Synergy and innovation in geriatric rehabilitation.

Background:

Geriatric rehabilitation consists of integrated multidisciplinary care, aimed at the recovery of function and social participation in frail elderly after an acute disease or functional deterioration. The aim is to recover in such a way that a certain level of activity and participation is regained in order to return to the former living situation. In 2013 the financing system for rehabilitation patients in nursing homes will change. Until now the Exceptional Medical Expenses Act was responsible for the cost. In 2013 the Healthcare Insurance Act will take over. The expectation is that it improves the quality and effectiveness of care and improve patient outcomes.



Objectives:

Seventeen partnerships of healthcare providers will start an innovative care program for geriatric rehabilitation. These programs will be monitored during the year by the research team.

This research should answer two key questions:

1. To which integrated care programs (at individual patient level) will these pilot projects lead? And what is the opinion of patients and there caregivers about these programs?

2. What effect has the new care program on the outcome of rehabilitation?

This research is of an explorative nature. There will be two cohorts one in March and the other one in September. Next to the geriatric rehabilitation patients, also their informal caregivers will be part of the research.

There are 4 different categories of patients:

1. CVA;

2. Trauma;

3. Elective joint replacement;

4. “Other diagnoses”.

In each group there will be approximate 100 patients included (per cohort).

N/A

There will be two cohorts, one in March 2011 and one in September 2011.



Instruments:

1. Questionnaire nurse/ elderly care physician/physiotherapist (with admission to and discharge from the rehabilitation department):

A. Health client (Cognitive Performance Scale, MDS depression Scale, Barthel Index, Functional Comorbidity Index, GGD monitor, Functional Ambulation Categories, Berg Balance Scale);

B. Care and treatment on rehabilitation department (self developed).

2. Questionnaire client (4 weeks after discharge from the rehabilitation department):

A. Demographic characteristics (Minimale Dataset (MDS);

B. Health/psychological and social well-being (MDS, RAND 36, GGD monitor);

C. ADL (MDS, KATZ 15);

D. Quality of life (MDS, Rand 36, Cantril’s Self Anchoring Ladder);

E. Independence (Frenchay Activities Index);

F. Social participation (Impact op Participatie en Autonomie);

G. Physical Self Efficacy (LIVAS: Bosscher);

H. Clients opinion about received healthcare (self developed).

3. Questionnaire caregiver (4 weeks after discharge from the rehabilitation department):

A. Demographic characteristics (MDS);

B. Perceived health (MDS, RAND 36);

C. Perceived burden caregiver (MDS, Self Rated Burden VAS and Carer QoL);

D. Perceived QoL (MDS, RAND 36, Cantril’s Self Anchoring Ladder);

E. Caregivers opinion about received healthcare (self developed).

Each partnership of organizations has developed an innovative care model for the rehabilitation patients. It differs for specific rehabilitation categories and can vary for each organization. The emphasize can be on different subjects such as integrated care, triage, intensifying treatment and different types of treatment. The implementation of this new model will take place during one year.