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218 Musculoskeletal & Neurological Rehabilitation KCE reports 57 value’ or outcome of a rehabilitation process is rather difficult because a lot of independent variables influence this outcome. Besides the identification of rehabilitation needs and goals other factors need to be taken into account to select appropriate intervention strategies: • Patient and environment related factors, such as age, motivation, social situation or profession (contextual factors) • Disease related factors, such as nature and course of the disease, individual variability throughout the disease course, age at disease onset, availability of disease modifying agents, disease stage. Some fundamental work still has to be done, also because of the lack of uniform outcome measures in rehabilitation. It is currently almost impossible to assess systematically the outcomes of rehabilitation as existing instruments measure functional status in different ways. The available patient assessment instruments make it difficult to identify whether similar patients are treated across different settings. The reflection on outcome measures within a quality approach should as much as possible line up with the current efforts being done to use and implement the ICF framework (as is the case internationally). It is recommended to choose as much as possible those instruments falling within one of the dimensions of ICF. Outcome elements not covered by the ICF framework (e.g. quality of life, satisfaction) and end points such as mortality should not be forgotten. These other dimensions have to be developed at longer time notice and international collaboration is needed on this issue. Moreover, many of the measures identified as potentially important in understanding quality of post-acute care, are not included in existing administrative data. It lacks objective and other (e.g. quality of life, integration) measures as well as global and disease specific process measures. Existing data sets may serve a variety of purposes, but currently do not include information needed to measure post-acute care quality and outcomes. They do not contain information needed to adequately measure the quality of care within and across post-acute care settings. Several countries are currently trying to develop and implement quality and performance measurement and try to connect it (at least the outcome measures) to the financing of the post-acute and long term rehabilitation. It is recommended to analyse these efforts and make an assessment on how performance and quality measurement could be integrated in the Belgian (post-acute) rehabilitation model. An analysis of their methods to develop quality systems for daily practice, in a context of limited scientific evidence would offer an added value. At short notice, it will not be possible to develop a quality system able to determine whether post-acute care has successfully maximized a patient’s function, allowing return to the most independent living environment, and reintegration into prior activities and lifestyle. This question should be dealt with on middle term. In a first stage, a model “light version” for a quality measurement system could be prepared, at least to compare activities, patient profiles and maybe some functional outcomes. The tool should enable a comparative analysis of post-acute facilities as a “benchmark”. It will offer a basis to debate profiles and (in due time) outcomes of activities of post-acute facilities. The “light” instrument should at least measure functional level, (some) pathologyspecific elements, some additional measures for risk adjustment (social characteristics, co-morbidity, …), and some items concerning patient’s perception. A longitudinal method would be ideal using an admission instrument and a follow up instrument for each patient, in order to compare base-line functioning and follow up function of each patient in different phases of the rehabilitation process (compare the Swedish registers). At short notice a cross sectional approach (e.g. an adapted MVG-RIM2) might the most feasible approach to get some basic quality indicators.
KCE reports 57 Musculoskeletal & Neurological Rehabilitation 219 Key Points • Belgium needs to develop an explicit conceptual framework for the organisation of post-acute musculoskeletal and neurological rehabilitation. • It is proposed to develop a stratified rehabilitation model in which the roles of rehabilitation organisations can be identified, taking into account characteristics of patients’ needs, disease trajectories, rehabilitation goals and epidemiological and geographical needs. • The stratified rehabilitation model rehabilitation 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 conceptual stratified rehabilitation model should be supported by a patient classification system: a systematic assessment of patients’ rehabilitation needs in the acute phase of the disease trajectory (PCS), within the framework of an outcome model as ICF. • Two criteria are used for separating the levels in this structure: complexity of rehabilitation needs and goals, and incidence and prevalence of consequences of health conditions. • An equitable geographical distribution of general rehabilitation services should be pursued (bottom-up). • A maximum of 20 to 30 rehabilitation centres are estimated to be necessary at the specific level; and 3 to 5 at the highly specific level. • Alternative options for the stratified rehabilitation model are given. • An epidemiological monitoring of musculoskeletal and neurological disorders and a follow up of the developments in rehabilitation sciences is important. Central registration of delivered services and activities is necessary. Based on these data, the proposed estimation of centres and services can be refined in the future if necessary. • Quality evaluation is an important part of every organisational/financial structure. Basic data registration is a first step to evaluate the rehabilitation process. In the Netherlands and Germany, quality and performance indicators are used, even without the use of a formal patient classification system (PCS). In the US, an accreditation system is available (CARF); according to experts a European accreditation system is under development.
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Dépôt légal : D/2007/10.273/19
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