The challenges of designing and delivering rehabilitation ...

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The challenges of designing and delivering rehabilitation ...

  1. 1. <ul><li>The challenges of designing and delivering rehabilitation interventions for long term neurological conditions </li></ul><ul><li>Daniel Friedland, Clinical Neuropsychologist </li></ul>
  2. 2. <ul><li>Introduction </li></ul><ul><li>I am a Clinical Neuropsychologist and have been working in neurorehabilitation for the last nine years in both the NHS and private sector </li></ul><ul><li>I have worked in community rehabilitation for about five years in the boroughs of Brent and Westminster </li></ul><ul><li>I currently work in the Westminster Rehabilitation Service, which is a community rehabilitation service. We see clients who have a neurological condition, and live in the borough of Westminster </li></ul><ul><li>We see clients in their own homes, and design and implement rehabilitation packages aimed at rehabilitating and supporting them </li></ul>
  3. 3. <ul><li>Who are we rehabilitating ? </li></ul><ul><li>Acquired neurological conditions e.g. </li></ul><ul><li>Traumatic brain injuries which may be sustained in motor vehicle accidents (50%), assaults (10%), sporting accidents (10%), falls (20%),and occupational accidents (10%) </li></ul><ul><li>80% about traumatic brain injuries are mild, 20% are moderate to severe. </li></ul><ul><li>Moderate-Severe brain injury can lead to persistent cognitive and physical difficulties requiring high levels of support </li></ul><ul><li>Cerebrovascular Disorders/Stroke: predominantly effects individuals over 65. A stroke can lead to persistent cognitive and physical difficulties requiring high levels of support </li></ul>
  4. 4. <ul><li>Who are we rehabilitating (2) ? </li></ul><ul><li>Progressive Neurological Conditions e.g. </li></ul><ul><li>Multiple Sclerosis is an autoimune condition in which the immune system attacks the central nervous system (CNS), leading to demyelination. It may cause numerous physical and mental symptoms, and often progresses to physical and cognitive disability. </li></ul><ul><li>The motor neurone diseases (or motor neuron diseases ) (MND) are a group of progressive neurological disorders that destroy motor neurones, the cells that control voluntary muscle activity such as speaking, walking, breathing, and swallowing. </li></ul><ul><li>Dementias eg Alzheimers Dementia, Vascular Dementia </li></ul>
  5. 5. <ul><li>Moderate-Severe Traumatic Brain Injury: Return to Work </li></ul><ul><li>Brooks et al (1987) Brain Injury. The rate of return to work was looked at in 98 severe TBI over 7 years. The employment rate dropped from 86% pre injury to 29% after injury </li></ul><ul><li>Ponsford et al (2006) Neuropsychological Rehabilitation . Australia: out of 77 moderate-severe head injury patients 38% were employed at 2 yr </li></ul><ul><li>Powell, Greenwood (2002) Journal Neurology, Neurosurgery and Psychiatry . A UK RCT into the effectiveness of community rehabilitation. 2 groups: one receiving rehab and one receiving information. 3/48 in the rehab group returned to work. 7/46 in the information group returned to work ie 11% returned to work. </li></ul><ul><li>Moderate-Severe brain injury has a significant effect on an individual’s life </li></ul>
  6. 6. <ul><li>Challenges in delivering rehabilitation for LTNC: Long term support (1) </li></ul><ul><li>The WRS and other community rehabilitation teams do not provide indefinite rehabilitation. Once rehabilitation goals have been achieved (or not achieved) clients are discharged. How do they get support? </li></ul><ul><li>We involve specialised support workers for our clients who have sustained brain injuries (SweetTree). This provides an invaluable link back to our rehab service. This service is funded by Social Services. However, this service is limited to Westminster and compensation claims. Other boroughs/PCT would benefit from this service </li></ul><ul><li>Linking clients into organisations such as Headway, MS Society for long term support </li></ul>
  7. 7. <ul><li>Challenges in delivering rehabilitation for LTNC: Timely interventions (2) </li></ul><ul><li>Clients who have had a TBI or stroke are sometimes discharged inappropriately to their homes rather than further specialised in-patient rehabilitation </li></ul><ul><li>When we pick up these clients it can weeks to months to get them into this specialised in-patient rehabilitation </li></ul><ul><li>This means that clients may miss out in in-patient rehab when they need it </li></ul><ul><li>This can be a funding issue and quick funding is crucial to avoid this problem </li></ul><ul><li>This is particularly true when clients need a structured Vocational Program eg Rehab UK. If funding takes too long clients can lose motivation and the rehabilitation process can be derailed </li></ul>
  8. 8. <ul><li>Challenges in delivering rehabilitation for LTNC: Integrating Fragmented Services (3) </li></ul><ul><li>We get referrals from a variety of places eg Hospitals, GP’s, self- referrals, referrals from Care Managers </li></ul><ul><li>Co-ordinating all of the professionals involved is very difficult especially when there are professionals from different agencies eg social services, CMHTs, our rehab team, hospital neurologists, in-patient units </li></ul><ul><li>Care Managers no longer provide this role </li></ul><ul><li>Compensation claims involving TBI now fund Case Managers who’s role it is to co-ordinate the package of rehabilitation </li></ul><ul><li>This Case Management role is certainly lacking in our service, and other community teams </li></ul><ul><li>This role would improve the overall rehabilitation package </li></ul>
  9. 9. <ul><li>Challenges in delivering rehabilitation for LTNC: Accessing specialised services (4) </li></ul><ul><li>We have a lot of difficulty in accessing appropriate psychiatric cover for clients who have neuropsychiatric difficulties following brain injury eg depression, psychosis, suicide risk </li></ul><ul><li>CMHT’s tend to not take on clients with brain injuries </li></ul><ul><li>Ideally, these clients need Neuropsychiatry </li></ul><ul><li>And ideally there should be funding to send these clients for these specialised referrals to Neuropsychiatry eg Queens Square </li></ul><ul><li>Accessing Neurologists with expertise in rehabilitation of brain injury is even difficult </li></ul><ul><li>Certain hospitals are more specialised for certain conditions and ideally these clients should be referred to these hospitals </li></ul>

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