|CHAPTER 5: PHYSICAL AND REHABILITATION MEDICINE IN HEALTH CARE SYSTEMS
|Year : 2019 | Volume
| Issue : 2 | Page : 70-75
5.1 Physical and rehabilitation medicine in health-care systems: Basic concepts, definitions, and models
Carlotte Kiekens, Koen H E Peers
Department of Physical and Rehabilitation Medicine, University Hospitals Leuven, KU Leuven; Department of Development and Regeneration, University of Leuven, Leuven, Belgium
|Date of Web Publication||11-Jun-2019|
Dr. Carlotte Kiekens
Department of Physical and Rehabilitation Medicine, University Hospitals Leuven, KU Leuven. Department of Development and Regeneration, University of Leuven, Leuven
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kiekens C, Peers KH. 5.1 Physical and rehabilitation medicine in health-care systems: Basic concepts, definitions, and models. J Int Soc Phys Rehabil Med 2019;2, Suppl S1:70-5
|How to cite this URL:|
Kiekens C, Peers KH. 5.1 Physical and rehabilitation medicine in health-care systems: Basic concepts, definitions, and models. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2019 Aug 20];2, Suppl S1:70-5. Available from: http://www.jisprm.org/text.asp?2019/2/2/70/259343
| Introduction|| |
A health-care system is the organization of people, institutions, and resources, which delivers health-care services to meet the health needs of target populations. Its primary intent is to promote, restore, or maintain health. The World Health Organization (WHO) describes health systems in terms of six core components or “building blocks” namely (1) service delivery; (2) health workforce; (3) health information systems; (4) access to essential medicines; (5) financing; and (6) leadership/governance. In this introductory chapter to physical and rehabilitation medicine (PRM) in health-care systems, we will first define what is PRM and its role in health-care systems with regard to the main United Nation (UN) and WHO documents, and then we will highlight the main components of PRM provision in health-care systems according to the six WHO building blocks, concluding with some ethical considerations.
| Physical and Rehabilitation Medicine|| |
The World Report on Disability describes the central role of the specialty of “Physical and Rehabilitation Medicine” as: “Diagnose health conditions, assess functioning and prescribe medical and technological interventions that treat health conditions and optimize functional capacity.” In the recently issued 3rd edition of the White Book on Physical and Rehabilitation Medicine in Europe, PRM is defined as “the primary medical specialty responsible for education and training patients and health care providers, health promotion, prevention, and medical diagnosis, functional assessment, treatment and rehabilitation management of persons of all ages experiencing disabling health conditions and their co-morbidities, specifically addressing their impairments and activity limitations in order to facilitate their physical and cognitive functioning (including behavior), participation (including quality of life) and modifying personal and environmental factors.” PRM is the “medicine of functioning;” PRM physicians establish a medical diagnosis; perform a functional assessment; and treat health conditions, impairments of physical, mental, and cognitive functions, as well as activity limitations. PRM physicians aim at improving participation and quality of life of their patients. This also includes improving health behavior and promoting the positive influence of personal and environmental factors on functioning. Considering the broad domain of issues addressed by PRM and rehabilitation in general, many different people need to be involved, including health-care professionals as well as other professionals such as vocational or educational. In many cases, nonprofessionals such as community-based rehabilitation workers, members of peer groups, and, in particular, families and friends from the immediate environment may be involved. The role of PRM physicians in a comprehensive rehabilitation system is visualized in [Figure 1]. It shows the levels of specialization in health-related rehabilitation and the role of PRM in service delivery, coordination of services, and education and training.
|Figure 1: Pyramid of the levels of specialization in health-related rehabilitation as well as the role of physical and rehabilitation medicine in service delivery, coordination of services, and education and training|
Click here to view
The European Union of Medical Specialists (UEMS) PRM Section has published a series of articles on the role of PRM physicians in different settings and health conditions, collected in two E-books called “The Field of Competence of Physical and Rehabilitation Medicine Physicians part I and part II.”, A third series of articles following a strict methodology is currently being prepared.
| Need for Rehabilitation in Health-Care Systems|| |
The WHO and the UN call for the worldwide strengthening of rehabilitation as a key health strategy of the 21st century. In May 2014, the WHO Global Disability Action Plan 2014–2021: “Better health for all people with disabilities” was endorsed by the WHO Member States at the World Health Assembly. It calls to remove barriers and improve access to health services and programs; strengthen and extend rehabilitation, assistive devices and support services, and community-based rehabilitation; enhance the collection of relevant and internationally comparable data on disability; and research on disability and related services. Article 25 of the UN Convention on The Rights of Persons with Disabilities (CRPD), declared in 2006, ensures people with disabilities the right to equally access “the highest standard of health without discrimination on the basis of disability” (CRPD Art. 25. Health). Contrarily, disability-based exclusion of health care is bolstered by a lack of awareness among policymakers about this minority group and their needs. Many obstacles exist such as a lack of training of health professionals, physical inaccessibility, and communication barriers. In the absence of equal access to health care, people with disabilities are at a serious risk of delayed diagnoses or secondary comorbidities. Article 26 of the CRPD calls on State Parties to organize, strengthen and extend comprehensive habilitation and rehabilitation services and programmes, particularly in the areas of health, employment, education and social services (CRPD Art. 26. Habilitation and Rehabilitation). In this context, further implementation of PRM in health-care systems is crucial. In October 2018, 40 years after the Alma Ata Declaration, at the Global Conference on Primary Health Care in Astana, Kazakhstan, the Declaration of Astana was presented where it is stated that rehabilitative services must be accessible to all, across the life course.
| Rehabilitation 2030: a Call for Action|| |
In February 2017, the WHO launched “Rehabilitation 2030: A call for action.” This important initiative has the objective to scale up rehabilitation services in countries around the world in light of the current global trends in health (the increasing prevalence of noncommunicable diseases and injuries) and aging. Rehabilitation 2030 is meant to draw attention to the increasing unmet need for rehabilitation in the world; to highlight the role of rehabilitation in achieving the Sustainable Development Goals proposed by the UN, and more specifically goal 3: good health and well-being; and to call for coordinated and concerted global action toward strengthening rehabilitation in health systems. The extent of disability worldwide has been studied in the “Global Burden of Disease Study 2013.” To ensure that rehabilitation is available and affordable for those who need it, the WHO made the following seven recommendations on rehabilitation in health systems:
- Rehabilitation services should be integrated into health systems
- Rehabilitation services should be integrated into and between primary, secondary, and tertiary levels of health systems
- A multidisciplinary rehabilitation workforce should be available
- Both community and hospital rehabilitation services should be available
- Hospitals should include specialized rehabilitation units for inpatients with complex needs
- Financial resources should be allocated to rehabilitation services to implement and sustain the recommendations on service delivery
- Where health insurances exist or are to become available, they should cover rehabilitation services.
PRM has a pivotal role in this action. The WHO action calls to strengthen rehabilitation as a health strategy, and health strategies are managed by physicians: the PRM physician is the physician of the rehabilitation team, of which he/she has the responsibility and leadership. Moreover, PRM physicians are the only ones with the understanding of all the aspects of rehabilitation from the perspective of the medical specialties and the rehabilitation professions: this allows better management at a micro, as well as at a meso and a macro level. A second Rehabilitation 2030 Multistakeholder Meeting will be held in July 2019.
| The Six Building Blocks|| |
Service delivery systems, the first building block of a health system, are responsible for providing health services for patients, persons, families, communities, and populations in general, and not only care for patients. Service delivery systems should consider the whole spectrum of care from promotion and prevention to diagnostic, rehabilitation, and palliative care, as well as all levels of care including self-care, home care, community care, primary care, hospital care, and long-term care, in order to provide integrated health services throughout the life course. The WHO is supporting countries in moving toward universal health coverage through improving the efficiency and effectiveness of their health service delivery systems. According to the WHO, rehabilitation is part of universal health coverage and should be incorporated into the package of essential services along with prevention, promotion, curative treatment, and palliation.
A conceptual description of health-related rehabilitation services has been proposed by Meyer et al. in 2014: “Rehabilitation services are personal and non-personal intangible products offered to persons with a health condition experiencing or likely to experience disability, or to their informal care-givers, within an organisational setting, in interaction between provider and person, addressing individual functioning needs that aim at enabling persons to achieve and maintain optimal functioning, considering the integration of other services addressing the individual's needs including health, social, labour and educational services. They are delivered by rehabilitation professionals, other health professionals, or appropriately trained community-based workers.”
To develop appropriate rehabilitation services, uniform criteria and a widely accepted language to describe and classify rehabilitation services are needed. A working group of the International Society of Physical and Rehabilitation Medicine (ISPRM)-WHO-Liaison Committee has developed a list of dimensions and categories to describe the organization of health-related rehabilitation services within an “International Classification System for Service Organisation in Health-related Rehabilitation (ICSO-R).” During a European workshop of experts of the UEMS PRM Section and Board, held in 2016 in Nottwil, Switzerland, the feasibility and applicability of ICSO-R to describe health-related rehabilitation was demonstrated. This workshop showed that the use of ICSO-R leads to more precise and comparable description of rehabilitation services as compared to a narrative approach. Currently, a revised version (ICSO-R 2.0) is being developed by the ICSO-R working group of the ISPRM-WHO-Liaison Committee, based on iterative testing, consultation, and an expert consensus process. In future, the ICSO-R could be used to describe and compare the existing rehabilitation services as well as model services for benchmarking and implementation of rehabilitation services into health systems and within a clinical quality management schedule. The second version of the ICSO-R describes two dimensions: the provider and the service delivery. For each dimension, a number of categories and subcategories are defined. At the level of service delivery, one category comprises the setting (2.7) with three subcategories: 2.7.1: the level of specialization of the provided care (primary, secondary, and tertiary); 2.7.2: the mode of delivery (inpatient, outpatient, community-based rehabilitation…); and 2.7.3: the phase of health care (types of rehabilitation services responding to patients' needs in different phases of their health conditions). The phase model of the PRM process comprises phases over the continuum of care, depending on the temporal aspects of a health condition: congenital or acquired, and if acquired whether it is acute or rather progressive or degenerative. When the health condition is congenital or acquired at young age, the term “habilitation” is used during growth. During this period of life, body functions have a high adaptability and connection. Habilitation refers to a process aimed at helping disabled children attain, keep, or improve skills and functioning for daily living. It includes the best possible residual development of the impaired function, the acquisition of new (compensatory) skills, and the avoidance of interference with the normal development of unaffected functions. Habilitation in children with an impairment or disability consists of a continuous process, with more intensive phases according to the developmental milestones.
The following subchapters of chapter 5 will deal with the different phases of rehabilitation: 5.2 – prevention and prehabilitation; 5.3 – acute rehabilitation; 5.4 – postacute levels of care; 5.5 – long-term care and community-based rehabilitation.
Strengthening rehabilitation services is one of the aims of the mentioned Global Disability Action Plan. Therefore, after analyzing in a country the existing services and defining the gaps (in the near future, using ICSO-R), Gutenbrunner et al. proposed to establish a Rehabilitation Services Advisory Team of experts, and then to provide advice to the country by Rapid Response Projects. In order to facilitate data collection at a national level, a checklist and a related questionnaire (Rehabilitation Service Assessment Tool [RSAT]) were developed and implemented by the same team. The RSAT comprises eight sections derived from five main domains of the most important areas of information (i.e., country profile; health system; disability and rehabilitation; national policies, laws, and responsibilities; and relevant nongovernmental stakeholders). This instrument was used to assess rehabilitation services in three countries namely Egypt, Democratic People's Republic of Korea, and Indonesia.,, In the meanwhile, the WHO developed the “Rehabilitation in Health Systems – A Guide for Action,” which has been tested in 2018 and will be implemented in 2019. “The Guide” will assist governments to strengthen the health system to provide rehabilitation. It leads governments through a four-phase process of rehabilitation situation assessment, strategic planning and development of a monitoring framework, evaluation and review processes, and then implementation of the strategic plan, including the following: (1) Systematic Assessment of Rehabilitation Situation, (2) Guidance for Rehabilitation Strategic Planning, (3) Framework for Rehabilitation Monitoring and Evaluation, and (4) Action on Rehabilitation.
In the efforts to strengthen rehabilitation, information on patients' functioning is required, together with a health information system.
Health information systems
To monitor the response of health systems to people's health needs, three health indicators are relevant. The first health indicator is mortality: a population's length of life and the survival of individuals with health conditions. The second is morbidity: the distribution of health conditions in the population and the use of health services. Both can be coded with the International Classification of Diseases (ICD). During its 11th revision, a third indicator of health is being defined, operationalized as a combination of biological health and lived health and captured by the term “functioning”. Functioning can serve not only as an indicator for a population's health state and the outcome of clinical interventions and service delivery, but also as an indicator for the impact on the population of the output of the health system on an individual's lived experience of health. The data for this indicator can be coded with the WHO's International Classification of Functioning, Disability and Health (ICF), endorsed in 2001. Functioning information is fundamental for the “learning health system” and the continuous improvement of the health system's response to people's functioning needs by means of the provision of rehabilitation. A learning health system for rehabilitation operates at three levels: the micro level of the individual patient's rehabilitation plan; the meso level of service provision management; and the macro level of rehabilitation policy that guides rehabilitation programming. The health information system for standardized documentation and coding of functioning information and the development of national rehabilitation quality management systems are crucial for this objective. As an example, the Learning Health System for SCI Initiative (LHS-SCI) clearly demonstrates the need for standardized health information to allow the implementation of the policy recommendations of the International Perspectives on Spinal Cord Injury report.,
To enhance the utility of the ICF in practice, ICF clinical tools that are simple to use are being developed worldwide. In China and Italy, simple, intuitive descriptions of ICF categories contained in the ICF Generic and Rehabilitation Sets were developed by means of a national, multiphase, consensus process., More country language modifications of the ICF clinical tool are ongoing or planned. This process is part of a larger effort toward the system-wide implementation of the ICF in routine clinical and rehabilitation practice to allow for the regular and comprehensive evaluation of health outcomes for continuous quality monitoring and management. An example of the implementation of clinical quality management for rehabilitation at a national level, at the micro-, meso- and macro-levels, referring to ICF as well as ICSO-R, has been described in Malaysia. Recently, a complete overview of worldwide projects for strengthening rehabilitation in health systems using functioning information, through the ICF as a reference framework, in rehabilitation practice, in clinical Quality Management for Rehabilitation, and in policy was published.
The capacity of health systems highly depends on the availability, knowledge, and performance of the health workforce. The Global Disability action plan defines the “number of graduates from educational institutions per 10,000 population – by level and field of education (e.g., PRM, physical therapy, occupational therapy, and prosthetics and orthotics)” as one of the success indicators for the implementation of rehabilitation services. Training of specialists in PRM should include not only medical knowledge on the wide field of competence, but also competence in patient care, specific procedural skills, and attitudes toward interpersonal relationship and communication, profound understanding of the main principles of medical ethics and public health, ability to apply policies of care and prevention for disabled people, capacity to master strategies for reintegration of disabled people into society, and principles of quality assurance. On April 28, 2018, training requirements in PRM in Europe were approved by the UEMS Council general assembly in Marrakesh (Morocco).
As rehabilitation interventions are applied by numerous medical specialties and different types of allied health professionals, the role of PRM in health and rehabilitation systems is also crucial to guarantee an appropriate use of the available resources and to identify and fill the workforce gaps. PRM physicians have an important role in education and training of most of the rehabilitation professionals such as physiotherapists and occupational therapists. In many settings, there is a lack of training for health professionals in the provision of appropriate medical care and rehabilitation services for people with disabilities. At present, the inclusion of disability and rehabilitation curricula is limited in most formal training institutions. The CRPD requires member states to develop initial and continuing training for professionals and staff to improve access to disability-inclusive health care, assistive devices and technologies, and rehabilitation services.
Assistive devices and technologies (“essential medicines”)
The CRPD (articles 2, 4, 20, 26, 29, 30, and 32) repeatedly stresses the importance of available and affordable assistive devices and technologies for persons with disabilities. Technology has evolved dramatically in the last decades and costs are exploding, while budgets are shrinking. There is a large gap between high-technology innovations, such as bionic prostheses or exoskeletons, and the access to basic orthoses, prostheses, or even wheelchairs, which remains low for a vast majority of people with disabilities. In 2014, the Global Cooperation on Assistive Technology (GATE) was launched in order to realize the CRPD obligations toward increasing access to assistive technology. The vision of the GATE initiative is: a world where everyone in need has high-quality, affordable assistive products to lead a healthy, productive, and dignified life. PRM physicians have an important role in prescribing assistive devices, especially when individualized or custom made, but also have to assure research on the safety and effectiveness of new technologies and are gatekeepers of the health insurance budget. PRM physicians and their teams teach patients how to adapt to a (newly acquired) health condition using compensatory mechanisms based on other body structures/functions, behavioral changes, and/or assistive devices such as prosthesis and orthosis (or technical aids).
Financing of systems of health care and funding of rehabilitation services vary to a great extent across regions and countries worldwide. For example, in most high- and higher middle-income countries, PRM interventions are usually covered by the public insurance package, especially for acute specialist rehabilitation, often completed with an out-of-pocket supplement for the patient, usually largest in more chronic and long-term care. Resource allocation toward PRM activities is mostly being decided by health policymakers. Again, adequate data collection as well as research on the effectiveness of rehabilitation interventions is crucial to help politicians and administrators make equitable and evidence-informed budgetary decisions. It should be emphasized that rehabilitation can reduce the economic and social burden of disability through promoting recovery and increasing the functioning of people. PRM physicians, together with patients and people with disabilities, should be the advocates of this cost-saving strategy.
Leadership and governance
Clinical governance implies defining and measuring quality, as well as accountability for achieving the set standards. These processes should be applied to the process of rehabilitation, structure of rehabilitation services, and the associated outcomes. The specificity of rehabilitation where multiple interventions are performed by multiple professions working together in an interdisciplinary way, and where the outcomes may be influenced by many external factors, complicates good governance. Therefore, it is recommended that each service identifies a lead clinician who has particular responsibility for governance. The PRM physician, with his/her broad view of the patient's diagnosis, prognosis, and consequent needs and goals, is the leader of the team. In his/her role of leading clinician, he or she should: (1) identify relevant guidelines and standards; (2) organize and lead regular local and regional governance meetings and promote contact with linked specialties; (3) describe governance activity to relevant bodies and report adverse incidents and complaints together with a proposed plan to address perceived difficulties; and (4) promote quality improvement throughout the service.
Implementing rehabilitation in a health-care system implies difficult choices at the macro (health policy), meso (health-care organization) and micro (patient interaction) levels. PRM physicians need to make choices mainly at the meso- and micro-levels on a daily basis. They should select the patients who can access a rehabilitation program or service. The aim of this triage is to address the right patient to the right level of care at the right time with the appropriate financing. To admit new patients, others need to be discharged. Hence, the patient's needs and goals need to be reassessed continuously, what is described as the “evaluation cycle” in chapter 3.5 on the outcomes of PRM programs. From a bioethical perspective, the following three moral principles prevail: respect for autonomy, beneficence versus nonmaleficence, and justice. The best choice for the patient (beneficence principle) may be in conflict with the available capacity of the rehabilitation service. Within the limited budgets in times of scarcity and growing needs, the available resources must be allocated in a just way (principle of justice). Ethical values and cultural beliefs of professionals and patients may influence choices in rehabilitation practice and may affect the outcome of the patients. Ethical and cultural issues should, therefore, be part of rehabilitation curricula and postgraduate training, also concerning the use of technology.
| Conclusion|| |
To achieve the UN Sustainable Development Goal 3: good health and well-being, the WHO launched “Rehabilitation 2030: A call for action” in 2017. With his/her broad view on the patient's diagnosis, prognosis, functioning needs, and rehabilitation goals, the PRM physician has a crucial role in strengthening rehabilitation in health systems. In this chapter, we highlight the main components of PRM provision in health-care systems according to the following six WHO building blocks: (1) service delivery; (2) health workforce; (3) health information systems; (4) access to essential medicines; (5) financing; and (6) leadership/governance. We conclude with some ethical considerations.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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