Rehabilitation Settings

Original Editors - Naomi O'Reilly, Kirenga Bamurange Liliane and ReLAB-HS

Top Contributors - Naomi O'Reilly, Vidya Acharya, Kim Jackson, Kirenga Bamurange Liliane, Tarina van der Stockt, Lucinda hampton, Ashmita Patrao and Oyemi Sillo      

Introduction

Rehabilitation is a multidisciplinary process that helps individuals to develop or strengthen their physical, mental, and social skills. The World Health Organisation defines rehabilitation as a set of measures that assist individuals who experience or are likely to experience disability, to achieve and maintain optimum functioning in interaction with their environment. It also reduces disability in individuals with health conditions in relation to their environment. Environments refer to the physical, social, and cultural contexts in which individuals and their communities live. In the ICF Framework Model that is most commonly used within rehabilitation, the personal and environmental components play a big role. Together, they comprise a person's context that needs to be considered in conjunction with rehabilitation. As such, we need to consider the range of settings in which rehabilitation takes place and consider the impact of the setting on rehabilitation.

The term healthcare or rehabilitation setting represents a broad array of services and places where healthcare occurs, including acute care hospitals, urgent care centres, rehabilitation centres, nursing homes, and other long-term care facilities, specialised outpatient services (e.g., haemodialysis, dentistry, podiatry, chemotherapy, endoscopy, and pain management clinics), and outpatient surgery centres. In addition, some healthcare services are provided in private offices or homes.

Rehabilitation service availability and the settings in which they are provided varies dramatically both within and across regions and nations. Rehabilitation is highly person-centred, meaning that the interventions and approach selected for each individual depends on their goals and preferences. Medical rehabilitation and therapy are typically provided in acute care hospitals for conditions with acute onset. While follow-up rehabilitation at a subacute, post-acute can be provided in a wide range of settings, including specialised rehabilitation wards or hospitals; rehabilitation centres; institutions such as residential mental and nursing homes, respite care centres, hospices, prisons, residential educational institutions, and military residential settings; or single or multi-professional practices (office or clinic). Longer-term rehabilitation may also be provided within community settings and facilities such as primary health care centres, schools, workplaces, or home-based therapy services.The following looks at some of the healthcare settings available but is not a fully inclusive list.

Hospital

According to the World Health Organisation, hospitals are an essential health service. They should complement and amplify the effectiveness of many other parts of the health system, providing continuous availability of services for acute and complex conditions, allowing the concentration of scarce resources within well-planned referral networks to respond efficiently to population health needs. Hospitals can be instrumental for care coordination and integration and also provide a setting for the education of doctors, nurses and other healthcare professionals and are a critical base for clinical research.

Hospitals are complex organisations that provide complete medical care, ranging from diagnostic services to surgery, to continuous nursing care that can have multiple specialised areas for triage and emergency care, inpatient and outpatient surgical and medical procedures, management of immunosuppressed populations (e.g., oncology or transplant recipients), rehabilitation services, and intensive care units. Some hospitals specialise in the treatment of specific conditions or populations e.g., Maternity Hospital, Children's Hospital. Hospitals are generally classified by the level of healthcare provided, type of treatment, facility size, and length of a patient’s stay. Most hospitals are in-patient facilities, providing both intensive care (emergencies and those with life-threatening conditions) and non-intensive care, requiring patients to stay under the supervision of specialised health care professionals until discharged but also provide outpatient-based services. In general, as hospitals work to improve efficiency, the goal is for care to continue to shift from an inpatient to outpatient basis and back into the community whenever possible, and as soon as possible.

Hospitals play a key role in a well-functional healthcare referral network. Given the current external pressures, health systems shortcomings, and hospital sector deficiencies exacerbated during the COVID-19 pandemic, this role has become ever more important, particularly in supporting other healthcare providers within the community and home-based services. Effective hospitals are designed for their users, with attention to the needs of special populations, such as children and the elderly. A well-designed hospital environment maximises the effectiveness of clinical care delivery and enhances the well-being of both the patients and hospital staff.

General Hospital

The General or District Hospital is probably the best-known type of hospital that people have access to. General hospitals are often the first level of Hospital-Based Care following the referral from primary care services or can be the first point of care in immediate and urgent threats to health through Accident and Emergency or Trauma Centres. They provide a wide range of services for patients of various age groups and with varying conditions or injuries.

Regional Hospital

Regional or Provincial Hospitals, are different from smaller General Hospitals and larger or specialised Tertiary-level Hospitals and have been defined by the World Health Organisation as a secondary-level hospital providing at least 5 to 10 clinical specialties with 200 to 800 hospital beds.

Specialised Hospital

Specialised Hospitals cater primarily and exclusively dedicated to one or a few related medical specialties, including specialised trauma centres, rehabilitation hospitals, children's hospitals, geriatric hospitals, maternity hospitals, and hospitals for dealing with specific medical needs such as psychiatric and certain disease categories such as cardiac, oncology, neurology and so forth. Research suggests that Specialised Hospitals can reduce the overall cost of health care when compared to general hospitals, which is thought to result from the limited amount of procedures or interventions that occur, which allow a specialist to become more efficient in the provision of services. According to the World Health Organisation, Specialised Hospitals provides an effective, affordable healthcare service for a defined population, in cooperation with Primary and Secondary Health Services, and also have a role in providing support to other health services through the provision of wide-ranging technical, education, and training for primary and secondary health care in relation to their specific area of speciality.

Teaching Hospitals

Teaching Hospitals can include all of the above types of hospitals but combine the provision of care to people with teaching and support to medical students, nurses, and other rehabilitation, health and social care professions that compose the rehabilitation team. Teaching hospitals are almost always affiliated with or co-located with a medical school, nursing school or one or more universities. They are generally also involved in ongoing clinical research. Students may observe clinical work in the hospital, as well as be involved in the provision of care at various stages throughout their medical training. In many countries, teaching hospitals provide a residency program for ongoing education for qualified professionals across the rehabilitation team. It includes physicians, podiatrists, dentists, and pharmacists who receive ongoing training after attaining their final qualifications, allowing them to further develop their skills under the direct or indirect supervision of a senior medical clinician registered in that specialty, such as an attending physician or consultant. This provides safe practice settings for new medical professionals to develop their skills while reaching ongoing education and clinical oversight.

Rehabilitation Center

Rehabilitation Centres are generally inpatient facilities that focus on subacute or post-acute rehabilitation of patients with various neurological, musculoskeletal, orthopaedic, and other medical conditions following stabilisation of their acute medical issues or deterioration in a chronic conditions. Rehabilitation Centres can be stand-alone, co-located with a Hospital or within a Hospital. Some rehabilitation hospitals will have physicians on staff, while others do not. Overall, Rehabilitation Centres were created to provide higher-level professional therapy such as physiotherapy, occupational therapy, speech and language therapy, prosthetics and orthotics to allow an individual to achieve and maintain optimal functioning in interaction with their environments.

Long-Term Care Facility

Long-term care is designed for individuals of any age, not just the older person, but who are injured, sick, or who have diminished physical or cognitive capabilities, who are unable to live within their home environment. Long-term care facilities can support people with short-term recovery needs, ongoing health conditions, or disabilities and depending on the underlying reasons for needing care, can be temporary or permanent. There are three main types of long term care facilities:

1. Assisted Living Communities

In assisted living facilities, people of all ages live in a home-based setting with access to care on call as required or 24-hour care around a number of areas, including meals, assistance with daily activities such as dressing, using the bathroom, taking medication, and healthcare services. These facilities are designed to help people complete their daily activities as safely and as independently as possible and optimise function within their environment.

2. Residential Care Home

Residential care homes are usually private homes that serve a group of residents living together, who are receiving care from live-in caretakers. While assistance with daily living activities is typically included, other nursing services and amenities will vary between homes based on the individual needs of the residents and their specific health conditions.

3. Nursing Home

Nursing homes are predominantly for individuals with complex medical needs who require constant nursing care. It is for those who can no longer maintain their independence or be cared for in their home who have difficulties performing daily activities and require a higher level of care than individuals living in retirement communities or assisted living. Nursing Homes provide skilled nursing care for residents, including rehabilitation services, activities, meals, supervision, and more. Nursing homes may also offer both temporary and periodic care, which is sometimes referred to as respite care or short-term rehabilitative stays following discharge from the hospital.

Hospice

"Rehabilitative palliative care is a paradigm which integrates rehabilitation, enablement, self-management, and self-care into the holistic model of palliative care. It is an interdisciplinary approach in which all members of the team, including nurses, doctors, psychosocial practitioners and allied health professionals, work collaboratively with the patient, their relatives and carers to support them to achieve their personal goals and priorities. Rehabilitative palliative care aims to optimise people’s function and wellbeing and to enable them to live as independently and fully as possible, with choice and autonomy, within the limitations of advancing illness. It is an approach that empowers people to adapt to their new state of being with dignity and provides an active support system to help them anticipate and cope constructively with losses resulting from deteriorating health.

Palliative care can be provided both within the home environment, as an outpatient within a Hospice Facility or towards the end of life within a Hospice Facility. Palliative care within a hospice facility is specialist care that focuses on quality of life for people and their caregivers who are experiencing an advanced, or life-limiting illness who are nearing the end of life. Hospice care provides ongoing compassionate care for people throughout the last phases of incurable disease so that they may live as fully and comfortably as possible. It is a model of care that provides not only medical support but also emotional and even spiritual support for patients and their families within a supportive environment that provides round the clock care.

Outpatient Clinic

An outpatient clinic, also known as an ambulatory care centre in some countries, is, as the name suggests, an outpatient setting for patients that provide medical care, including diagnosis, observation, consultation, treatment, intervention, and rehabilitation services. Outpatient clinics provide easier access to high-quality, non-emergency care including, rehabilitation, and can be provided across a number of different settings, including within the hospital setting, specialised rehabilitation centre or with a stand-alone outpatient clinic.

General Medical Practice

A General Medical Practice or Doctor's Office based in the community is most commonly the first point of call for health issues for the largest number of people. General Medical Practices can be a facility with just one medical doctor or can be a facility with multiple medical professionals from the Rehabilitation Team.

Primary Health Care Centres

Primary Health Care Centres can provide a single point of access to a range of health services and have a key role in delivering a reformed health service. They offer an ideal alternative to hospitals for the management of many aspects of care for long-term conditions like diabetes, asthma or chronic obstructive pulmonary disease (COPD). Primary Health Care Centres are more commonly now being developed to facilitate and support access to diagnostics, and to provide minor surgery, thus reducing the need for hospitalisation. They include services provided by general practitioners, dentists, community nurses, pharmacists and midwives, and all other members of the rehabilitation team.

Day Centre

A day centre is a non-residential healthcare setting that provides care generally for adults from across a wide range of population groups, that can include adults with a specific chronic condition like dementia or cognitive impairment, adults with a wide range of disabilities including stroke, limb loss, multiple sclerosis and for the older person, often who is living alone in order to support health, social and daily living needs. These facilities most commonly provide a long term service for many individuals, in some cases respite care enabling caregivers to work or have a break from their caregiving responsibilities but also provide transitional care or short-term rehabilitation services following hospital discharge.

Day centres can provide health promotion through a wide range of services and meaningful activities, of which rehabilitation is just one aspect, and often play a key role in preventing re-hospitalisation following discharge and may help delay the need for admission into residential long-term care settings. The focus of care within these centres can be based on either a social model (focusing more on peer socialisation and prevention services) or a biopsychosocial model (including skilled assessment, treatment, and rehabilitation goals) in order to improve participants health. For participants, who in many cases would otherwise stay at home alone, social stimulation and interaction with other people and recreational or rehabilitation activities have been shown to improve or maintain physical fitness, cognitive function and emotional well being, which can build up confidence and ability to maintain quality of life and an independent lifestyle.

With an ageing population and increased numbers of people living with chronic health conditions, demand for daycare centres is increasing worldwide, and it provides a significant opportunity for ongoing rehabilitation services to support people to maintain their quality of life.

Community-based Rehabilitation

Acute medical illness can be associated with a temporary reduction in our ability to carry out the normal activities of daily living. Therefore rehabilitation is often needed during recovery from an acute medical illness so that patients can return to the same level of functioning and independence. Community rehabilitation is a viable alternative to hospital inpatient treatment for selected patients, and would be the preferred option to maintain patients’ independence. Rehabilitation in the community should be offered to patients as an alternative to routine hospital inpatient rehabilitation, depending on their clinical condition and after discussing risks and benefits.

Home-based Health Care

Home health care involves part-time medical services ordered by a physician for a specific condition. These services may include nursing care to help a person recover from surgery, an accident, or illness. Home health care may also include physical, occupational, or speech therapy and temporary home health aide services. These services are provided by home health care agencies approved by Medicare, a government insurance program for people over age 65.

Telehealth

While not a specific rehabilitation setting, telehealth has grown exponentially within the realm of rehabilitation, particularly over the COVID-19 pandemic with restrictions on face-to-face intervention. As such telehealth can represent a digital form of rehabilitation setting and is likely to remain in clinical use even as we come out of the COVID-19 pandemic.

Telehealth is the delivery of health-related services and information via electronic communication. The terms telehealth and telemedicine can be used interchangeably, but they have slightly different definitions. Telemedicine refers specifically to the remote delivery of healthcare services and clinical information using telecommunications technology, such as internet, wireless, satellite and telephones. Telehealth is defined as the use of electronic communications, such as telephone, tablet, or computer, to share medical information from one place to another with the intention of improving a patient’s health. Telehealth is an expansion of telemedicine, but unlike telemedicine, which focuses on curative aspects of health, it encompasses preventive, promotive, curative, and rehabilitative aspects of health, and many different healthcare professions are involved in its delivery.

Whether through their physical location, physical ability, living situation or transportation choices, many patients may have difficulty gaining access to face-to-face health care and rehabilitation. Those patient limitations, new technological capabilities and the push to lower costs in healthcare have all come together to motivate further development and use of telehealth applications. This might look like live telephone or video conferencing between the patient and their healthcare or rehabilitation professional or it may incorporate a patient with altered functioning wearing a device to allow remote monitoring from their medical team.

Setting by Level of Care

Primary Care

Primary care is delivered in community-based settings, including outpatient or home-based settings, as the low-level care and consultations provided to patients generally do not require hospitalisation. Primary care can be provided at a doctor’s office, primary health care centre, urgent care centre or within the home. The Emergency Room is also often a source of primary care for the un- or under-insured. However, primary care can also be provided in different settings, such as urgent care centres providing same-day appointments or services on a walk-in basis.

Secondary Care

Secondary care is typically delivered within a General or Regional Hospital, predominantly within an inpatient setting but can also be within an outpatient setting within the same Hospital or within an alternative Outpatient Clinic.

Tertiary Care

Tertiary care is delivered typically within a Specialised Hospital setting.

Quaternary Care

Quaternary care is delivered in very specialised settings typically within a Specialised Hospital, Universities and can also occur in Private Medical Centres or Laboratories.

Setting by Phase

Acute Rehabilitation

• General Medical Practice
• Primary Care Centres
• Hospitals

Subacute Rehabilitation

• Hospitals - Often in specialised rehabilitation wards
• Rehabilitation Centres
• Long Term Care Facilities
• Hospice
• Educational Facilities
• Workplaces
• Out-Patient Clinics
• Telehealth

Post Acute Rehabilitation

• Rehabilitation Centres
• Primary Health Care Centres
• Day Centers
• Home-care Therapy Services
• Long Term Care Facilities
• Educational Facilities
• Workplaces
• Telehealth

Long-term Rehabilitation

• Long Term Care Facilities
• Community-Based Rehabilitation
• Primary Health Care Centres
• Day Centers
• Home-based Care
• Education Facilities
• Workplaces
• Telehealth