The feasibility of acute and vocational rehabilitation for patients injured in motor vehicle accidents as proposed by RABS

Transcription

1 The feasibility of acute and vocational rehabilitation for patients injured in motor vehicle accidents as proposed by RABS The idea of reintegration of persons who have sustained injuries in motor vehicle accidents into the workplace is ideal. Theoretically, it is common practice that following injuries sustained in an accident, a patient would firstly receive acute treatment, usually at a local hospital or clinic. During this patient s stay at the acute facility, he or she would be introduced to supplementary health intervention aiming to improve this patient s level of independence and assist him or her in returning home safely. This would include physical and mental rehabilitation. Referrals are also carried out in this phase to ensure post-hospital care. Secondly, such a patient will be discharged and is expected to attend post-hospital rehabilitation to promote basic function and ADL (Activities of Daily Living). Following the latter, the patient would receive vocational rehabilitation, if he or she is a suitable candidate, to ensure successful return to work. Below is an illustration of the proposed process of service delivery for recovery following injuries sustained in a motor vehicle accident: Accident resulting in injuries Acute hospitalization: including supplementary health intervention Post-discharge rehabilitation Vocational rehabilitation Return to open labour market This is indeed an idea to strive for, yet in our current circumstances, not feasible. The factors influencing the feasibility of this idea are as follow: 1. The injured person is usually taken to the hospital nearest to the accident site. Whether it is a government or private hospital, screening will first be performed and in many cases, the patient will be transferred to another hospital for treatment. It should be noted that it occurs quite regularly that a patient is involved in an accident far from his place of residence. He or she will therefore also be hospitalized far from home. Should this be the case, it is of utmost importance that the communication between the admission acute hospital and the patient s local hospital or clinic is effective. A patient is mostly expected to return to a hospital (whether it is the admission hospital or the hospital the patient was referred to) for follow-up visits on an out-patient basis. Having to travel far distances to do so, often hinders the patients ability to attend these sessions. During contact with patients who have sustained injuries in motor vehicle accidents, they are asked why they never returned to the hospital for follow-up sessions. The answer is usually that they often encounter financial difficulties. This is plausible when considering costs incurred when travelling utilizing public and private modes of transport. The lack of inherent motivation is also a great factor, since traveling longer distances often exacerbate pain, particularly in individuals who have suffered orthopaedic injuries. The emotional effects of a motor vehicle accident which often manifests as fear, anxiety and 1

2 flashbacks when travelling in a motor vehicle is an even greater hindrance for patients to travel long distances. 2. Lack of supplementary health intervention in the acute phase as well as postdischarge. As explained, it is expected that supplementary health practitioners, such as a physiotherapist or occupational therapist, assess a patient during the acute hospitalization, to determine the need for rehabilitation. In many instances, the patients, for whatever reason, did not receive supplementary health intervention in the acute hospital. For example: The patient will be discharged without walking aids, etc. Supplementary health intervention in the acute hospital is not only important to ensure that the patient can return home safely, but also to initiate post-discharge medical care. The practitioner should refer such a patient to his or her nearest physiotherapist or occupational therapist and should contact these therapists and ensure that the patient s postdischarge plan is set in place. In most of the cases referred for medico-legal assessments, the patients did not receive post-discharge supplementary health intervention. The reasons for this include: i. They never received intervention in the acute hospital. ii. If they had to return for follow-up sessions, it was usually a follow-up session with the doctor. The patients regularly reported that a lack of finances to travel or their pain affected their ability to attend these sessions. 3. Unavailability of proper post-discharge management. Idealistically, a patient s care should be handed over to his/her nearest hospital, clinic or doctor. This, seemingly seldom occurs and due to lack of adequate post-discharge patient management systems, a greater number of patients slip through the cracks. Most often, those patients from impoverished backgrounds. 4. Deficiency of appropriate post-discharge rehabilitation in rural areas. If indeed the patient received all the necessary interventions during the acute hospitalization and referrals are set in place, the question remains if the patients who reside in rural areas will receive (or receives) appropriate treatment. Having worked in a rural area, it is well known that the ratio of therapist and patient is regularly imbalanced and medical practitioners and therapists visit rural clinics either once a week or once a month. The question is asked if one could expect intensive rehabilitation or appropriate post-discharge rehabilitation in a rural area. 5. Deficiency of proper rehabilitation facilities. One could argue that these patients could receive in-patient multi-disciplinary team rehabilitation at a rehabilitation unit. Yet, one should keep in mind that not all patients qualify for these services. Again, there is also the question of private patients versus government patients and if private and governmental services are available equally. If a person who sustained injuries in a motor vehicle accident will require multi-disciplinary inpatient rehabilitation, will governmental or private institutions render this service? 6. Are there sufficient institutions available, whether private or governmental, and will the institutions have the required facilities for such a patient load? In reality, research indicates that there appears to be a major lack of such facilities particularly the physical and mental rehabilitation and vocational rehabilitation 2

3 (when considering the proposed scheme) in both the private and governmental institutions. 7. Current difficulties with all areas of medical service delivery. It is well known that there are several areas in our medical field that need improvement at baselevel (acute phase) to ensure that: i. All patients receive appropriate medical treatment. ii. All patients receive supplementary health assessment and intervention. iii. All patients have fair access to post-discharge rehabilitation and medical services. iv. All patients receive post-discharge rehabilitation (this entails all supplementary health intervention focusing on the patient s basic level of function including ADL and personal care, mobility, etc. This needs to be in place prior to receiving vocational rehabilitation). 8. Geographical location and availability of services affecting vocational rehabilitation. Vocational rehabilitation facilities are not readily available and not well known. For example, there is only one vocational rehabilitation facility in the Free State. Therapists at this facility are only aware of another facility in the Western Cape. It therefore appears that communication between some of these facilities is not established. 9. Receiving vocational rehabilitation is already restricted in terms of the availability of these facilities. Now should a facility be identified, it is highly likely that the patient will need to travel to this facility. Traveling and accommodation will pose a hindrance, for vocational rehabilitation does not occur in one session, but requires several sessions and can be a lengthy progress ranging from three to 12 months depending on the severity of the patients injuries. Idealistically, following vocational rehabilitation, a person needs to work in a protected environment, something like a half-way work area where the therapist can monitor the person s work and progress in conjunction with the employer. This of course is subject to the availability of such occupations/employment/work stations and is unquestionably subject to the willingness of an employer to accommodate persons with disabilities/difficulties. This in itself is challenging when considering our country s high unemployment rate and restricted employment opportunities. Having all patients attend vocational rehabilitation, will require the following: i. Readily available resources: Vocational Rehabilitation centers available in most towns and cities. ii. Travel allowance for patients to reach such institutions. iii. Accommodation allowance for patients during their time of rehabilitation. There are also other questions that come to mind when considering the scheme/idea set out afore: 1. RABS appear to suggest that all patients who were involved in a motor vehicle accident receive vocational rehabilitation. However, the question arises if all patients are candidates for vocational rehabilitation? For example, 3

4 the 55 year old patient who underwent serious debilitating injuries. Is it fair to expect a person who is deemed unfit for work by other experts, to receive vocational rehabilitation? From a therapist s point of view, spending time on vocational rehabilitation on a patient who is not a candidate for such, wastes precious therapy time that could have been spent on a suitable candidate. 2. In most cases, the patients (most patients who could not afford a medical aid) did not receive rehabilitation or proper rehabilitation. When the patient s case comes to the foreground with his or her claim against the RAF, a few years have usually passed, and this without receiving the appropriate treatment. This in itself affects the patient s potential to rehabilitate, especially if one considers that recovery is best attained in the few days or weeks after an injury. This has a negative impact on the viability of the process of return to work. To conclude: the initial idea mentioned is ideal, yet there are several practical factors that makes this idea not feasible. In turn, another scheme (that has been partially implemented) is suggested (areas of the scheme in red indicates a need for improvement): Motor vehicle accident and injuries Acute hospitalization and supplementary health intervention Post-discharge rehabilitation to reach MMI Vocational rehabilitation if necessary or applicable Medico-legal intervention Ideally, the following process should be considered: 1. Services at the acute level (base level) should be enhanced to ensure that all patients receive optimal care as well as supplementary health intervention (whether the patients are admitted to governmental or private hospitals). At this level post-discharge treatment plans are already established and is the initiating phase of all rehabilitation. If this is not instituted, the whole scheme fails, since the suggested prerequisite vocational rehabilitation relies on prior basic function rehabilitation. 2. The patient undergoes post-discharge rehabilitation. However, this will require that the initial medical interventions are optimal and up to date and no patient falls through the cracks. During this phase, suitable candidates for vocational rehabilitation are identified. If a patient receives the necessary post-discharge rehabilitation, the patient will either return to work on his or her own or still be unable to return to work. It is for the latter group that suitability for vocational rehabilitation should be established. Time should not be wasted on providing vocational rehabilitation on patients who does not fit the criteria for vocational rehabilitation. The latter emphasizes the importance of post-discharge rehabilitation, since therapists who provide this service will be able to identify if the patient is a suitable candidate for vocational rehabilitation or not. Following rehabilitation and MMI, the 4

5 medico-legal assessments are performed to assess the residual problems which will be those that will probably be of a permanent nature. 3. Receiving vocational rehabilitation. Idealistically, the patient will receive vocational rehabilitation at a local facility for a certain period of time. However, the service should not end at basic vocational rehabilitation but should include the re-integration in the workplace. As seen in the Annexures, vocational rehabilitation facilities are available, yet scarcely. In addition, it is questionable if the therapist ratio will be able to support and treat the vast patient load that has been involved in motor vehicle accidents. Thus, these services (vocational rehabilitation facilities with the service of re-integration into the workplace) need to be increased. This is easier said than done, since the following will be basic needs of increasing such facilities: a. Trained occupational therapists (this include therapists who is capable of performing managerial work and vocational rehabilitation). b. Available facilities in urban and rural areas. This includes the vocational rehabilitation facility with appropriate equipment and resourced as well as a protected work environment. c. Available half-way work stations: This entails the re-integration of post-vocational rehabilitation patients into the workplace. The therapist will be involved in the patient s work and naturally will need to work with the employer. Employers and employment will therefore firstly need to be identified and provided with the necessary resources to provide such services. d. Following a period of re-integration into the workplace, the employer will have the opportunity to either employ the patient permanently or not. Other opportunities should also be available to enable to patient to seek employment that he or she is suitable for. This in itself already poses a hindrance, since it is well known that South Africa has limited employment opportunities. It should also be known that most of these patients will most probably require some sort of accommodation in the workplace. Most of the patients assessed in our practices fall under unskilled or semi-skilled work, fields that are satiated in South Africa. The concern is therefore: Even if the aforementioned intervention plans and facilities are implemented in South Africa, will the rehabilitated patient be certain of obtaining and securing employment thereafter? To conclude: After the availability of vocational rehabilitation facilities was researched, it has been concluded: While gathering information, it was evident that although Private and Government Hospitals have multi-disciplinary teams that include Occupational Therapists who offer rehabilitation, vocational rehabilitation is not provided to its entirety. Aspects such as work hardening, work visits and recommendation of structural adaptations at the work place are not conducted. Private Occupational Therapy Practices, offer vocational rehabilitation, secondary to their main focus being Functional Capacity Evaluations or Medico-legal Evaluations. Only a few Occupational Therapy Practices offer vocational rehabilitation as the main component in their practice. The suggested scheme as indicated on page 1, seems 5

6 ideal in theory. The proposed scheme indicated on page 4 appears to be a more practical suggestion. However, before such a scheme could be successfully implemented an enormous transformation needs to occur in our country that entails a titanic challenge to ensure that the foundation of the suggested scheme is in place. Firstly, the basic medical intervention scheme needs to be enhanced, secondly postdischarge medical intervention and thirdly, re-integration into the workplace if applicable. As mentioned afore, this is an idea to strife for, yet does not appear to be in place at the moment. Should this scheme become a prerequisite to obtain reimbursement following the involvement in a motor vehicle accident, this may lead to discrimination and neglect of such patients placing the disadvantaged members of society at an even greater drawback. Authors and researchers: Alice Nieuwoudt Maretha Davel Lesego Mashishi Michelle Marè Müller Rentia Nel 6