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 Table of Contents  
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 93-97

5.5 Physical and rehabilitation medicine in health-care systems: Long-term care and community-based rehabilitation

1 Institute of Physical Medicine and Rehabilitation, Faculty of Medicine, University of São Paulo, Sao Paulo, Brazil
2 Department of Rehabilitation Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
3 Health Rehabilitation Research Group, Department of Physical and Rehabilitation Medicine, Faculty of Medicine, University of Antioquia, Medellin, Colombia

Date of Web Publication11-Jun-2019

Correspondence Address:
Marta Imamura
Institute of Physical Medicine and Rehabilitation, Faculty of Medicine, University of Sao Paulo, Sao Paulo
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisprm.jisprm_21_19

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How to cite this article:
Imamura M, Omar Z, Giraldo-Prieto M, Lugo-Agudelo LH. 5.5 Physical and rehabilitation medicine in health-care systems: Long-term care and community-based rehabilitation. J Int Soc Phys Rehabil Med 2019;2, Suppl S1:93-7

How to cite this URL:
Imamura M, Omar Z, Giraldo-Prieto M, Lugo-Agudelo LH. 5.5 Physical and rehabilitation medicine in health-care systems: Long-term care and community-based rehabilitation. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2019 Aug 20];2, Suppl S1:93-7. Available from: http://www.jisprm.org/text.asp?2019/2/2/93/259347

  Long-Term Care and Community-Based Rehabilitation Along the Healthcare System Top

The United Nations Convention on the Rights of People with Disabilities serves as a foundation for the continuum of rehabilitative care, as it is stated in articles 25 and 26 of this Convention.[1] Due to the chronic disabling impact of several health conditions, many people with disabilities are likely to require further rehabilitation and social support following discharge from either acute hospital care or outpatient rehabilitation programs, to achieve rehabilitation goals and to enable community reintegration.[2] Other people with disabilities may require rehabilitation services entirely delivered in the community to better serve their needs. In fact, based on the moderate quality evidence from research in several health conditions, the World Health Organization (WHO) strongly recommends that both community and hospital rehabilitation services should be available.[3]

In the continuum of rehabilitative care, long-term care is the care provided over an extended period, usually for a chronic condition or disability, requiring periodic, intermittent, or continuous care. Longer-term rehabilitation may be provided within community settings and facilities such as primary health-care centers, rehabilitation centers, schools, workplaces, or homes. Physical rehabilitation interventions may vary in training program content, intensity, and duration, as well as in the timing of provision postinjury or disease.[4]

Rehabilitation services delivered in the community must be understandable, coherent, and easy to navigate. These services should have a point of entry for the patients with stable medical conditions who have already fulfilled their rehabilitation needs in facilities of higher complexity level or no immediate need of advanced rehabilitation. They may come from the lower, or the higher complexity levels of health, should not be in a longer waiting list and services should be accessible to them in terms of architecture and service. The content of most rehabilitation programs are similar and include physical rehabilitation, exercise and physical training, functional enablement, patient, family and caregiver education, psychological and social support. Community-Based Rehabilitation (CBR) is a strategy within general community development for the rehabilitation, poverty reduction, equalization of opportunities, and social inclusion of all people with disabilities. CBR is implemented through the combined efforts of people with disabilities themselves, their families, organizations, and communities, and the relevant governmental and nongovernmental health, education, vocational, social, and other services. A common framework for CBR programs from a broader multisectoral development strategy includes five components: Health, education, livelihood, social services, and empowerment. The health component of CBR includes actions on promotion, prevention, medical care, rehabilitation, and assistive devices, although there may not be a general consensus on how to develop such actions and what they should include.[5]

On a parallel way, the concept of primary care rehabilitation refers to health rehabilitation services in the lower-complexity health-care services. Besides CBR, rehabilitation at the primary care level is provided by means of several modalities: a conventional clinic separately provided by health rehabilitation professionals without coordination, an outreach program that requires transportation of mobile complex rehabilitation resources to the community, self-management programs that put emphasis on education and active participation of the patient, case management of groups with high risk and complex needs that is driven by a professional that coordinates the services requirements, and finally, a shared care model based on the long-distance communication of a general practitioner and a rehabilitation specialist who use a telehealth tool to provide a coordinated care.[6]

  Impact of Rehabilitation in the Low-Complexity Health Level Top

Scientific evidence about the positive results of home or community delivered rehabilitation programs is more prolific from high-income countries than low-income countries.[7],[8],[9],[10] People who complete either intensive community-based or a residential rehabilitation plan obtain greater functional and adaptability improvements and increased participation than patients who receive an incomplete program.[8],[9]

Effect sizes seem to vary according to the time that postacute care is provided, being high (1.0) when acutely initiated and moderate when chronically initiated (0.5).[8] As a health strategy, rehabilitation reduces admissions to long-term nursing homes, institutionalization, and maintain quality of life in people with disease or injury.[11]

Evidence from high-income countries indicates that education to enhance self-care is cost-effective and improves health outcomes at a relatively low cost in vulnerable patients such as arthritis, chronic obstructive pulmonary disease, or elderly with chronic pain conditions. CBR programs that include exercise in patients with risk of falls or home programs for children with speech, language, and communication needs are cost-effective to reduce institutionalization.[11],[12] In stroke survivors, these programs are cost-effective if the transition of the inpatient to the community is shifted through an enablement program before they are discharged to home care and linked to continued care in geriatric units or a program with an appropriate home environment and adequate social support.[13] However, the long-term sustainability of the CBR programs is uncertain if they are not incorporated into the health policies system of the countries.

  Evidence for Rehabilitation Services Delivered in the Community Top

Living in a community where there is an integrative service delivery (ISD) network is better than living in a community without ISD network, for elders (>75-year-old) with moderate level of disability and mild cognitive problems, on outcomes of utilization of rehabilitation services and continuity of care (daily hours of care and assistance). This service delivery model at the community reduces the number of elderly people with unmet needs and also reduces the prevalence of unmet needs.[14]

In a systematic review (SR) of Cochrane about long-term care facilities, such as home care or hospitals where people with disabilities permanently live, physical rehabilitation showed to be more effective than conventional interventions or no rehabilitation interventions, despite a small magnitude of effect. This SR involved 67 randomized controlled trials (RCT) and 6300 participants. The estimated effects of physical rehabilitation at the end of the intervention were an improvement in the Barthel Index (0–100) score of six points higher than control (seven RCT, 857 people, mean difference 6.38, 95% confidence interval: 1.63–11.12; P = 0.0084), larger than the minimally clinical important difference that is 1.85 in stroke patients,[15] and an improvement in the Functional Independence Measure (0–126) score of five points higher than control (four RCT, 303 people, mean difference 4.98, 95% confidence interval: −1.55–11.51; P = 0.14). Physical rehabilitation does not increase the risk of mortality in elderly care home residents (25 RCT, 3721 people) (risk ratio 0.95; 95% confidence interval 0.80–1.13; P = 0.54).[16] More than 50% of services are provided or paid by family members or technologies are not covered by the health system. Urgent measures should be taken to reduce the burden to families, and rehabilitation services should be part of the regular budget of ministries: It not only protects human rights, but also it is a good investment because it builds human capital.[2]

  Patients' Needs and Complexity of Disability Top

For long-term disabling conditions, age, gender, ethnicity, marital status, level of education, and even diagnosis may not influence the need of rehabilitation services, while the baseline levels of dependency and physical and cognitive impairments account for 40% of the rehabilitation services received in the community.[17] Some of their needs could be well addressed in community services, as for people with acquired brain injury, who report a high incidence of psychosocial needs years after the traumatic event.

Rehabilitation services might follow a model based on the complexity of the disability and severity of its underlying cause according to person's needs. The disability assessment should include a comprehensive physical, cognitive, psychological assessment, the functional skills, and the environmental assessment. The person' s needs might be screened not only for health and personal care but also for social care, rehabilitation and family/caregiver needs. In consequence, patients should be classified to a primary care or more complex levels of Rehabilitation.[18]

The patients with a high functional level may have conditions of high functional independence with none or mild health problems, such as being able to manage their personal care at home or activities of daily living independently, being mobile or able to independently transfer with none or minimal assistance, having a caregiver or good family support, and minimal or no cognitive issues affecting their ability to achieve instrumental activities. They could receive rehabilitation services at a low complexity level of rehabilitation services.

On the other hand, patients with low functional level may require important support for activities of daily living, may have dependency for toileting, severe mobility problems or some cognitive impairment affecting their ability to engage in instrumental activities and might require an specialized service of rehabilitation until the patient achieve a better functional status with stabled gains.[17],[19]

A person with a long-term disability may be in a healthy status with lower needs and be independent for daily living; however, his/her health status may worsen and could lose functional skills, so the required health care may shift from a low to a high complexity rehabilitation service. The contrary may happen when the health and functional status are already controlled at a higher level.

  Delivery of the Rehabilitation Services in Long-Term Facilities and in the Community Top

As any health-related rehabilitation service, both long-term and community delivered rehabilitation should provide a clear definition of the services and technology that are offered, the targeted persons and their health condition, their caregivers, the organizational setting, the interaction between provider and person, the strategy and tools for the assessment of functional needs and skills, the strategy to integrate other services that cover a multisectoral approach pertaining to the health status and required professional resources.[20]

The physical medicine and rehabilitation physician may play several actions.

To coordinate a transition care program from the high to the middle or low complexity care rehabilitation units, to set up a system for early detection of warning signs according to the model of the International Classification of Functioning, Disability and Health for a referral to a higher level of complexity, to support a general practitioner on medical conditions that may be managed in the primary care setting, to collaborate with the rehabilitation team on medical prognosis for proper allocation of resources, to provide education on rehabilitation plans and patient health status, to contribute with professional training (for the rehabilitation workforce, stakeholders, patients, and caregivers), to advocate for the rights of persons with disabilities, to define strategies to overcome barriers for access to health services, to attend persons with complex disabling conditions from areas with limited access in an outreach program and to implement research projects on how to improve the health status of people with disabilities.

Rehabilitation programs under the WHO framework rehabilitation cycle include multidimensional assessment, stringent assignment to therapies, regular team meetings with all health professionals involved in the care of the patient, goal setting tailored to the individual patient, interventions tailored to the patient's needs, and regular treatment evaluation with the care team and the patient.[21] Health-care rehabilitation interventions may vary in training program content, intensity, and duration, as well as in the timing of provision postinjury or disease. However, it should be designed around the needs and goals of the individual, assessed by a specialized multi-disciplinary team who will determine the best use of the team's resources.[19]

According to the authors' opinion, CBR can help persons with disabilities to overcome barriers for access to health services, to train workers at the low complexity levels of care about disability issues, to educate and empower family members and to include persons with disabilities and family members to actively participate in the society. In addition, it guides on what to strengthen to advocate for the rights of persons with disabilities. It defines the areas to conduct research on factors determining the health status of persons with disabilities, assessing care barriers, and finding ways to overcome met and unmet needs.

In response to patients' needs, rehabilitation services may be classified according to a model of levels of care[22] that are defined by the complexity of services. Each region or country might develop less or more levels according to their national policies, context and resources but always should have well defined services either for the lowest and for the highest level of complexity of disability.

  Human Resources Top

Human resources should include at least a general practitioner, a nurse, and a therapist or another professional who may play a similar role as a rehabilitation assistant or community rehabilitation worker. Countries should implement strong retention measures to stimulate workers to stay in underserved areas to overcome the need-based shortages and lack of access to rehabilitation workers.[23] There is ongoing evidence that telemedicine, tele-education, and internet-based distance learning is a key tool to improve access for a timely service delivery and to reduce access barriers to the health system. Telehealth is based on the use of information and communication technologies to deliver health services, medical care, and information to patients, families, and health-care workers on remote locations. It is a tool for knowledge diffusion, knowledge transfer, patients' follow-up, and promotion of health and disease prevention by means of virtual strategies. It includes telecommunication technologies, such as telephone, cellphone, internet, E-mail, or real-time videoconferences to guarantee the knowledge transfer among stakeholders, as well as real-time medical appointments or chart review, warning phone calls, or monitoring of the clinical files to assess the adherence of professionals to the clinical guidelines.[24],[25] Effective experiences have been reported on the field of cardiac rehabilitation, weight and glycemic control, nutritional behavior, systolic blood pressure, and quality of life in diabetes and reduction of hospitalization in patients at high risk of complications.[26],[27]

To achieve an effective education of the health teams, there is a need to strengthen the knowledge translation (KT). KT is the iterative and dynamic process that includes the synthesis, dissemination, interchange, and ethical application of knowledge to improve the health of the population, to provide more effective health products and services to strengthen the health system. Effective models of KT in rehabilitation might come from research in this field.[28]

  Financing Top

Determining service use and costs are an important analysis for the implementation of long-term and community care. It seems that age, motor impairments and dependency of varying kinds were the strongest predictors of costs: Being younger and more severely disabled were predictors of higher formal service costs, explaining 32% and 30% of the variation in costs respectively at 6 and 12 months post discharge. Interestingly, health-care reduces significantly after the 1st year of community delivered services, whereas the costs of social welfare continue the same.[29]

A number of cross-sectional studies report annual cost estimates of health services in the context of individual long-term neurological conditions as well as other long-term chronic illnesses.[30] Others have investigated overall service costs for up to 3 years' postonset. In general, the acute and inpatient rehabilitation has higher costs than community settings. Understanding that health and social costs are higher for more dependent people, rehabilitation interventions should consider reducing and preventing disability.[29]

  Vulnerable Groups in the Community Top

Several clinical and social needs remain unmet for people living in the community.[14],[31] People with disabilities from ethnic minority groups, and from those living in the most deprived areas report higher levels of unmet needs.[31] Being a woman, living alone, having a higher level of disability, more cognitive impairments, and a lower level of empowerment were linked to initial unmet need. Due to heterogeneity related to the health condition, the wide range of rehabilitation needs should be accessed through a systematic needs assessment and monitoring tools that can be used in daily practice.[32]

  Outcome Assessment of Rehabilitation Services Delivered at the Community Top

The follow-up might take in account the assessment of patient's 'conditions and the assessment of the service provision, in close collaboration with local communities.[7] For the patients, the follow-up may include functional independence, education, economic independence, participation in family and community life, physical change, spiritual change, early detection of complications that should be continuously monitored in long-term care.[33] It is therefore important to monitor and re-assess needs periodically after baseline assessment, as health conditions may vary with progressive conditions, sudden onset conditions, those with predominantly spinal or physical disabilities and those with predominantly behavioral, or cognitive or communication disorders.[29]

  Conclusion Top

The long-term sustainability of the CBR programs is uncertain if they are not incorporated into the health policies system of the countries.

Due to the chronic disabling impact of several health conditions, many people with disabilities are likely to require further rehabilitation and social support following discharge from either acute hospital care or outpatient rehabilitation programs, to achieve rehabilitation goals and to enable community reintegration.

Both patients with high functional levels as well as those with a low functional level need attention at low complexity levels. The specific actions depend on the needs of each patient and the achievements that have been obtained in the rehabilitation processes.

There is ongoing evidence that telemedicine, tele-education, and internet-based distance learning is a key tool to improve access for a timely service delivery and to reduce access barriers to the health system.

According to the context and resources of each country, rehabilitation services should be classified in terms of the complexity of services to respond to patients' needs.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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