Dr Michael Fischer, Chairman of the International Medical Board at VAMED, was guest contributor last year in the most-read doctors magazine in Austria. VAMED is Circle Health’s partner in their joint venture, Circle Rehabilitation.
His article “Personalised rehabilitation: interdisciplinary, systematic, individual” was published in “Ärzte Exklusive” (“Doctors Exclusively”). For a case study, he used VAMED’s rehabilitation centre Kitzbühel, where he is Medical Director.
“Health, mobility, communication, employment, but also self-determination and participation in social life,” Dr Fischer writes, “are increasingly important aspects that must be included in rehabilitation goals in order to relieve the health system in the long-term.”
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.
Coordination of treatment strategy
Seamless cooperation of the entire rehabilitation team is important. All people involved in the rehabilitation process (including relatives if necessary), must engage in a regular exchange of information and should have the same level of information at all times. Team meetings are an important platform for this. The “International Classification of Functioning, Disability and Health (ICF)” is the basis for a common language.
Within the rehabilitation team there must be continuous coordination of the treatment strategy: important contextual factors are compared, lack of progress is discussed and general questions are clarified. Understanding the needs and goals of everyone involved in the treatment process is crucial to good communication and the quality of the outcome.
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.
Personalised therapy concepts
Individualization and personalization are becoming more and more important in medicine regardless of specialization: never before has research focused so comprehensively on targeted, individualized therapies. This is especially useful in rehabilitation: For athletes, individual training programs have long been common practice – and it is only logical that rehabilitation patients benefit from it.
Practical example: Rehabilitation Centre Kitzbühel
The orthopedic rehabilitation centre in Kitzbühel serves as a good example of what personalized rehabilitation using the ICF system can look like. There, the new approach has already been implemented and by the end of 2017 it should be phased in at all the VAMED Group’s rehabilitation facilities.
Already at the time of admission, there is a wide-ranging activity- and participation-oriented assessment for each patient. In comprehensive admission examinations using internationally standardized tests and questionnaires, an interdisciplinary team of physicians, nursing staff, psychologists, dieticians, physiotherapists and occupational therapists determines the patient’s overall functional state based on objective measurements and assesses the physical and social impairments.
Among other things, strength and flexibility as well as the mental state of the individual are assessed. Under medical supervision, an individual treatment plan is developed together with the patient according to assessment outcome. The patient himself plays an important part in this process, and defines personal goals together with the treatment team. Based on measurable benchmarks and the current level progress of the patient, the treatment plan is optimized during rehabilitation in interdisciplinary therapy sessions for the best possible achievement of the goals. For individualized and optimized treatment, a total of 31 ICF-based rehabilitation goals were categorized in Kitzbühel and linking to them 22 validated test procedures were defined.
At the end of the rehabilitation stay as well as three, six and twelve months after the completion of the treatment, the patient should repeat the initial assessment. For example, if a patient with initially measured depressive moods improves his or her value on the Hospital Anxiety and Depression Scale (HADS) from more than 8 points to 7 or less, his or her mental state is “no longer clinically relevant “and success of the therapy clearly measurable.
The same applies to physical goals such as the improvement of fine motor skills, sensory or other physical and emotional abilities and skills. If goals have not been achieved or if there is still a need or potential for improvement, the patient may be given further individualized treatment recommendations for the time after rehabilitation.
Prim. Priv.-Doz. Dr. Michael Fischer
Medical Director Rehazentrum Kitzbühel, VAMED
About the author
Dr Michael Fischer is Chairman of the International Medical Board of VAMED AG, Vienna, and Medical Director of the Rehabilitation Centre Kitzbühel.
About the Journal
Published in “Ärzte Exklusiv” (“Doctors Exclusively”), which is the magazine with the highest circulation for doctors. The magazine comes out 10 times a year and reaches ALL doctors and apothecaries in Austria. It is published by “ÄrzteVerlag” (“Doctor Publishing”), which also oversees magazines focusing on medical careers and localised health issues and has existed for more than 20 years. It has an approx. monthly readership of 1m.