A Guide to the Rehabilitation clinic in Växjö,

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1 A Guide to the Rehabilitation clinic in Växjö, Brain Injury Rehabilitation Inpatient Program Postadress: Box 1223, VÄXJÖ Besöksadress: J F Liedholms väg 14, Växjö E-post: Telefon: Telefax: Revised & collaborated with the management team Last rev:

2 Table of Contents The Rehabilitation Clinic in Växjö... 3 Assignment and Organization... 3 Specialized Rehabilitation... 3 Rehabilitations Place in the Chain of Care... 3 Criteria for Admission... 4 Health Care Levels... 5 The Three Units Within the Clinic... 5 Documentation... 7 Environment... 7 Rehabilitation... 7 Biopsychosocial ground... 7 Ideology... 8 Team... 9 Coordinator/Coach... 9 The Rehabilitation Process Duration and Intensity of Care Treatments Follow-up and outcomes Results and Statistics Integration Cost, Charges, and Fees Travels In Patient Program Description Criteria for Inpatient Care Results, Outcome, and Quality of Care Result and statistics Brain Injury Rehabilitation Description of Diagnosis Follow-up

3 The Rehabilitation Clinic in Växjö The rehabilitation clinic is located in Växjö at the St. Sigfrid s Campus near Lake Trummen, in an area surrounded by trees and breathtaking nature. In 2001, the clinic moved from the central hospital downtown Växjö to this beautiful area. The clinic offers a peaceful, comfortable, and healing environment, which seeks to aid in your personal rehabilitation process. The environment around the rehabilitation center is built in a way to provide an extensive continuation of care, and an array of different activities are available outside the clinic, in nearby parks, and around the lake. A restaurant, library, and a kiosk are also available for your convenience on campus. Assignment and Organization Landstinget is responsible for the health care in Kronoberg s County. This is governed by elected authorized political representatives. There are two hospitals, 33 primary care clinics, 15 dental care clinics, rehabilitation, and psychiatry located within this region. Landstinget Kronoberg is operated as a Federation with nine different units: Emergency unit, Children and Women unit, Surgery unit, Medical unit, Medicine Service unit, Primary care- and Rehabilitation unit, Psychiatry unit, Service unit, and Dental Care unit. The Rehabilitation clinic is part of the Primary Care and- Rehabilitation unit. Specialized Rehabilitation The rehabilitation clinic focuses on specialized rehabilitation for patients over 18 years old (most of them from Kronoberg s County). This means that our expert faculty and staff have longstanding experiences, and in-depth knowledge of every different group s health conditions. Our goal and mission is to create the most comfortable rehabilitation possible. We strive to be able to help, support and enable the patient to move on to an active, productive, and as independent life as possible. The rehabilitation will guide and support the patient s goals in family life, work, school, and recreation. It is important to us that a patient s integrity and participation continues regardless of their disability. Rehabilitations Place in the Chain of Care Emergency Care Växjö or Ljungby / regional care Community home care Self care Home Rehabilitation clinic: specialized rehabilitation Primary care rehabilitation Continued support Most patients that are admitted to the rehabilitation clinic arrive from the hospital or regional care, but can also be referred from the primary care, or community home care. Patients can also contact the clinic later on in their rehabilitation process, if they feel the need to. In some cases there may be a need to extend or renew the rehabilitation period, if their functional status changes, or if the patient has other special requirements. 3

4 Follow ups are an example of continued support for patients after their treatments. Usually this is done by the clinics that discharge them, and/or it could be done by another health care or home care professional. Patients over 65 years old who live on the west side of the county, and do not need cognitive training, can be offered inpatient rehabilitation, or day rehabilitation at the hospital in Ljungby. There are guidelines for different diagnosis which Landstinget Kronoberg follows, to provide excellent safe care, and to assure the right level of care. These guidelines will decide if a specific diagnosis or condition will be treated at the clinic. If this is the case, it will also decide where in the chain of care the diagnosis will be treated. In some cases with some conditions, for example ALS and RA, the rehabilitation clinic is not part of the chain of care. For more information about the rehabilitation guidelines for a specific diagnosis and what is permitted, go to Landstinget homepage: Fastställda rehabriktlinjer Criteria for Admission All inclusion criteria have to be met. If one or more exclusion criteria are present, then the patient is not admitted for rehabilitation, or the ongoing rehabilitation is discontinued. Inclusion Criteria - Be 18 years of age or older - Have a need for specialized rehabilitation - Have rehabilitation potential, or have a need for specialized environmental changes Exclusion Criteria - Unstable cardiovascular and/or respiratory problems - Ongoing medical treatments and/or an assessment that will affect a good outcome for the rehabilitation program - Serious untreated psychological disease, or unstable behavioral condition, which can affect the patient or other patient s rehabilitation - Apparent drug, narcotic, or alcohol addiction Criteria to transfer or to discharge a patient from the ongoing rehabilitation program - When any of the exclusion criteria occur, or are recognized during the rehabilitation period - When continued treatments will no longer benefit the patient and their goals - When the rehabilitation goals are achieved earlier than expected - When the need for specialized rehabilitation has been achieved and/or the rehabilitation goals can be reached in another way - When the need for highly specialized rehabilitation emerge during the rehabilitation Neuro rehab and brain injury rehab continue during that time period as determined from the planned goals and treatments. Both the goals and treatments can be revised during rehabilitation and may therefore also affect the rehabilitation length. The time period of pain rehabilitation follow the predetermined period for the pain management program. The planned period for rehabilitation is valid as long as the patient has clinical benefits, and is expected to reach their goals with the help of specialized rehabilitation, and if not any of the criteria for transfer or suspension of rehabilitation arises or is noted. Discontinuance of ongoing rehabilitation period When the rehabilitation period is discontinued due to the request of the patient or the rehab team, a regular discharge plan is done. To avoid any misunderstandings it is important to clearly explain, and 4

5 to give enough information in the most professional way, to the patient and the family why the treatment is being discontinued. The patient and their family should also be informed of other possible alternatives to the ongoing rehabilitation, and the possibility to return with a new referral. Health Care Levels The clinic accepts patients to both inpatient and outpatient care. The outpatient program includes rehabilitation reception or day time care. If patients have to travel far, then there is the possibility to stay at a patient hotel nearby. Inpatient care means that the patient stays either 7-days or 5-days/week. When changing care it is preferred to do so without any interruption in the rehabilitation process. The Three Units Within the Clinic The rehabilitation clinic and its treatments are divided into three different units: neurological rehab, brain injury rehab, and pain rehab. Neurological rehab: inpatient and outpatient program for patients with neurological injuries. For example, Multiple Sclerosis, Spinal cord injuries, Post Polio, and Parkinson s disease. This unit also treats leg amputee patients, and patients with multiple-traumas (patients with injuries occurring simultaneously in several parts of the body). Brain injury rehab: inpatient and outpatient program for patients with brain injuries. For example stroke, traumatic brain injury, infections, and tumors. Pain rehab: outpatient program for patient with chronic pain (not malignant). This is usually given as a class. Management Team Medical Physician Manager/ Medical director Specialized rehabilitation for patients with acquired brain injury inkl. Stroke Specialized rehabilitation for patients with chronic pain Specialized rehabilitation for patients with neurological injury as well as leg amputation Program Manager Brain-rehab Pain-rehab Neuro-rehab Program Manager Inpatient-program Rehabilitation goals focus on ADL s and transfers Inpatient-program Rehabilitation goals focus on ADL s and transfers Program Manager Outpatient-program Rehabilitation goals focus on ADL s, transfers, living and recreational activities Outpatient-program Rehabilitation goals focus on work/school or something equivalent to that. Program Manager Pain rehab-program Classes that focus on understanding and managing pain, and ability to increase patient s daily activities Outpatient-program Rehabilitation goals focus on ADL s, transfers, living and recreational activities Outpatient-program Rehabilitation goals focus on work/school or something equivalent to that. Program Manager 5

6 For each program there is one person that is responsible to oversee the program. The head of the clinic is responsible for the entire rehabilitation clinic, together with the medical team, which includes the doctors and the unit supervisors. Referral There are two methods for admission to the rehabilitation clinic. One is a referral from a doctor, or you can get your own. This you print from the: rehabiliteringsklinikens hemsida, or have it mailed to you with help from the receptionist at the rehabilitation clinic: Admission Facility Rejection of Referral; (usually because of wrong rehab choice) Pain rehab program Referral Assessment of Referral Acceptance of Referral; (decision about rehab unit, priority level, level of care, program etc.) Day program Inpatient program Acceptance; but need assessment Examination / assessment Discontinued specialized rehabilitation A referral that arrives to the rehabilitation clinic is assessed with help of criteria and Landstinget s guidelines. After acceptance the patients are placed on a waiting list to be seen by a medical professional, or the patient will be accepted straight to rehabilitation. If a patient needs to change rehab care, or program during his/her already planned care, then we strive for a change without interruption of the rehabilitation process. We want the transition to happen as smoothly as possible, and with the need of the patient s wishes and goals. The patients are usually referred to the rehabilitation clinic from the primary care clinic, or from the medical unit at the hospital in Växjö. During 2012, 727 referrals were handled at the clinic. The goal is for all referrals to be assessed within 5 working days and 1 working day for the referrals from the emergency unit at the hospital. The waiting time for treatment is validated by the warranty of care. Outpatient rehabilitation 2012: Median time for referral arrival to admission: 8 days Median time for the acceptance of the referral to admission: 6 days Day rehabilitation (not pain rehab) 2012: Median time for referral arrival to admission: 60 days Median time for the acceptance of the referral to admission: 43 days For similar information about pain rehab, please refer to the specific program brochure. 6

7 Documentation All professionals shall comply and follow the law and regulation: patientdatalagen (2008:355) and Socialstyrelsens regulation (SOSFS 2008:14), about how to handle information and documentation within the health care system. All documentations and patients are under confidential agreement. It is the responsibility of all professionals involved with a patient to read all documentation about that patient, and to make sure to follow any changes in their rehabilitation process. The patient has the right to be treated confidentially, but if necessary (and the patient gives permission) the patient s information is allowed to be shared to other health units. For example, some of these units include home care, primary care etc. This can then be done either by phone, documentation, or planned meetings. All medical documentations are written in Cambio Cosmic; a computerized health care information system, which is used by Landstinget, the district, and many private health care professionals in the region. Environment The rehabilitation clinic is divided between two floors, and is adapted to accommodate the disabled patients. The clinic has rooms to rest in, a common area with a kitchenette, and a combined dining area/social area, for the patients, their friends and family, for when they come and visit. The rehabilitation clinic has two inpatient units with 21 beds. Of these beds are 13 single rooms. The rooms are efficiently accommodated and equipped with everything needed, including all adaptive equipment for the patient during the duration of the rehabilitation. All of these necessities are provided by the clinic. In case the patients have adaptive equipment from prior therapy, it is recommended that they bring it, in order to accomplish the best result possible in practicing their transfer technique. We have well equipped exercise rooms, weight rooms, group rooms, and individual rooms. There is a swimming pool, a computer room, a woodworking room, an exercise garden and a kitchen available. There are also equipments to coordinate recreational sporting activities in the big hall, and also for outside. The outside environment around the clinic offers a wide range of possibilities. There are paved paths right by the entrance of the clinic to make the outdoor available for patients with wheelchairs, walkers, etc. The green park surrounding the area is ideal for wonderful walks and other outdoor activities. We also have tennis, lawn bowling, mini golf, and fishing possibilities. Rehabilitation Biopsychosocial ground The theory behind rehabilitation comes from a biopsychosocial ground that is based from WHO International Classification of Functioning, Disability and Health, ICF. 7

8 A patient s functional state and functional limitation is a dynamic interaction between health conditions (diseases, disorders, injuries, trauma etc.) and contextual factors. - Body Functions are physiological functions of body systems (including psychological functions) - Body Structures are anatomical parts of the body such as organs, limbs, and their components. - Activity the execution of a task or action by an individual - Participation is involvement in a life situation - Participation Restrictions are problems an individual may experience in involvement in life situations - Environmental Factors make up the physical, social and attitudinal environment in which people live and conduct their lives. Environmental Factors influence some components of functional state and functional limitation - Personal Factors make up one component of the Contextual Factors. These factors are not classified in the ICF, because of the great social and cultural variation that are connected to it The rehabilitation process does not only include the medical part of rehabilitation but also the social, psychological, and work related activities. This can lead to treatments that focus on improving the physical and psychological function and/or to change the environment or the use of adaptive equipments to compensate for ones disability. Ideology We believe in an individual based mission statement that states: All patients have the right to be treated with dignity and respect All patients should have access to all rehabilitation resources to accomplish the best possible outcome All patients have the right for the best possible and most fair choices This includes working towards: - The best rehabilitation possible for an individual. This is accomplished for each patient by offering continuing education to patients, families, the professional team, outcomes of results, and access to quality register - That the patient/patient group will have good continuation of the health care process with Landstinget. Also, when necessary, a good transition to another care giver - That we continue to conduct education to our professionals about questions that deals with how to greet patients and family, cultural differences etc. and to adjust to the clinic s routines and polices to be able to correspond to many different perspectives - That the patient is part of the team, and that the goals and arrangements are built on the patient s wants and needs. We also want, if the patient wishes to, that the patient s family participates in the rehabilitation process - That the patient and their families receive as much information and education as possible to elevate the potential for the best, and just rehabilitation result - That the patients with difficulties in communicating have access to an interpreter when needed 8

9 Team A team is used when the rehabilitation process needs involvement from many different professionals. An interdisciplinary team works towards a coordinated, goal oriented, and time limited achievements. The coordination of the rehabilitation process is determined by what is necessary for the patient, and can change over time. Beside the patient, close family (if appropriate), the team of one or more could also include: From neurological rehab or brain injury rehab: - Medical Doctor: have full responsibility medically for the patient s rehabilitation and decides the need for special rehabilitation, the adequate level of care, and when a patient is medically treated - Registered Nurse: responsible for the overall rehabilitation care in support of the physician - Practical Nurse: help with the rehabilitation care in support of the registered nurse - Physical Therapist/Rehabilitation assistant: focus on movements, possible movements, movement potential, and behavior of movement - Occupational Therapist/Occupational Therapist assistant: focus on activities to enhance functional performance and participation in daily activity - Speech Therapist: focus to improve communication, language, speech, and patients with swallowing difficulties - Social Worker: focus on being an advocate for the patient and their family. Also gives advice and support in life changing situations - Neuropsychologist/psychologist: focus on assessment, support, psychological treatments, crisis therapy, and assessment of cognitive functional limitations - Uroterapeut/sexologist: focus with problems with the bladder and sexual dysfunction - Dietist: work with the patient for a better diet and diet plan From pain rehab: - Medical Doctor: have the most comprehensive medical responsibility, and to select the optimal medicine for the patients. Be able to explain the reason for pain and to handle questions about medical insurance plans. - Psychiatric nurse: gives the patient the necessary tools to handle challenging situations, gives support, and increases the process of acceptance. - Psychologist: educate the patient about the effects of living with pain and the different areas it might influence on a daily basis, and to give treatments to improve daily functions. - Physical Therapist: focus on treatments that involve movements to increase/encourage well being and health. - Occupational Therapist: focus on encouraging the patient to become independent in daily activities. - Rehab assistant: improves living habits and gives pain/stress releasing treatments. Coordinator/Coach One of the team members is the appointed leader to organize the patient s rehabilitation plan. This means that he/she coordinates the rehab process, and make sure the patient and everyone involved receives all the information and education that are needed. Also, the leader helps with facilitating patients and their families to participate in the rehabilitation. The patient meets with their coordinator regularly to discuss different aspect of the rehab plan. 9

10 The Rehabilitation Process Patient and the team s assessment Rehabgoal The plan and its action Evaluation / assessment New Goal The plan and its action Outcome of rehab goals Followups The coordinator/coach and the patient go through the patient s resources, limitations, and expectations together. The team s decisions are based on the ICF model, the functional limitation, structure divergence, limitation around activity, participation, and the influence of environmental factors. The ICF model is used as a foundation to establish a rehabilitation plan with a rehabilitation goal and a partial rehabilitation goal. This is done together with the patient so he/she have the possibility to correct, and to influence the plan and its goals. The plan also describes the patient s main goals and duration of time of care expected to be able to accomplish these goals. These goals are constantly reviewed and evaluated during the entire duration of the treatment. New goals can always be added and changed when necessary. The discharge and the plan after discharge are started ahead of time. The rehab goals are evaluated, and a potential follow-up is also planned. This is documented in the intial rehabilitation plan. Duration and Intensity of Care The specialized rehabilitation process is one part of the rehabilitation that the patient might need to be able to accomplish his/her goals. The content and the time needed for rehabilitation is decided by the necessity and individual conditions. It could be anything from a few weeks to many months. The median time for inpatient rehabilitation is about 30 days. The day rehabilitation is about 2-3 treatment days for 6 weeks. Besides the rehabilitation programs, the clinic also offers other programs and classes, for example, MS program, Stroke program and walking program. When the patient participates in these programs, and also in the pain rehabilitation program, then it follows the schedule for that particular program. The intensity of the treatments is individualized and varies over time, depending on what the patient needs. The usual treatment intensity for inpatients is 3 hours a day with a paramedicinare - this includes Physical, Occupational, and Speech Therapist, either individually or in a group. The usual treatment for day rehab is 2-3 hours/2-3 days per week with a paramedicinare either individually or in a group. In addition to these treatment periods there are also additional treatments by doctors, nurses and self training. Inpatients also have in-conjunction with the treatment period, an additional time in the evenings and the weekends with the in house health care professionals. Treatments The patient s daily treatment program is individually based. Besides the treatments that are acquired for a better function, there could also include a plan to in some way find compensations for functional limitations and to adjust to environmental factors. Learning new ways to accomplish an activity can improve the patient s possibilities for activities and participation. The treatment can also include pedagogical approach, advice, and support to help both the patient and the family to handle their life situation in the best possible way. Lab analyzes, X-ray, consultation, etc. Rehabilitation is included in council care and use the lab service, specialist operations, etc. available on the hospitals. Patient Responsible physicians provide notice of results to the patient. Rehabilitation has daily service from the pharmacy for drug delivery. See additional information on the website; Landstinget Kronoberg. 10

11 Follow-up and outcomes Follow-ups are based on the clinic s routine to follow-up different rehabilitation programs and diagnosis, and are modified on individual necessity. The follow-ups are usually done 3, 6, 12 months after discharge. These are done either by an appointment at the clinic and/or a phone call. The progress is evaluated against the discharge plan, rehabilitation plan, changes in the patient s function, and ability of activities and participation. Besides the follow-up of the entire rehabilitation period, there is also a follow-up using the different quality index, for example WebRehab and NRS model. Results and Statistics The clinic follows the clinical results regularly, and uses it for statistics for many different parameters. This is done to be able to follow the development over time to ensure the best quality of care. In the different guides: inpatient and outpatient, neurological, brain injury, and pain rehab, some of the results and statistics are identified. Integration Integration occurs in accordance to the patient s wishes and needs. If the patient is in need of help from the community home care or another care taker, then the patient and his/her family is invited to a health care plan meeting. When necessary, the social insurance office, employment office, and the patients employer are invited to the meeting as well. Cost, Charges, and Fees The rehabilitation is financed through the social system. You can find more information about the different individual fees, high cost protection, and all other fees and charges at Landstinget s homepage: vårdguiden, and read more at: Patiententavgifter i Kronoberg. Landstinget s customer service might also be able to answer some questions about high cost limit cards, charges, invoices, payment plans etc. Tel Food and medicine are included for the inpatient, but not for the outpatient. Treatment equipments are free during the ongoing rehabilitation period. There could potentially be a charge for social events, certifications, and materials. Travels Patient travels Travels are reimbursed by Landstinget for travels to and from the different health care s within the region. Receive more information at: Landstingets hemsida, and if you still have more questions please contact the receptionist at the clinic: Transport Service Sigfrid s: One will find Service trip dial a ride between Växjö hospital and the Sigfrid s campus. This needs to be booked in advance, at least an hour before departure. The trip is booked with Service trips Parking The rehabilitation clinic offers free parking close by. There are 7 handicap parking spaces around campus. 11

12 In Patient Program Description Neurological- and Brain Injury Rehabilitation The inpatient program includes neurological and brain injury rehabilitation. It is for patients that are unable to stay at home, because of their disease or injuries, and extensive need for care. The patient has acquired a decreased functional ability that makes day to day life difficult to maintain. It could be for example difficulties with communication, transfers, gait, and being able to wash and dress themselves. Inpatient program means that the patient stays either 7-days or 5-days/week. When a patient stays for 7-days it is the inpatient s medical doctor s responsibility to care for the patient medically 24 hours/day 7 days/week, even when the patient leaves for a day or two. 5-day care is permitted when the patient is able to stay at home from 4 P.M Friday afternoon to the first weekday after the weekend arriving at 7 A.M, the earliest. The doctor at the rehabilitation clinic has the medical responsibility for the patient when he/she is at the clinic. If the patient needs hospital care or any other health care during the time he/she is not at the clinic, then the patient would seek care in the same way the patient did before he/she was admitted to the clinic. Criteria for Inpatient Care Admission criteria for the inpatient program - The need of specialized rehabilitation care, which relates to personal care and transfers in conjunction with this, and/or the need for rehabilitation care 24 hours per day - Medical Reasons - In need of environmental arrangement only. To try out different programs. For example programs in prevention of contracture, individual or work related adaptive equipment and /or techniques to increase participation, education/guidance from home care or other supporting professionals. This includes the patients that cannot be active and take part of the rehabilitation because of disease/or injury Examples of reasons of outpatient care even when patients are placed in inpatient care. - When treatment arrangements do not need inpatient care, then the patient can be treated as an outpatient. When the treatments are focused on accomplishing easier activities of daily living and including transfers between these activities Example of change of care, program From 7-day care to 5-day care - After an evaluation, and it has been decided that the patient is able to stay at home over the weekend with or without extra help (for example from home care) From inpatient care to outpatient care - When an assessment shows that the patient has a much greater possibility to reach his/her rehabilitation goals if changing programs to another level of care Discharge - When the rehabilitation goals are reached - When not even specialized rehabilitation goals are able to be reached The change of the level of care, program, or discharge is made together with the patient and their family. The medical doctor is fully responsible that the medical issues (if there are any) are not an obstacle to this change. 12

13 Inpatient Rehabilitation Program The inpatient s main rehabilitation goal is that the patient is able to move back home and become selfreliant. The purpose is for the patient to be able to transfer, wash and dress oneself, go to the bathroom, eat, communicate, and to do easy daily activities as self-sufficient as possible. The patient and their family are also educated on how the patient can take care of personal hygiene, and how to prevent potential complications. An important principal in the rehabilitation process is to train towards goal oriented tasks. Exercises can focus on practicing personal hygiene, dressing, transfer, gait, and how to eat and drink. By taking part of the daily activities at the clinic, for example making the bed and doing the laundry, then the patient has these additional goals to accomplish. The patient along with their family, and eventually other care takers, are continuously trained, educated, and informed for the patient to be able to accomplish these activities at home. The success of participation is education about ones diagnosis, possible rehabilitation treatments and any other possibilities. Therefore, the patient s rehabilitation team has an important role to inform and educate both the patient and their family. In the beginning of the rehabilitation period all patients receive a binder with information. Inside, one will find all the relevant information about the patient s illness, injuries, rehabilitation plan, and training program. A day program is coordinated on a weekly schedule, Monday through Friday, with appointments for treatments, assessment, rest etc. Then there are an additional self training program that are added to the evenings and weekends with help (if necessary) by the in house health care professionals. We encourage and prefer the patients close family to participate with the rehabilitation as much as possible, for example, by participating in their exercise program, the rehabilitation meetings, and the overall care. It is of the upmost importance to the team to give the family support, education, and information about the patient s rehabilitation. The Rehabilitation Process The patient, and perhaps the family, is greeted by the health care professional when they arrive. The coordinators for the patient are the contact nurse and the practical nurse. They make sure to communicate, to the other team members, any views about the rehabilitation process, wishes, and any other particular needs the patient might have. The coordinators are also responsible for the patient s participation in the daily activities, in accordance to the rehabilitation plan. The medical doctors are responsible for inpatient admission. This is done the first day they arrive. physiotherapist and occupational therapist try out help/adaptive equipments and make a transfer assessment. Within two weeks of arrival an appointment for the first rehabilitation meeting with the patient and the team is made, and if the patient wishes, this can also include their family. During the meeting a rehabilitation plan is completed. This plan becomes the building blocks for the rehabilitation process. Recurring meetings are done every other week, or every three weeks to assess and to revise the goals. The discharge plans and eventual change of health care level are also done during these meetings. Leave of absence is a very important part of the rehabilitation. The staff, together with the patient and their family, works very hard to fulfill this as soon as possible. The first leave of absence usually happens as a home visit, together with the occupational and physical therapist, to be able to assess the home, accessibility, and possible need for adaptive equipment. The home visit is also coordinated with 13

14 the community occupational and/or physical therapist. The nurse from the clinic administers and organizes the medical needs during the leave of absence. The rehabilitation clinic reimburses the round-trip for the first leave of absence. After that the patient is expected to be able to travel by service trips, private trips, or self pay. The leave of absence is granted, at the most, from Friday afternoon until Monday morning. In some cases, the leave of absence is granted on a week day, as an exception to make it easier for the community staff to be able to plan the care. When the patient is admitted to the 5 day care, then the round-trips during the weekends are free. During the entire rehabilitation process there is a gradual plan for discharge. There might be a need to educate and instruct the people that might be helping the patient in the future. When the need for help from, for example home care during the weekend s leave of absence or for future discharge, then an organized, coordinated health care meeting is planned, SVPL. Also attending this meeting, besides the patient and their family, is the home care staff and the staff from the rehabilitation clinic. At this meeting the focus is mainly on the patients goals, wishes, and to help them accomplish as much as possible. The rehabilitation plan also summarizes the discharge plan and the future plan after the patient being discharged. Besides, the eventual overall help it can also include seeking help for self care. For example, self training, exercises, secondary prevention, a contact with other medical health-care professionals, or a plan for follow-ups. The patient also receives a medical summary when discharged. Inpatient s Resources at the Rehabilitation Clinic: Medical Doctor: Available during the day/ weekdays. All other times readiness : which means possibility for immediate contact by phone with two hour calling-up time. Have full responsibility medically for the patient s rehabilitation. Evaluate functional limitations and relation with known organ injuries. The medical doctor is responsible for the assessment, decisions and viewpoints for the medical treatments. Is also fully responsible for past assessments, evaluations, and if there is a need for further additional examinations, or a need to refer the patient to another specialist. Example of contributions: - Medical information and advice to patients and their family - Educate on relevant medical views on the disease to the others in the team - Issuing of certifications Registered Nurse (RN): Available 24 hours a day, 7 days a week Has full responsibility for all health care services. They coordinate and communicate with home care staff, primary care staff, and the families. They also give professional health care services, assess and perform special nursing duties. For example, some of these nursing duties include urinary/bowel function, food intake, skin, sleep; administer medications and medical procedures in support of the medical doctor. Assist in preventing health issues, motivates, and offers help for the patient to change their life habits. Practical Nurse (LVN): Available 24 hour, 7 days a week Work with general health care. Helps the patient feel as comfortable as possible based on the needs and the patient s capabilities. Perform different tests and examinations ordered by the medical doctor and delegated by the registered nurse. After delegation from the occupational, physical, and speech therapist the nurse assist in practicing personal hygiene, transfers, and communication/swallowing function with the patient. 14

15 Physical Therapist: available during the day/weekdays Through evaluation, exercise training, and treatments improving the patient s function, to increase activity and participation in, for example shorter transfers and personal hygiene. This is done by: - Evaluating possible movements, movement potential, and behavior of movement - Individual treatment strategies to improve the patient s function and motor skills - When necessary learn new strategies and techniques - When necessary to compensate for functional limitations, for example by trying out adaptive equipments - When necessary assist in home visits to encourage leave of absence or discharge Rehabilitation assistant: available during the day/weekdays Training and treatments delegated by the Physical Therapist Occupational Therapist/ available during the day/weekdays Focus on encouraging the patient to live a life as active as possible, in agreement with the patient s wishes, needs, and accordance with what the patient can do in relationship to environmental demands. This is done by: - Mapping of the patient s previous and current activity performance in personal hygiene, and general daily living activities. - Relearning and training new ways to accomplish activities of daily living. - Compensation, for example by using adaptive equipments and adjusting activities to match the patient s current situation. Occupational assistant: available during the day/weekdays Training and treatments delegated by the Occupational Therapist Speech Therapist: available during the day/weekdays Evaluate and treat patients with speech, reading, and writing difficulties/deficits. Offers help for patients with dysphagia (difficulty in eating and swallowing in a secure way). This is done by: - Mapping of language skills. For example speech, reading, and writing - Individual adjusted training program in speech and language - Offering help together with the patient and their family to find and develop an overall communication skill that works - Assessment of swallowing deficits - Training techniques and strategies to cope with swallowing difficulties Social Worker: available during the day/weekdays Provide a complete psycho social assessment in order to give advice and support for the patient and their family in life changing situations. This assessment helps the social worker to focus on being an advocate for the patient and their family. They offer: - Emergency/crisis and support groups for the patient and their family - Information and education to increase the possibilities for the patient to take advantage of the community s resources, so the patient is able to normalize one s life as much as possible, despite their illness and functional limitations - Support and help to contact other authorities and institutions. Neuropsychologist/psychologist: during the day/weekdays Focus on evaluating cognitive, emotional, interpersonal status, plus provide general psychological assessment and pain assessment. Analyzing the availability and possibilities for the patient s family to be able to participate, support, and handle a roll change that the new situation demands. 15

16 Examples of treatments: - Individual support groups - Insightful oriented psychological treatments - Emergency and crisis therapy, and support groups for the patient and/or their family - Suggestions of cognitive treatments by relearning old habits or relearning of internal or external compensation strategies. Uroterapeut/sexologist: one day/week Support the team and meet the patient for a private conversation. It could include a wide range of topics, such as urinary leakage, exercise, difficulties in emptying ones bladder and for sexual advice. Dietist: One day every other week Diet advice depending on diagnosis or functions, and follow-up as needed. Dietitian also provides advice to the health care staff for individual patient cases. Team Communication Inpatient To secure that the rehabilitation process continues according to the rehabilitation plan, it is very important with the communication between the team members. Except during the rehabilitation meeting each and every member of the team is expected to meet the patient and their family privately when necessary. Team conference and reports, about the patient, is presented every week. A medical round with the nurse and the medical doctor is done twice a week. All professional staff reads the medical journal before their designated treatment period and complements this with a verbal report. Collaboration To be able to support the patient in the best way possible, the clinic collaborates with many different departments. This collaboration takes place in accordance to the patient s wishes and needs. Some of the departments are: - Different units within Kronoberg s health care region, especially the medical clinic s stroke unit. The clinic for surgery/ coronary artery surgery/amputation and the neurological team - Certified orthopedic technician from Team Olmed visit the clinic one afternoon a week. They analyze and try out different orthopedic equipments, also arrange follow-ups and evaluation together with a Physical Therapist. When necessary an appointment for consultation can be scheduled - Skåne s university hospital, medical rehabilitation clinic - Central adaptive equipement department - Communal and private health care services - Different organizations (patients Associations) for example NHR (Neurologisk Handikappades Riksförbund). DHR (Delaktighet Handlingskraft Rörelsefrihet), Strokeförbundet, Hjärnkraft, Afasiföreningen, Personskadeförbundet RTP. Kfa (Koalition för amputerade) 16

17 Results, Outcome, and Quality of Care For, continuing updates of results these outcome measures are registered for example: - The patient s experience if a goal has been reached (by measuring, with help of a modified version, PSFS scale 0-10) - To what level the patient returns to their ordinary living arrangements (registered in Web Rehab Sweden) - The level of functional independence by analyzing personal hygiene, shorter transfers, and simple living activities/tasks( through using FIM=functional independence measure) - Patient-perceived health status EQ-5D The quality of care follows certain different parameters in accordance to a national quality register index (Web Rehab Sweden) over time. It follows the patient s experiences about their rehabilitation period, the patients and their family s experiences of participation, and if they have received enough information. The register index also follows the effect of the rehabilitation, the ability to measure the outcome on each individual patient compared to other patients located at the same unit, and/or patient with the same diagnosis throughout the country. Result and statistics The information is from Web-rehab and refers to the inpatients discharged during Number of patients 152 Age, median (min max) 68 yr. (25-95yr.) Duration of care median (min 30 days (9-344) max) Women/men K: 40% M: 60% The largest diagnosis-group Percentage distribution Admission from: (days of care, median) Stroke 52% (30 days) Stroke unit 48% Demyelination diseases 7% (30 days) Other emerg. clinics 22% Another neurological diagnosis 9% (30 days) Home 21% Orthopedic activities/ Other diseases and injury within mobility apparatus 7% (25 days) First time at the rehabilitation 82% Independent with ADL IN OUT according to FIM (median values) (max 91) Physical items Difference In - Out 13 (max 35) Cognitive items Difference In-Out 2 Living and dependent after discharge Independent living w/o supportive 47% assistance Independent living w/ supportive ass. 35% Assisted living (incl. short time living) 14% Stroke is the largest diagnosis within the inpatient program. Of all the patients admitted to the program, about 80 % are admitted right after being diagnosed with a condition, or when a previous patient relapses. 17

18 Almost half of the patients at the inpatient program can return home, living independent without supportive assistance. Some of the patients need to be admitted to the community s short term living, before going home. The reasons could be for example, that they are waiting for certain living modifications to be made. According to FIM, the level of independence is recorded over time to be able to map out and to follow the development of the different groups of patients, at admission and discharge. An effective measurement for inpatient rehabilitation program is for example, counting the amount of days required to reach certain FIM points. The effective measurement 2012 was 2 days, which is a good number. Patients experience during the rehabilitation period (satisfied and very satisfied) Collaboration with the staff Very Satisfied 71% Satisfied 18% Sum: 89% Own influence with the rehabilitation including rehabilitation plan Very Satisfied 49% Satisfied 37% Sum: 86% Information and greeting toward family members Very Satisfied 55% Satisfied 23% Sum: 78% Rehabilitation Very Satisfied 54% Satisfied 32% Sum: 86% 18

19 Brain Injury Rehabilitation The Brain Injury Rehabilitation program includes patients that have suffered from stroke, traumatic brain injury, or injuries due to infections, tumors, etc. This program also includes patients that do not have full potential for a successful rehabilitation. They include: - Patients that are in need of environmental adjustments (from specialized professionals), but their injuries are to extensive to expect a successful rehabilitation - Patients that cannot utilize immediate rehabilitation after being discharged from acute care, but are expected to reach rehabilitation potential within 3 months. These patients receive a referral and are evaluated at home/assisted living by the team and the professional staff from the rehabilitation clinic. If the patient is not able to reach a successful rehabilitation within the 3 months, then the patient is discharged. A new referral can always be issued at a later time. Description of Diagnosis Stroke is defined as a focal neurological deficit, resulting in either ischemic or hemorrhagic lesions in the brain, which persists beyond 24 hours. If the symptoms resolve completely within 24 hours, then it is transient ischemic attacks (TIA). Stroke is one of the most common of our diseases, about as common as heart attacks. In Sweden about people suffer a Stroke every year, about 500 in Kronoberg s region. This is a very large group, and many presents with remaining decreased abilities, that could lead to a decreased quality of life. The extent of the problems, prognosis, and type of symptoms are different depending, partially, on lesion-location in the brain. There could be noticeable and/or hidden functional limitations. Symptoms are, for example dizziness, hemiplegia, difficulties in eating/drinking/swallowing, communication deficits, neglect (inability to process and perceive stimuli), fatigue, decreased memory, difficulties concentrating, decreased problem solving, mood swings, and initiative deficits. Traumatic Brain Injury, TBI occurs when a physical, external force traumatically injures the brain. The extent of the problems with a traumatic brain injury can vary from mild; a short lived alteration of the psychological condition, to severe; long-lasting unconsciousness or amnesia (lost of memory) after the injury. In Sweden about people suffer a TBI every year (based on the amount of people that visited the emergency room for traumatic brain injury). About 80 percent of these numbers have a mild injury. This usually occurs in connection with motor vehicle accidents, falls, or assault. The treatment with modern neurosurgical intensive care have increased the last few years, which have lead to a major increase in survival rate for patients with Traumatic Brain Injury. Changes after a brain injury could mean that things that were obvious before are now difficult or even impossible to perform. A brain injury can result in memory deficits, difficulties concentrating, mental fatigue, mood swings, altered sleep cycle, personality change, decreased motor skills, paralysis, speech deficits, and decrease balance. It is common that the patient has difficulties doing things simultaneously, or starting a task over again when one was unexpectedly interrupted. Many need to live a quieter life after the injury. 19

20 Brain Injury Rehabilitation Treatments After the injury it is very important for patients suffered from a Stroke to get a considerable amount of physical and mental stimulation, to be able to regain as much functional ability as possible. How much and how fast the patient will recover is individually. For many patients, the rehabilitation is a long lasting process. Treatments for traumatic brain injury and stroke patients could include: - Treating risk factors and preventing the patient to fall ill again. For example, treating high blood pressure/hypertension, diabetes, atrial fibrillation, obstruction of the aorta, and hyperlipidemia - Educating and follow-up secondary preventions of complications, by getting help with, for example, good life style choices, information on smoking, drinking, diet, and physical activity - Treatments for depression and sleep deprivation - Treatments to increase swallowing function, and increase speech, language, and communication skills - Treatments to improve the management of the urinary/bowel function, and prevent leg/hand edema. - Treatments in mental and physical stimulation - Improving muscle strength, endurance, balance, gait and treatments for spasticity and pain - Goal directed tasks, for example, wash and dress oneself. Accomplishing easier activities of daily living, for example making breakfast etc. and including transfers between these activities. - Trying out and adjusting new adaptive orthopedic equipments to compensate for decreased functional-and activity abilities - Support and education on how to deal with intimate relations, for example sexual dysfunction - Educating the patient on the disease/injury and the consequences that the diagnosis can have on one s life. Also, developing life-coping strategies. - Educate and teach family members, and other professionals, for example on how to support the patient in the right way Follow-up The follow-up concerning risk factors for the stroke patients are done at the primary care unit. This is completed to prevent the activity-and participation level that has been reached, not to get worse (which is usually the case, especially with older stroke patients). It also includes a plan for continued treatments, and a follow-up for the treatments, according to the clinic s routines. If the patients have succeeded beyond expectations it is important to notice a possible need for additional treatments, to be able to improve the patient s activity-and participation level. For questions about the content of the guide, please contact the rehabilitation clinic in Växjö, at the front desk:

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