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180 Musculoskeletal & Neurological Rehabilitation KCE reports 57
8.6.2 The organisation of the Rehabilitation sector
8.6.2.1 The underlying conceptual ideas
In Sweden rehabilitation is a concept including all medical, psychological, social and
work-related measures to help sick and injured to regain conditions for an improved
life. Different institutions are responsible for different areas, but it are mainly the local
social and health services that are getting the prime responsibility to organize
rehabilitation.
The county councils are responsible for patients until they are fully medically treated,
more specifically until they no longer require hospital care. After this phase, the
physician (together with staff from social care services, other outpatient services and
the patient) develops a care-plan designed to achieve further rehabilitation. Once the
patient is fully medically treated and a care-plan has been developed, responsibility for
the patient is transferred to the municipality.
The responsibility for home nursing and rehabilitation lies between the county councils
and the municipalities, which causes tensions.
The municipalities are responsible when people need rehabilitation without
hospitalization: generally maintenance training (conscious training to prevent loss of
function and to maintain or improve the functions of the individual)
The counties, however, are responsible for discharged patients to have a carefully
arranged plan of rehabilitation. All patients who need it, have a continuing rehabilitation
plan, no matter who has the responsibility. But, it is difficult to make a clear delimitation
between rehabilitation in the health system (counties) and maintenance training and
prevention of loss of function in the social system (municipalities). A gradual shift from
the specialised rehabilitation at hospitals to the rehabilitation that is normally carried
out in the municipalities appears to be taking place. Between the two sectors a grey
area in which patients can get jammed insofar as none of the rehabilitative bodies accept
responsibility for the rehabilitation of a given patient. The delimitation between the two
sectors (in connection with the obligation to continue or to start training) are typically
related to the discharge from hospitals.
The collaboration and the division of labour between hospital and health and social care
units vary from municipality to municipality and from one hospital department to
another.
8.6.2.2 Rehabilitation facilities
The Swedish rehabilitation facilities do cover the range from acute hospital facilities,
over specialised units within the hospitals, inpatient and outpatient hospital services,
specialised rehabilitation centres and long term care facilities.
The county-wise organisation makes it almost impossible to sketch a clear picture on
how these facilities play a role in the rehabilitation landscape. There are great local
variations in the numbers of beds and rehabilitation practices.
Collaboration between services has been suggested as a means to increase effectiveness
and reduce costs especially in the care and rehabilitation of long-term illness. In Sweden,
a special legislation named SOCSAM was introduced in 1994, enabling financial
collaboration between governmental and municipal authorities for crossing the
boundaries between medical rehabilitation and social welfare related rehabilitation. But
the development of really integrated seamless care is still to be debated.
In the more recent period the debate on coordination of care was partly driven by
county council cost containment. There are considerable problems in the “grey area”
where responsibility moves from county councils to municipalities. The municipalities
claim that patients are now sent home “quicker and sicker” because counties have a
financial incentive to discharge them as early as possible. Municipalities are sometimes
unable to provide necessary medical care and they have no direct access to medical