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204 Musculoskeletal & Neurological Rehabilitation KCE reports 57 9.2 ORGANISATION OF POST-ACUTE MUSCULOSKELETAL AND NEUROLOGICAL REHABILITATION 9.2.1 An organizational model for post-acute musculoskeletal and neurological rehabilitation in Belgium: different options. Four dimensions are important when developing an organisational model for musculoskeletal and neurological rehabilitation: • the phase (parts of the disease trajectory): acute, post-acute and chronic. We stick to a generalised division in three phases. For each particular pathology more detailed schemes can be developed (examples were given in the chapter international comparison phased model neurology, Dobkins model for stroke) • the setting: inpatient versus ambulatory. • the idea of a mono- or multidisciplinary approach is related to human resources issues • the complexity of the rehabilitation needs and goals and thus of the required rehabilitation activities: simple or complex. Since the study of other countries (see chapter 8) yielded no single organizational model, and since each model has advantages as well as disadvantages, several options will be given for the organization of musculoskeletal and neurological rehabilitation in Belgium. The policy options discussed in this chapter only consider the post-acute phase. Post-acute rehabilitation cannot be isolated from rehabilitation in the acute and chronic phase. The organisation and financing issues there are particular, and to far from the initial goal of this project. 9.2.1.1 A Stratified Rehabilitation Model The conceptual stratified rehabilitation model for the post-acute phase is developed as a support tool for organising rehabilitation. Moreover, it tries to translate and optimise the existing informal organisation of musculoskeletal and neurological rehabilitation in Belgium. Figure 9.3 visualises the ideas underlying this conceptual model. This rehabilitation model is organised around three differentiated types of rehabilitation services, taking into account patients’ rehabilitation needs and goals: • General rehabilitation services • Specific rehabilitation services • Highly specific rehabilitation services. The services of the different rehabilitation levels funtion in a collaborative way throug a clearly structured network. Between the different centres can be referred depending on the phase of the trajectory and when necessary considering geographical factors. Two criteria are used for separating the levels in this structure: • complexity of rehabilitation needs and goals • incidence and prevalence of consequences of health conditions. The implementation of this model thus requires a systematic assessment of patients’ rehabilitation needs in the acute phase of the disease trajectory. It is recommended to keep in mind the framework of the International Classification of Functioning, disability and health (ICF) while performing this assessment. The value of this framework is generally accepted in rehabilitation medicine from a clinical point of view. However, it should be noted that ICF currently is not ready yet to be used as an organizational and managerial tool. The assessment should be based on diagnosis, required intensity of
KCE reports 57 Musculoskeletal & Neurological Rehabilitation 205 care, rehabilitation needs and goals as well as on personal and environmental criteria. The assessment has to be repeated periodically and can result in a transfer of an individual to another type of organisation within the network. This assessment is a crucial tool to assign a patient to a rehabilitation programme, which in turn is decisive for the referral to a certain type of rehabilitation organisation. Each rehabilitation facility offering rehabilitation programmes, will receive an adapted funding. Budget allocations can be more transparent and logic, and adapted to the resources required to offer a rehabilitation programme. Of course, the assessment has to be perfomed by an objective but specialised professional. Several options exist. This assessor could either be the treating rehabilitation specialist in the acute phase, the rehabilitation specialist in the post-acute phase, a representative of the insurance organism, a completely independent party, or a collaboration between two or three of these parties. In chapter 8 several examples will be given in the studied countries. The better the PCS is conceived, the better chance there is for objectivity in the assessment. The rehabilitation needs and goals will lead to a mono- or a multidisciplinary approach as is mentioned in the comments on the definition of musculoskeletal and neurological rehabilitation. Another dimension is the complexity of the rehabilitation needs and goals. Short-term (or temporary) rehabilitation needs and goals are considered as simple. For example: rehabilitation in case of simple sport injuries, or after total hip, knee or shoulder replacement. Long-term (or permanent) rehabilitation needs and goals are considered as complex. For example: rehabilitation in case of spinal cord injury or multiple sclerosis. Rehabilitation needs and goals in case of a health condition which often causes important long-term functional impairments but can partially recover such as stroke, Guillain-Barré syndrome and multiple trauma, are also considered as complex. The model also takes into account options for hospitalised (inpatient) or ambulatory (outpatient) rehabilitation services. However, it is not clear yet neither in literature (See chapter 3), nor among experts in what conditions one can choose for hospitalised or ambulatory settings. This dimension is not visualised in the model. The implementation of this model will require the implementation of an elaborated quality or performance assessment instrument, measuring at least the clinical patient outcomes of the rehabilitation process. An accreditation system could be an alternative (see CARF in the US).
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Dépôt légal : D/2007/10.273/19
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