VAMED’s Rehabilitation Centre Kitzbühel is shining example of personalised care, medical director says

Personalised rehabilitation: Interdisciplinary, systematic, individual

The role of the doctor is defined in the Austrian rehabilitation plan 2016 as follows: “… rehabilitation is always tied to a responsible doctor …”. He is both an executive and a supervisor. He analyzes, controls and monitors the entire rehabilitation process.

The basic approach and the way of working in medical rehabilitation have changed considerably in recent years: nowadays, doctors, nurses and physiotherapists are supported by massage and lymph therapy, occupational therapy, psychology, dietology, speech therapy, sports science, orthopedic technology and social services. The physicians play a central role here: They coordinate the interdisciplinary team, treat (accompanying) illnesses and ultimately decide which therapeutic steps are taken and when.

Status of “functional health”

At the beginning and during rehabilitation, objective benchmarks, tests and questionnaires are used to determine the level of “functional health”, functional abilities and to keep track of progress (= assessment). Rehabilitation goals are primarily set in accordance with the expectations of the patient as well as with targets set by acute medicine, curative medicine. Within the therapeutic team, these goals are defined together with the patient and evaluated on an ongoing basis. The individual treatment plan is created accordingly (= assignment) and the therapeutic measures are carried out (= intervention). It needs to be clarified whether there is a need and ability for rehabilitation and what the rehabilitation prognosis looks like. All these parameters ultimately determine the achievability of the specified rehabilitation goals.

If, despite appropriate steps, there is no improvement or even new problems arise, the strategy initially defined by the doctor will be revised and adjusted. Under certain circumstances, feedback must also be sent to the appropriate department of “acute medicine”, for example surgery.

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Individual goals with ICF

On the basis of ICF, the wishes and circumstances of the patient are taken into consideration. Two patients with the same clinical picture or the same physical limitations might have very different needs in everyday life. For example, one stroke patient with hemiplegia might receive a lot of support from his relatives at home while another lives alone in a second-floor flat without an elevator.

ICF thus makes it possible to describe the functional state of health of the patient and the associated social impairment and subsequently enables to carry out transparent and comprehensible rehabilitation.

Personalisation for better therapy results

Especially in the past decades, uniformity of service delivery has become indispensable: Life expectancy is steadily rising, as is the number of chronic illnesses. At the same time, the need for rehabilitation is increasing alongside. Health, mobility, communication, employment, but also self-determination and participation in social life are increasingly important aspects that must be included in rehabilitation goals in order to relieve the health system in the long term. A therapy concept based on ICF is thus not only economical, but also the best for each individual patient.

Another advantage of ICF compared to previous models is its new approach. It does not focus on deficits but rather resource, which can be applied objectively to everyone, with or without disabilities. This makes ICF not only more practical, but also more advanced in its thought concept. There is a deliberate shift away from the question of what the patient cannot do. Instead, the focus lies on what the patient needs. ICF can be used on an individual, institutional and social level. It is based on a multi-axis model since it also incorporates biopsychosocial aspects.

Measuring and evaluating successes

ICF makes the results of rehabilitation measurable: based on this, systematic assessment of quality of results should be done and process as well as result evaluated on an ongoing basis. ICF is used worldwide to describe and evaluate healthcare facilities, such as rehabilitation clinics and nursing homes. The measurement and evaluation of individual and systematized processes in the sense of quality management with structural, process and result quality is indispensable today and a precondition for the constant further development of rehabilitation programs. In addition, ICF is used to collect health-economic data that enables monitoring of health and medical expenses and facilitates in turn identifying health policy strategies for the future. ICF is thus fit for everyday use to generate data for rehabilitation research.

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Overall rating 16th November 2016