Rehabilitation Phases

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Introduction

There is a growing need for rehabilitation within health systems as the worldwide population is increasing. According to the World Health Organisation (WHO) 1 in 3 people need to access rehabilitation., yet there are more than 50% of people who need rehabilitation in low and middle-income countries that do not receive access to rehabilitation. The type of care and rehabilitation needs will vary hugely dependant on a number of factors that are influenced specifically by both the acuity of the condition and the complexity of the condition. The type of care will vary to cover the individual's needs, ranging from acute care in acute illness/injury or exacerbation of a current condition that requires need for rapid intervention, through to sub-acute care and long term care when the individual's condition is more stable.

Acute Care

A reasonable working definition of acute care should include the most time-sensitive, individually-oriented diagnostic and curative actions whose primary purpose is to improve health and as such the proposed definition includes the health system components, or care delivery platforms, used to treat sudden, often unexpected, urgent or emergent episodes of injury and illness that can lead to death or disability without rapid intervention. Thus acute care is a branch of health care where a patient receives active but short-term treatment for a severe injury or episode of illness, an urgent medical condition, or during recovery from surgery that are generally delivered by teams of health care professionals from a range of medical and surgical specialties.

Acute care encompasses a range of clinical health-care functions, including urgent care, pre-hospital emergency care, emergency or trauma care, acute care surgery, critical care and short-term inpatient stabilization. It may require a visit or stay in an urgent care centre, hospital emergency department, or other short-term stay facility, along with the assistance of diagnostic services, surgery, or follow-up outpatient care in the community. Hospital-based acute inpatient care typically has the goal of discharging patients as soon as they are deemed healthy and stable. Acute care settings include emergency department, intensive care, coronary care, cardiology, neonatal intensive care, and many general areas where the patient could become acutely unwell and require stabilization prior to transfer to another higher dependency unit for further treatment. Acute care can include some of the following health care functions and delivery platforms;

Urgent Care

Most commonly carried out by General Practitioners (GPs,) or within minor injury units for conditions that may need immediate care but are not life threatening and thus do not warrant urgent attention within a hospital setting e.g. minor injury (sprain, strain, fracture), seasonal illness, fever, or following an exacerbation of a chronic disease.

Pre-Hospital Care

As the name suggests short term stabilisation focuses on stabilising the individual to minimise or control the symptoms of their condition until they can receive further treatment or care. Generally this is Prehospital care, that is carried out and provided before the patient arrives at the hospital, for example, delivery of a person with trauma. divided according to WHO into three steps:

1. First Responder Care
2. Basic Prehospital Care
3. Advanced Prehospital Care

Emergency Care

May be carried out by General Practitioners (GPs,) to prevent irreversible complications but frequently occurs at an emergency department in a hospital: where they can assess the airway, breathing, circulatory, and treat critically ill people to stabilize their condition. Depending on the degree of severity, some cases can be managed exclusively within the emergency department while others will be referred to a specialist with appropriate referral and transport facilities. For example: severe wounds / injury (may cause internal bleeding); stroke; heart attack.

Acute Surgery

Acute surgical needs include intra- abdominal crises: eg, appendicitis, intestinal obstruction (the most common cause of hospital admission).

Intensive Care

A patient’s needs can also change rapidly in the hospital. Therefore, intensive care units are necessary. The ICU is another example of acute care. Patients who have a sudden decline in their health can be treated quickly with the help of specialized tools and practitioners.

Critical Care, for the patient who need ICU, usually with respiratory problems.

Services Provided at Acute Care

The patient is in need of a multidisciplinary approach to ensure they will return to functional daily life.

• Therapy usually lasts three hours or more per day.
• They receive therapy at least 5 days/ week, and daily assessment face-to-face and therapy plan is updated continuously.
• Patients will receive a combination of rehabilitative care (physical, occupational, respiratory, and speech therapy as needed) according to the patient’s condition and pre-requisites for each case.

Acute care helps patients to improve their quality of life and help them to improve till transferred to sub-acute care or next step of care (whatever it is). The selection of transfer of inpatient, from acute care to next rehabilitation phase, is an important decision impacting the quality care provided to the patient and their life.

Sub-acute Care

Sub-acute care is care provided for patients who are not severely ill, generally have a stable condition, but require ongoing support to manage a new or changing health condition. It helps them to regain their ability to carry out activities of daily life. It provides care for those no longer meeting the criteria of acute care but still in need of care at a hospital with more intense care than usual. There are many definitions for sub-acute care according to associations and literature as listed here.

Often seen as a stepdown from, or precursor to, acute care, subacute care usually takes place in a skilled-nursing facility where patients receive a limited amount of treatment. Examples include rehab centers where physical, occupational and/or speech therapy are delivered. Other types of subacute care include wound care, IV antibiotic therapy, pain management, dialysis, and physician-mandated treatment for cardiac, pulmonary and other conditions such as diabetes or hypertension. Subacute care also can include short-term, post-surgical care with the patient remaining in the facility vs. visiting it for treatment.

Where it Occurs

It is carried out at hospitals, homes, health care centres, or specialist rehabilitation centres.

Benefits Sub-acute Care

• Decreases the time of hospitalization (if in hospital).
• Help to act independently as soon as possible and to understand next steps thus bringing the patient to the highest level of function as quickly as able.
• Help to return to normal life pre-injury/ illness, help to manage the changes that happened and manage their everyday tasks.

Services Provided at Sub-acute Care

Therapy lasts for 2 hours or less/ day. Patients’ family members are involved in the meeting with their care team to ensure everyone is working toward the same goals. The focus is on regaining strength, mobility, and long-term functionality over the course of therapy A combination of physical, occupational and speech therapy are used for best results if the patient needs it. Examples here

Criteria Sub-acute Care

The Inter Qual Level of Care Criteria:

• Contain criteria about patient admission, hospitalization time, and discharge review criteria that match with patient states at every phase of care acute, sub-acute, and discharge to home.
• According to IQC, to determine the patient at acute care availability to sub-acute care, should meet the criteria of pre-admission eligibility that tested via pre-admission review.
• The patient must fulfil criteria from one of the following (having an illness, injury, or surgery, impairments that require assistance, meeting clinical stability, a patient having an ability to endure a rehabilitation program, finally can’t be able to be managed in a lower level of care than he/she tested in.
• The patient should be medically stable to can include him/her in the rehabilitation programme and can co-operate, in other conditions some patients are in acute care, medically stable and can take part in.

Post Acute Care

While post-acute care also provides continued medical treatment after a hospital stay, it maintains an emphasis on recuperation, rehabilitation, and symptom management. Patients in recovery from cardiac or pulmonary disease, stroke or neurological disorders, or orthopaedic surgery often require rehabilitative therapies to help bridge the gap between hospital and home. The goal of post-acute rehabilitation is to maximize patient wellness and independence so they can get back to the business of living their best lives. Post-acute care services range from intensive short-term rehab to longer-term restorative care. Some patients will achieve full recovery, while others learn to manage the symptoms of a chronic illness.

There is some crossover here with subacute care, in that post-acute care can also include rehabilitation and other services after an acute-care episode. Post-acute care, however, also covers palliative services for patients who are nearing the end of life, and these along with other post-acute services can be delivered in a facility or via outpatient treatment in the patient’s home.

Of the three, there is significant growth in the post-acute care area due to a growing aging population, many of whom desire to age in place and so require more in-home and outpatient services. The marketplace for these providers, as with the other two, is regulated at varying levels depending on the municipality and state, and all fall under the overarching guidelines at the federal level, such as those set forth by the Centers for Medicare and Medicaid Services.

Long Term Care

Long Term Care (LTC) is care provided for either a short or long period of time, to people with chronic illness or disability, who don’t need specialized medical care, they may be an adult or elder person, in order to improve their quality of life, and helping them to meet their needs over time.

Include assisting with medical needs and daily living activities eg, dressing, moving from bed to chair, bathing, etc. LTC need unspecialised, unskilled care and can be provided at home, nursing homes, LTC facilities. The focus is on services and interventions to increase the person’s independence.

Care communities provide a broad range of health care, personal care, and supportive services for adults who have limited self-care capabilities. In USA about 2.1 million reside in long-term care facilities.

Types

• Informal/ unpaid care, often provided by one’s relatives and friends. Nowadays, there is a decline in informal care especially in modern societies, where the tendency is to form small families and to be independent. According to the WHO the majority of informal LTC is provided by spouses and adult children especially daughters and two-thirds of primary caregivers are women

• Formal/ paid care, provided by health care institution, nursing, eg; LTC facilities