation Council, BAR), services and assistence concerning different spheres of participation were considered. Regulations from various legislative texts have been collated and grouped according to the overarching goal they may contribute to in the individual case. The consened recommendations thus provide a canon of possible services and indicate respective funding bodies. Existing legislation opens up possibilities to develop and refund such services, but clarification is often required, as well as sufficient financial security to develop and try out new service models. At BAR level, further negotiations about ambulatory medical rehabilitation services have just been initiated.
- The aim is not to build up isolated paralle structures for people with acquired brain injury. However, they often don‘t integrate well in existing facilities for people with mental or multiple impairments. Thus it is necessary to adapt some aspects (e.g. open separate groups for them) General requirements for phase E rehabilitation services: - Greater integration of medical, social, occupational and other services (under the roof of one provider, or through individual purchase = personal budget) - Flexible delivery (time span, frequency, level of support, in-patient/out-patient/mobile rehabilitation)