SERVICE CHALLENGES FOR SPECIALIST REH
Current rehabilitation services are provided across a range of settings, by different organisations and by many health professions and carers. Services are o
determined by agencies, professions and service settings without an overall governing system which identifies service gaps and
This self-determination and uncoordinated approach presents challenges in accessing reliable data about
such services across the country.
offering level 1 complex specialist re
In the absence of national specifications for specialist community rehabilitation, service agreements between the HSE and voluntary s
depend largely on the strength of
This leads to an observed inequity in access to community rehabilitation Future service development should
clear continuum of services with clear points of transition between services. The rehabilitation medicine model of care aims to outline and describe such a service based on best evidence, with particular focus on specialist rehabilitation services level 1, level 2 and level 3 (chapter 2
• Tertiary Specialist Rehabilitation Services
• Patients with severe physical, cognitive,
• Team supported by Consultant in
Rehabilitation Medicine
Level 1
45
EVOLUTION AND FUNCTION OF THE SERVICE
S FOR SPECIALIST REHABILITATION S
Current rehabilitation services are provided across a range of settings, by different sations and by many health professions and carers. Services are o
agencies, professions and service settings without an overall governing system which identifies service gaps and priorities at a national level.
n and uncoordinated approach presents challenges in ing reliable data about provision of services and numbers of people ch services across the country. Currently, there is only one national service
lex specialist rehabilitation.
In the absence of national specifications for specialist community rehabilitation, between the HSE and voluntary service providers
largely on the strength of business cases and competencies inequity in access to community rehabilitation
ture service development should be developed based on a model that outlines a clear continuum of services with clear points of transition between services. The
model of care aims to outline and describe such a service based on best evidence, with particular focus on specialist rehabilitation services
(chapter 2).
• Team supported by Consultant in
Rehabilitation Medicine
Level 2
• Patients with more complex needs than can be supported by generic rehabilitation team Current rehabilitation services are provided across a range of settings, by different
sations and by many health professions and carers. Services are often self-agencies, professions and service settings without an overall
priorities at a national level.
n and uncoordinated approach presents challenges in
provision of services and numbers of people availing of tional service
In the absence of national specifications for specialist community rehabilitation, ervice providers (VSPs) business cases and competencies of those VSPs.
inequity in access to community rehabilitation.
be developed based on a model that outlines a clear continuum of services with clear points of transition between services. The
model of care aims to outline and describe such a service based on best evidence, with particular focus on specialist rehabilitation services –
Patients with more complex needs than can be supported by generic rehabilitation team
46
In addition specialist rehabilitation services need to address a number of factors in the healthcare environment and the wider society that place a greater demand on services and long term care:
SERVICE CONFIGURATION
There is clear international evidence that effective rehabilitation can only be
achieved with appropriate resourcing as discussed and evidenced in chapters 2, 3, 4 and 8. Resourcing these services in a climate of recession and reduced health spend is a significant challenge.
Higher intensity therapy improves both patient outcomes and service efficiency.
Ireland lags well behind most other countries on this issue. For example, in the US, it is mandatory to provide three hours of therapy per day for at least five days per week in an in-patient rehabilitation setting. (ref required)
Early referral to rehabilitation medicine has been shown to reduce disability; however there is presently limited access to acute rehabilitation medicine assessment. A lack of rehabilitation bed capacity results in inappropriate usage of acute care beds and delays in discharge from acute care. (ref required)
Strategic, coherent evidence-based planning around capacity, needs and resourcing at appropriate levels of care is vital if people requiring services are to move in and out of the continuum without experiencing undue delays and without the system itself becoming blocked at different levels. Absence of data regarding incidence and
anticipated care needs presents a major challenge in assuring appropriate planning.
POPULATION AND SOCIETAL FACTORS
Advances in medicine and related fields mean that there are more people surviving acute injury with greater levels of disability. Changing family structures and patterns result in clinicians being unable to assume existence of family support structures for disabled people.
Those who are most severely disabled, even after a period of intensive rehabilitation, are susceptible to medical co-morbidities related to immobility, including decubitus ulcers, infections, contractures and venous thromboembolism. They and their families need support from professionals across all 3 levels of service delivery to manage and minimize the psychological, social and economic consequences of their disability.
INTEGRATION AND COORDINATION OF SERVICES
Neurological and limb absence specialist rehabilitation encompasses a range of diverse conditions and settings. The interface between disability management and specialist rehabilitation requires agreed guidelines and protocols regarding access and pathways of care.
47
The interface across services for children, adult and older people presents a
particular challenge and requires collaborative approaches to care. For instance, in Ireland currently due to an under-resourced service, there are substantial difficulties for service users accessing specialist rehabilitation medicine services after discharge from their formal in-patient rehabilitation if their condition deteriorates or changes.
HSE PROSTHETICS AND ORTHOTICS REVIEW 2012
A recent HSE review of prosthetic and orthotic services78 made specific recommendations regarding best practice. The recommendations include:
• Development of clear clinical pathways for the care of patients who need to avail of these services. In line with the policy in most other countries, it is
recommended that this service should be provided as close as possible to the patient’s home.
• The expertise of healthcare professionals who have received the necessary training in providing this service should always be involved in the care pathway for this patient population
• In the case of Prosthetic services, it is recommended that primary and complex cases must be referred to a Consultant in Rehabilitation Medicine for assessment prior to a prosthetic device being prescribed for that patient
• In the case of orthotic services, it is recommended that complex cases should be referred to a Specialist Multidisciplinary team which should include appropriate consultant care.
• Where third party suppliers are involved in the care of these patients, these suppliers must have demonstrated compliance with appropriate HSE National Standards (under development) and these supply arrangements must comply with EU and National Procurement Regulations and the HSE’s requirements for value for money, transparency and management of risk.
(more narrative on implementation plans needed)
78Prosthetic & Orthotics and Specialised footwear supply project, HSE, Dec 2012; awaiting release for consultation
48