REGION KRONOBERG. Revised by: Management Team. Authorised by: Gunilla Lindstedt Head of Operations Date: 22 April Produced by: Management Team

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1 Guide to the Rehabilitation Clinic, Växjö Postal address Street address Tel. +46 (0) Box 1223 Rehabilitation Clinic SE Växjö, Sweden J F Liedholms väg 14 Växjö Page 1 of 8

2 Contents 1. Assignment The purpose and aims of rehabilitation Foundations and ideology... 3 a. Ideology... 3 b. Biopsychosocial approach Rehabilitation s place in the care chain Environment s... 5 c. Inpatient Care... 6 d. Outpatient Care... 6 e. Pain Management Rehabilitation Process... 7 a. Referral and invitation... 7 b. Evaluation and Rehabilitation Phase... 7 c. Follow-up phase Results, evaluation and quality assurance... 8 These programme descriptions have been produced to provide patients, relatives and other stakeholders with information about how rehabilitation is performed in the various programmes. The provides an overall view of the activities at the clinic. It explains what specialist rehabilitation is, the clinic s place in the care chain, its ideology and values, organisation, etc. descriptions and guides are available: Guide to the Rehabilitation Clinic, Växjö, the Pain Management, the Inpatient Care, the Outpatient Care. These documents are available at the clinic website: Region Kronoberg Rehabilitation Clinic. Contact the clinic s reception: +46 (0) if you want the descriptions sent to you. Produced by: Management Team Date: 2013 Revised by: Management Team Date: 20 May 2016 Inspected by: Clinic Committee Date: 8 April 2016 Authorised by: Gunilla Lindstedt Head of Operations Date: 22 April 2016 Page 2 of 8

3 1. Assignment Region Kronoberg is responsible for healthcare in the County of Kronoberg. The operational organisation of the region has nine centres: Emergency Centre, Paediatrics and Gynaecology Centre, Surgical Centre, Medical Centre, Medical Service Centre, Primary Care and Rehabilitation Centre, Psychiatric Centre, Service Centre and Dental Care Centre. The Rehabilitation Clinic is part of the Primary Care and Rehabilitation Centre. The clinic runs specialist rehabilitation following a somatic disease or injury, primarily for adults from the County of Kronoberg. Specialist rehabilitation means that each profession has extensive experience of each patient group and in-depth theoretical knowledge. Region Kronoberg has produced rehabilitation guidelines for different diagnoses in order to provide an effective care chain with good and safe care. These guidelines determine whether specific diagnoses or conditions are treated at the Rehabilitation Clinic; and if so, in which part of the care chain. 2. The purpose and aims of rehabilitation The main aims of rehabilitation are to create the greatest well-being for the patient and to make their lives as active and independent as possible. The purpose of rehabilitation is to support them to meet the goals they have set for their family life, their working life and their free time. It is important to maintain the patient s integrity and participation, even if they need a lot of help. The long-term aims of the Rehabilitation Clinic are: satisfied inhabitants whose trust in our activities remains high the patients are happy with the rehabilitation they receive the people of Kronoberg turn to healthcare in Kronoberg first patients and relatives more involved in care high patient safety good accessibility within healthcare effective, high-quality activities an attractive employer with employees who enjoy their work and develop easy to recruit and retain employees with the right competence a sustainable and balanced financial situation the competence of the employees is employed as effectively as possible to meet the needs of the patients 3. Foundations and ideology a. Ideology We work with an individual-centred philosophy, based on values around Respect for people : - everyone has the right to be treated with dignity and respect - everyone should have access to the rehabilitation they need to achieve the best possible results - everyone should have the right and opportunity to make informed choices This means, for example, that: - the patient is part of the team, and the goals that are set up and the action that is taken are based on the wishes and needs of the patient. We prefer the patient s relatives to be involved in the rehabilitation process, if this is something the patient wants. Page 3 of 8

4 - we place a lot of focus on giving the patient and their relatives as much information and training as they need to maximise their ability to make informed decisions and achieve good rehabilitation results - we work hard to provide the best possible rehabilitation for each individual patient. This is achieved, for example, by providing continuous training, assessing the results and linking them to quality registers - we work to ensure that the individual patient/patient groups experience a good care chain in the County Council and when necessary, are transferred effectively to a different healthcare provider - we run continual training for staff on, for example, how to treat patients with respect, multicultural issues, etc., and to adapt the procedures and policies at the clinic based on a diversity perspective b. Biopsychosocial approach We take a biopsychosocial approach to our rehabilitation, based on WHO s International Classification of Functioning, Disability and Health, ICF. The functioning and disability of a person are seen as a dynamic interaction between health conditions (diseases, disorders, injuries, trauma etc.) and contextual factors. This means that as well as medical procedures, rehabilitation includes social, psychological and work-related measures. 4. Rehabilitation s place in the care chain Emergency healthcare in Växjö/Ljungby or regional healthcare Municipal home nursing and rehabilitation Self care Home Rehabilitation Clinic: specialist rehabilitation Primary care rehabilitation Continued support Most of the patients admitted to the Rehabilitation Clinic come from hospital, primary care and regional care services. Sometimes an additional rehabilitation period is required. Following a period of rehabilitation at the clinic, the patient often requires continued rehabilitation, either through self care, exercising by themselves or services from the municipality or primary care. The continued support may include follow-ups by the clinic and/or another healthcare provider or the municipality. Page 4 of 8

5 5. Environment The Rehabilitation Clinic is located in the Sigfrid district of Växjö. The clinic is on two floors. Accessibility and the environment have been adapted to people with disabilities. The clinic has a rest room, a common room with a kitchenette, a canteen and a lounge for patients and relatives. There is WiFi access - wireless network. The training areas are well-equipped, as are the group rooms and rooms for individual treatments. There is a pool, training yard, training kitchen, computer room, workshop, etc. There is also equipment for sports in the exercise hall and outdoors. The area around the clinic is like a park, with green spaces, perfect for walks and spending time outdoors. There is also an asphalt trail that starts by the clinic. Tennis, boules, mini golf and fishing are available in the area as well. 6. s Management Team (Head of Operations, Department s, Head Doctor/Medical Director) Specialist rehabilitation for patients with acquired brain injuries, including strokes Brain injury rehabilitation Specialist rehabilitation for patients with neurological diseases and injuries, as well as leg amputations and multi-trauma Neuro rehabilitation Specialist rehabilitation for patients suffering long-term pain Pain rehabilitation Inpatient Care Pain Management Outpatient Care Rehabilitation is performed in three different programmes in the neuro rehabilitation, brain injury rehabilitation and pain rehabilitation units. Neuro rehabilitation: Patients with neurological diseases and injuries, including MS, spinal cord injuries, post polio and Parkinson s disease. The neuro rehabilitation programme also treats patients who have had a leg amputated and patients who have suffered multi trauma, i.e. several serious injuries at the same time in different parts of the body. Brain injury rehabilitation: Patients with acquired brain injuries, including strokes, traumatic brain injuries or brain injuries caused by infection or tumours. Pain rehabilitation: Patient management programmes in course form as part of the outpatient care for patients with long-term non-malignant pain, mostly from the musculoskeletal system. The clinic accepts patients - who are 18 years old or over. Patients from 16 years old may be accepted, following a special agreement - if the condition/diagnosis falls within the remit of the clinic, including the Region s rehabilitation guidelines - if specialist rehabilitation is required to achieve the aims of the rehabilitation - if they have circulatory and respiratory stability Page 5 of 8

6 - if there is no ongoing medical treatment and/or evaluation, severe mental disease or misuse (tablets, narcotics or alcohol) that risks the rehabilitation of the patient himself/herself or the other patients c. Inpatient Care The Inpatient Care is for patients whose functions are impaired to such an extent that they find it difficult to carry out everyday activities. This could include, for example, problems moving or walking, washing or getting dressed, or communicating. More than 100 patients are accepted onto the programme in a one-year period. The primary diagnosis group is stroke, which accounts for 65% of the patients. The content and length of the rehabilitation period are adapted to the individual. The most common rehabilitation period is 30 days, but this can vary significantly. Treatment/training from a paramedical practitioner (physiotherapist, occupational therapist, speech therapist, psychologist and social welfare officer) is carried out on weekdays between around 9.00 and Training at weekends and evenings is possible; this is carried out with the help of nurses or the patient exercising by themselves. The intensity is adapted to the individual and varies over time. The most common is around 3 hours per day for treatment by a paramedical practitioner, either individually or in a group. Treatments by a doctor and nurse may be given, or the patient can exercise by himself/herself. d. Outpatient Care The Outpatient Care is for patients whose functions are impaired to such an extent that this restricts their movement, affects their home and free time activities, and their work/school activities. They can normally manage by themselves or with support in their own home. They must need two or more professions in the specialist rehabilitation. Around 130 patients are accepted onto the programme in a one-year period. The primary diagnosis group is stroke, which accounts for around 30% of the patients. The content and length of the rehabilitation period are adapted to the individual The most common rehabilitation period is 7 weeks and 2-3 days per week, but this can vary significantly. Treatment/training from a paramedical practitioner (physiotherapist, occupational therapist, speech therapist, psychologist and social welfare officer) is carried out on weekdays between around 9.00 and The intensity is adapted to the individual and varies over time. The most common is around 3 hours per day for treatment by a paramedical practitioner, either individually or in a group. Application in the home environment and treatment be a doctor/nurse may be included, and the patients may need to exercise by themselves. e. Pain Management The Pain Management is for patients suffering long-term non-malignant pain that has developed or is at risk of developing into a condition where pain controls their lives to a significant extent. Around 40 patients are accepted onto the programme in a one-year period and basic courses are held for up to 12 patients approximately every three weeks. Approximately 20% suffer pain in their lower back, while around half of the patients think that the worst pain area varies. The programme is mostly carried out in course form, in accordance with the guidelines for multi-modal rehabilitation and in interdisciplinary teams. Cognitive behaviour therapy is used, focusing on how participants manage in everyday situations. Page 6 of 8

7 Evaluation phase: Basic course: 4 days (Monday to Thursday), 5-6 hours/day. Individual evaluation: This starts with an evaluation by a doctor. if the rehabilitation programme is considered to be suitable, the patient will be further evaluated by an occupational therapist, psychologist, physiotherapist for one day (6 hours including breaks). Rehabilitation phase: Rehabilitation course: 8 weeks: Monday-Friday 3-4 hours/day; 24 days at the clinic and 16 application days at home. Application: 12 weeks. Daily application in the home environment. Treatment and other measures that are adapted to individual are normally carried out at the clinic. Conclusion: 1 day approximately 3 months after the rehabilitation course 7. Rehabilitation Process Referral and invitation Waiting list Evaluation and Rehabilitation Phase Follow-up Phase Referral Needs evaluation Treatment Follow-up Rejection Evaluation Application a. Referral and invitation Referrals can be written by a qualified healthcare professional. The patient can also write a self-referral. The referral form can be obtained from the Rehabilitation Clinic website or from reception by calling +46(0) The referral is assessed based on criteria from the clinic (programmes). b. Evaluation and Rehabilitation Phase Rehabilitation in these programmes is performed by a team, which includes the patient and, where appropriate, the relatives. The team works in an interdisciplinary way and provides coordinated, goalsdriven and fixed-term action. The team members will be determined by the needs of the patients and the level of care, and may change over time. One of the team members is the coordinator/coach and coordinates the patient s rehabilitation. They make it easier for the patient and any relatives to be involved in the rehabilitation process. The rehabilitation starts with an evaluation phase, to provide the data to be able to plan how rehabilitation should continue. During this period of time, the team, which includes the patient, assesses, for example, disabilities, restrictions for activities and participation, as well as obstacles and resources. A written rehabilitation plan is produced with the patient, setting out how they can be involved in the process. The plan is based on the assessment that the patient and the rest of the team make of resources, obstacles, expectations, disabilities, structural deviations, restrictions for activities and participation, and environmental factors that could have an impact. The goals, length and intensity of the period, sub-goals and actions are documented in the rehabilitation plan. The plan is regularly Page 7 of 8

8 evaluated and, where necessary, revised during the rehabilitation process. A plan is produced well in advance for when the patient is discharged from the clinic and for the period afterwards. Resources: Doctor: weekdays For inpatient care, Preparedness A also applies; 30 minute response time Nurses, assistant nurses: 24 hours a day, every day of the week Physiotherapists, rehabilitation assistants: weekdays Occupational therapists, occupational therapy assistants: weekdays Speech therapists: weekdays Social welfare officers: weekdays Psychologists: Monday to Thursday , Friday Urine therapist: Monday Dietitian: Every other Tuesday: Medical secretary: weekdays c. Follow-up phase After the end of the Inpatient and Outpatient Care, the patient is followed up, either by them coming back for a visit or by a telephone call approximately three months after they have been discharged, but this will depend on the individual. After the end of the Pain Management, the patient is followed up one year after the programme has finished. 8. Results, evaluation and quality assurance The Rehabilitation Clinic has an organisation in place that aims to continually improve the quality and results of all of its activities. There are working groups that cover all operational areas, for example, rehabilitation, accessibility, patient safety including hygiene, fire and safety, medical devices, staff and the work environment, technology and healthcare documentation. The working groups perform internal checks and reviews, and follow action plans that have goals and action points in order to improve quality and results. Reports are submitted to the Management Team every third. The Groups are also responsible for providing staff, patients and other stakeholders with training and information. The clinic encourages and promotes further training and collaboration in research and development. The programmes develop care programmes for the patient groups. They are involved in networks and take part in County-wide development and quality work. Time is allocated for personal development and continuing training for all professions and for the teams in the programme. The clinic is connected to rehabilitation quality registers: WebRehab Sweden, the National Register of Pain Rehabilitation and Senior Alert. This enables the clinic to monitor its quality and results and compare them with the country as a whole. The clinic uses CARF International an international, independent and non-profit accreditor of healthcare services. Results from the clinic can be obtained from reception, tel: +46(0) or from the clinic website. If you would like information about a specific programme, please refer to the programme description for Inpatient Care, Outpatient Care or Pain Management. They can be downloaded from the clinic website or contact the clinic s reception; +46(0) Page 8 of 8

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