Download A Guide to the Rehabilitation clinic in Växjö

A Guide to the
Rehabilitation clinic in
Växjö
Postadress: Box 1223, 351 12 VÄXJÖ
Telefon: 0470-59 22 50
Besöksadress: J F Liedholms väg 14, Växjö
Telefax: 0470-59 22 05
E-post: [email protected]
Revised & collaborated with the management team
Last rev: 2014-01-31
Table of Contents
The Rehabilitation Clinic in Växjö ......................................................................... 3
Assignment and Organization ................................................................................. 3
Specialized Rehabilitation........................................................................................................ 3
Rehabilitations Place in the Chain of Care .............................................................................. 3
Criteria for Admission.............................................................................................................. 4
Health Care Levels ................................................................................................................... 5
The Three Units Within the Clinic ........................................................................................... 5
Documentation ......................................................................................................................... 7
Environment ............................................................................................................................. 7
Rehabilitation ................................................................................................................... 7
Biopsychosocial ground ........................................................................................................... 7
Ideology.................................................................................................................................... 8
Team ......................................................................................................................................... 9
Coordinator/Coach ................................................................................................................... 9
The Rehabilitation Process..................................................................................... 10
Duration and Intensity of Care ............................................................................................... 10
Treatments .............................................................................................................................. 10
Follow-up and outcomes ........................................................................................................ 11
Results and Statistics .............................................................................................................. 11
Integration .............................................................................................................................. 11
Cost, Charges, and Fees ......................................................................................................... 11
Travels .................................................................................................................................... 11
This Guide is a general overview to the rehabilitation clinic in Växjö. Additional information
regarding the different programs could be provided for you upon request at the inpatient or
outpatient rehabilitation clinics;
Inpatient Traumatic Brain Injury and Neurological Rehabilitation
Outpatient Traumatic Brain Injury and Neurological Rehabilitation
Outpatient Pain Rehabilitation
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The Rehabilitation Clinic in Växjö
The rehabilitation clinic is located in Växjö at the St. Sigfrid’s Campus near Lake Trummen, in an area
surrounded by trees and breathtaking nature. In 2001, the clinic moved from the central hospital
downtown Växjö to this beautiful area. The clinic offers a peaceful, comfortable, and healing
environment, which seeks to aid in your personal rehabilitation process. The environment around the
rehabilitation center is built in a way to provide an extensive continuation of care, and an array of
different activities are available outside the clinic, in nearby parks, and around the lake. A restaurant,
library, and a kiosk are also available for your convenience on campus.
Assignment and Organization
Landstinget is responsible for the health care in Kronoberg’s County. This is governed by elected
authorized political representatives. There are two hospitals, 33 primary care clinics, 15 dental care
clinics, rehabilitation, and psychiatry located within this region. Landstinget Kronoberg is operated as
a Federation with nine different units: Emergency unit, Children and Women unit, Surgery unit,
Medical unit, Medicine Service unit, Primary care- and Rehabilitation unit, Psychiatry unit, Service
unit, and Dental Care unit. The Rehabilitation clinic is part of the Primary Care and- Rehabilitation
unit.
Specialized Rehabilitation
The rehabilitation clinic focuses on specialized rehabilitation for patients over 18 years old (most of
them from Kronoberg’s County). This means that our expert faculty and staff have longstanding
experiences, and in-depth knowledge of every different group’s health conditions.
Our goal and mission is to create the most comfortable rehabilitation possible. We strive to be able to
help, support and enable the patient to move on to an active, productive, and as independent life as
possible. The rehabilitation will guide and support the patient’s goals in family life, work, school, and
recreation. It is important to us that a patient’s integrity and participation continues regardless of their
disability.
Rehabilitations Place in the Chain of Care
Emergency Care
Växjö or Ljungby /
regional care
Community
home care
Self care
Home
Rehabilitation clinic:
specialized
rehabilitation
Primary care
rehabilitation
Continued support
Most patients that are admitted to the rehabilitation clinic arrive from the hospital or regional care, but
can also be referred from the primary care, or community home care. Patients can also contact the
clinic later on in their rehabilitation process, if they feel the need to. In some cases there may be a need
to extend or renew the rehabilitation period, if their functional status changes, or if the patient has
other special requirements.
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Follow ups are an example of continued support for patients after their treatments. Usually this is done
by the clinics that discharge them, and/or it could be done by another health care or home care
professional. Patients over 65 years old who live on the west side of the county, and do not need
cognitive training, can be offered inpatient rehabilitation, or day rehabilitation at the hospital in
Ljungby.
There are guidelines for different diagnosis which Landstinget Kronoberg follows, to provide excellent
safe care, and to assure the right level of care. These guidelines will decide if a specific diagnosis or
condition will be treated at the clinic. If this is the case, it will also decide where in the chain of care
the diagnosis will be treated. In some cases with some conditions, for example ALS and RA, the
rehabilitation clinic is not part of the chain of care. For more information about the rehabilitation
guidelines for a specific diagnosis and what is permitted, go to Landstinget homepage:”Fastställda
rehabriktlinjer”
Criteria for Admission
All inclusion criteria have to be met. If one or more exclusion criteria are present, then the patient is
not admitted for rehabilitation, or the ongoing rehabilitation is discontinued.
Inclusion Criteria
- Be 18 years of age or older
- Have a need for specialized rehabilitation
- Have rehabilitation potential, or have a need for specialized environmental changes
Exclusion Criteria
- Unstable cardiovascular and/or respiratory problems
- Ongoing medical treatments and/or an assessment that will affect a good outcome for the
rehabilitation program
- Serious untreated psychological disease, or unstable behavioral condition, which can affect the
patient or other patient’s rehabilitation
- Apparent drug, narcotic, or alcohol addiction
Criteria to transfer or to discharge a patient from the ongoing rehabilitation program
- When any of the exclusion criteria occur, or are recognized during the rehabilitation period
- When continued treatments will no longer benefit the patient and their goals
- When the rehabilitation goals are achieved earlier than expected
- When the need for specialized rehabilitation has been achieved and/or the rehabilitation goals
can be reached in another way
- When the need for highly specialized rehabilitation emerge during the rehabilitation
Neuro rehab and brain injury rehab continue during that time period as determined from the planned
goals and treatments. Both the goals and treatments can be revised during rehabilitation and may
therefore also affect the rehabilitation length. The time period of pain rehabilitation follow the
predetermined period for the pain management program.
The planned period for rehabilitation is valid as long as the patient has clinical benefits, and is
expected to reach their goals with the help of specialized rehabilitation, and if not any of the criteria for
transfer or suspension of rehabilitation arises or is noted.
Discontinuance of ongoing rehabilitation period
When the rehabilitation period is discontinued due to the request of the patient or the rehab team, a
regular discharge plan is done. To avoid any misunderstandings it is important to clearly explain, and
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to give enough information in the most professional way, to the patient and the family why the
treatment is being discontinued. The patient and their family should also be informed of other possible
alternatives to the ongoing rehabilitation, and the possibility to return with a new referral.
Health Care Levels
The clinic accepts patients to both inpatient and outpatient care. The outpatient program includes
rehabilitation reception or day time care. If patients have to travel far, then there is the possibility to
stay at a patient hotel nearby. Inpatient care means that the patient stays either 7-days or 5-days/week.
When changing care it is preferred to do so without any interruption in the rehabilitation process.
The Three Units Within the Clinic
The rehabilitation clinic and its treatments are divided into three different units: neurological rehab,
brain injury rehab, and pain rehab.
Neurological rehab: inpatient and outpatient program for patients with neurological injuries. For
example, Multiple Sclerosis, Spinal cord injuries, Post Polio, and Parkinson’s disease. This unit also
treats leg amputee patients, and patients with multiple-traumas (patients with injuries occurring
simultaneously in several parts of the body).
Brain injury rehab: inpatient and outpatient program for patients with brain injuries. For example
stroke, traumatic brain injury, infections, and tumors.
Pain rehab: outpatient program for patient with chronic pain (not malignant). This is usually given as
a class.
Management Team
Medical Physician Manager/”Medical
director”
Program
Manager
Specialized rehabilitation for
patients with acquired brain
injury inkl. Stroke
Specialized rehabilitation for
patients with chronic pain
”Brain-rehab”
”Pain-rehab”
Inpatient-program
Rehabilitation goals focus
on ADL’s and transfers
Outpatient-program
Rehabilitation goals focus
on ADL’s, transfers, living
and recreational activities
Program
Manager
Outpatient-program
Rehabilitation goals focus
on work/school or
something equivalent to
that.
Specialized rehabilitation for
patients with neurological
injury as well as leg amputation
”Neuro-rehab”
Program
Manager
Inpatient-program
Rehabilitation goals focus
on ADL’s and transfers
Program
Manager
Pain rehab-program
Classes that focus on
understanding and
managing pain, and
ability to increase
patient’s daily activities
Outpatient-program
Rehabilitation goals focus
on ADL’s, transfers, living
and recreational activities
Program
Manager
Outpatient-program
Rehabilitation goals focus
on work/school or
something equivalent to
that.
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For each program there is one person that is responsible to oversee the program. The head of the clinic
is responsible for the entire rehabilitation clinic, together with the medical team, which includes the
doctors and the unit supervisors.
Referral
There are two methods for admission to the rehabilitation clinic. One is a referral from a doctor, or you
can get your own. This you print from the: rehabiliteringsklinikens hemsida, or have it mailed to you
with help from the receptionist at the rehabilitation clinic: 0470-592250.
Admission
Facility
Rejection of Referral;
(usually because of
wrong rehab choice)
Referral
Assessment
of Referral
Pain rehab
program
Day
program
Acceptance of Referral;
(decision about rehab
unit, priority level, level of
care, program etc.)
Acceptance;
but need assessment
Inpatient
program
Examination /
assessment
Discontinued
specialized
rehabilitation
A referral that arrives to the rehabilitation clinic is assessed with help of criteria and Landstinget’s
guidelines. After acceptance the patients are placed on a waiting list to be seen by a medical
professional, or the patient will be accepted straight to rehabilitation. If a patient needs to change rehab
care, or program during his/her already planned care, then we strive for a change without interruption
of the rehabilitation process. We want the transition to happen as smoothly as possible, and with the
need of the patient’s wishes and goals.
The patients are usually referred to the rehabilitation clinic from the primary care clinic, or from the
medical unit at the hospital in Växjö. During 2012, 727 referrals were handled at the clinic. The goal is
for all referrals to be assessed within 5 working days and 1 working day for the referrals from the
emergency unit at the hospital. The waiting time for treatment is validated by the warranty of care.
Outpatient rehabilitation 2012:
Median time for referral arrival to admission: 8 days
Median time for the acceptance of the referral to admission: 6 days
Day rehabilitation (not pain rehab) 2012:
Median time for referral arrival to admission: 60 days
Median time for the acceptance of the referral to admission: 43 days
For similar information about pain rehab, please refer to the specific program brochure.
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Documentation
All professionals shall comply and follow the law and regulation:”patientdatalagen (2008:355)” and
Socialstyrelsens regulation (SOSFS 2008:14), about how to handle information and documentation
within the health care system. All documentations and patients are under confidential agreement. It is
the responsibility of all professionals involved with a patient to read all documentation about that
patient, and to make sure to follow any changes in their rehabilitation process.
The patient has the right to be treated confidentially, but if necessary (and the patient gives permission)
the patient’s information is allowed to be shared to other health units. For example, some of these units
include home care, primary care etc. This can then be done either by phone, documentation, or planned
meetings.
All medical documentations are written in Cambio Cosmic; a computerized health care information
system, which is used by Landstinget, the district, and many private health care professionals in the
region.
Environment
The rehabilitation clinic is divided between two floors, and is adapted to accommodate the disabled
patients. The clinic has rooms to rest in, a common area with a kitchenette, and a combined dining
area/social area, for the patients, their friends and family, for when they come and visit. The
rehabilitation clinic has two inpatient units with 21 beds. Of these beds are 13 single rooms. The rooms
are efficiently accommodated and equipped with everything needed, including all adaptive equipment
for the patient during the duration of the rehabilitation. All of these necessities are provided by the
clinic. In case the patients have adaptive equipment from prior therapy, it is recommended that they
bring it, in order to accomplish the best result possible in practicing their transfer technique.
We have well equipped exercise rooms, weight rooms, group rooms, and individual rooms. There is a
swimming pool, a computer room, a woodworking room, an exercise garden and a kitchen available.
There are also equipments to coordinate recreational sporting activities in the big hall, and also for
outside.
The outside environment around the clinic offers a wide range of possibilities. There are paved paths
right by the entrance of the clinic to make the outdoor available for patients with wheelchairs, walkers,
etc. The green park surrounding the area is ideal for wonderful walks and other outdoor activities. We
also have tennis, lawn bowling, mini golf, and fishing possibilities.
Rehabilitation
Biopsychosocial ground
The theory behind rehabilitation comes from a biopsychosocial ground that is based from WHO
International Classification of Functioning, Disability and Health, ICF.
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A patient’s functional state and functional limitation is a dynamic interaction between health
conditions (diseases, disorders, injuries, trauma etc.) and contextual factors.
-
-
Body Functions are physiological functions of body systems (including psychological functions)
Body Structures are anatomical parts of the body such as organs, limbs, and their components.
Activity the execution of a task or action by an individual
Participation is involvement in a life situation
Participation Restrictions are problems an individual may experience in involvement in life
situations
Environmental Factors make up the physical, social and attitudinal environment in which people
live and conduct their lives. Environmental Factors influence some components of functional state
and functional limitation
Personal Factors make up one component of the Contextual Factors. These factors are not
classified in the ICF, because of the great social and cultural variation that are connected to it
The rehabilitation process does not only include the medical part of rehabilitation but also the social,
psychological, and work related activities. This can lead to treatments that focus on improving the
physical and psychological function and/or to change the environment or the use of adaptive
equipments to compensate for ones disability.
Ideology
We believe in an individual based mission statement that states:
All patients have the right to be treated with dignity and respect
All patients should have access to all rehabilitation resources to accomplish the best possible outcome
All patients have the right for the best possible and most fair choices
This includes working towards:
- The best rehabilitation possible for an individual. This is accomplished for each patient by offering
continuing education to patients, families, the professional team, outcomes of results, and access to
quality register
- That the patient/patient group will have good continuation of the health care process with
Landstinget. Also, when necessary, a good transition to another care giver
- That we continue to conduct education to our professionals about questions that deals with how to
greet patients and family, cultural differences etc. and to adjust to the clinic’s routines and polices to
be able to correspond to many different perspectives
- That the patient is part of the team, and that the goals and arrangements are built on the patient’s
wants and needs. We also want, if the patient wishes to, that the patient’s family participates in the
rehabilitation process
- That the patient and their families receive as much information and education as possible to elevate
the potential for the best, and just rehabilitation result
- That the patients with difficulties in communicating have access to an interpreter when needed
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Team
A team is used when the rehabilitation process needs involvement from many different professionals.
An interdisciplinary team works towards a coordinated, goal oriented, and time limited achievements.
The coordination of the rehabilitation process is determined by what is necessary for the patient, and
can change over time. Beside the patient, close family (if appropriate), the team of one or more could
also include:
From neurological rehab or brain injury rehab:
- Medical Doctor: have full responsibility medically for the patient’s rehabilitation and decides the
need for special rehabilitation, the adequate level of care, and when a patient is medically treated
- Registered Nurse: responsible for the overall rehabilitation care in support of the physician
- Practical Nurse: help with the rehabilitation care in support of the registered nurse
- Physical Therapist/Rehabilitation assistant: focus on “movements,” possible movements,
movement potential, and behavior of movement
- Occupational Therapist/Occupational Therapist assistant: focus on activities to enhance functional
performance and participation in daily activity
- Speech Therapist: focus to improve communication, language, speech, and patients with
swallowing difficulties
- Social Worker: focus on being an advocate for the patient and their family. Also gives advice and
support in life changing situations
- Neuropsychologist/psychologist: focus on assessment, support, psychological treatments, crisis
therapy, and assessment of cognitive functional limitations
- Uroterapeut/sexologist: focus with problems with the bladder and sexual dysfunction
- Dietist: work with the patient for a better diet and diet plan
From pain rehab:
- Medical Doctor: have the most comprehensive medical responsibility, and to select the optimal
medicine for the patients. Be able to explain the reason for pain and to handle questions about
medical insurance plans.
- Psychiatric nurse: gives the patient the necessary tools to handle challenging situations, gives
support, and increases the process of acceptance.
- Psychologist: educate the patient about the effects of living with pain and the different areas it
might influence on a daily basis, and to give treatments to improve daily functions.
- Physical Therapist: focus on treatments that involve movements to increase/encourage well being
and health.
- Occupational Therapist: focus on encouraging the patient to become independent in daily activities.
- Rehab assistant: improves living habits and gives pain/stress releasing treatments.
Coordinator/Coach
One of the team members is the appointed leader to organize the patient’s rehabilitation plan. This
means that he/she coordinates the rehab process, and make sure the patient and everyone involved
receives all the information and education that are needed. Also, the leader helps with facilitating
patients and their families to participate in the rehabilitation. The patient meets with their coordinator
regularly to discuss different aspect of the rehab plan.
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The Rehabilitation Process
Rehabgoal
Patient and the
team’s assessment
The plan and
its action
Evaluation /
assessment
New The plan and
Goal
its action
Outcome of
rehab goals
Followups
The coordinator/coach and the patient go through the patient’s resources, limitations, and expectations
together. The team’s decisions are based on the ICF model, the functional limitation, structure
divergence, limitation around activity, participation, and the influence of environmental factors. The
ICF model is used as a foundation to establish a rehabilitation plan with a rehabilitation goal and a
partial rehabilitation goal. This is done together with the patient so he/she have the possibility to
correct, and to influence the plan and its goals. The plan also describes the patient’s main goals and
duration of time of care expected to be able to accomplish these goals. These goals are constantly
reviewed and evaluated during the entire duration of the treatment. New goals can always be added
and changed when necessary. The discharge and the plan after discharge are started ahead of time. The
rehab goals are evaluated, and a potential follow-up is also planned. This is documented in the intial
rehabilitation plan.
Duration and Intensity of Care
The specialized rehabilitation process is one part of the rehabilitation that the patient might need to be
able to accomplish his/her goals. The content and the time needed for rehabilitation is decided by the
necessity and individual conditions. It could be anything from a few weeks to many months. The
median time for inpatient rehabilitation is about 30 days. The day rehabilitation is about 2-3 treatment
days for 6 weeks. Besides the rehabilitation programs, the clinic also offers other programs and
classes, for example, MS program, Stroke program and walking program. When the patient
participates in these programs, and also in the pain rehabilitation program, then it follows the schedule
for that particular program.
The intensity of the treatments is individualized and varies over time, depending on what the patient
needs. The usual treatment intensity for inpatients is 3 hours a day with a “paramedicinare”- this
includes Physical, Occupational, and Speech Therapist, either individually or in a group. The usual
treatment for day rehab is 2-3 hours/2-3 days per week with a “paramedicinare” either individually or
in a group. In addition to these treatment periods there are also additional treatments by doctors, nurses
and self training. Inpatients also have in-conjunction with the treatment period, an additional time in
the evenings and the weekends with the in house health care professionals.
Treatments
The patient’s daily treatment program is individually based. Besides the treatments that are acquired
for a better function, there could also include a plan to in some way find compensations for functional
limitations and to adjust to environmental factors. Learning new ways to accomplish an activity can
improve the patient’s possibilities for activities and participation. The treatment can also include
pedagogical approach, advice, and support to help both the patient and the family to handle their life
situation in the best possible way.
Lab analyzes, X-ray, consultation, etc. Rehabilitation is included in council care and use the lab
service, specialist operations, etc. available on the hospitals. Patient Responsible physicians provide
notice of results to the patient. Rehabilitation has daily service from the pharmacy for drug delivery.
See additional information on the website; “Landstinget Kronoberg”.
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Follow-up and outcomes
Follow-ups are based on the clinic’s routine to follow-up different rehabilitation programs and
diagnosis, and are modified on individual necessity. The follow-ups are usually done 3, 6, 12 months
after discharge. These are done either by an appointment at the clinic and/or a phone call. The progress
is evaluated against the discharge plan, rehabilitation plan, changes in the patient’s function, and
ability of activities and participation.
Besides the follow-up of the entire rehabilitation period, there is also a follow-up using the different
quality index, for example WebRehab and NRS model.
Results and Statistics
The clinic follows the clinical results regularly, and uses it for statistics for many different parameters.
This is done to be able to follow the development over time to ensure the best quality of care. In the
different guides: inpatient and outpatient, neurological, brain injury, and pain rehab, some of the
results and statistics are identified.
Integration
Integration occurs in accordance to the patient’s wishes and needs. If the patient is in need of help
from the community home care or another care taker, then the patient and his/her family is invited to a
health care plan meeting. When necessary, the social insurance office, employment office, and the
patients employer are invited to the meeting as well.
Cost, Charges, and Fees
The rehabilitation is financed through the social system. You can find more information about the
different individual fees, high cost protection, and all other fees and charges at Landstinget’s
homepage:”vårdguiden”, and read more at: Patiententavgifter i Kronoberg. Landstinget’s customer
service might also be able to answer some questions about high cost limit cards, charges, invoices,
payment plans etc. Tel 0470-589650. Food and medicine are included for the inpatient, but not for the
outpatient. Treatment equipments are free during the ongoing rehabilitation period. There could
potentially be a charge for social events, certifications, and materials.
Travels
Patient travels
Travels are reimbursed by Landstinget for travels to and from the different health care’s within the
region. Receive more information at: Landstingets hemsida, and if you still have more questions please
contact the receptionist at the clinic: 0470-592250.
Transport Service Sigfrid’s:
One will find Service trip “dial a ride” between Växjö hospital and the Sigfrid’s campus. This needs to
be booked in advance, at least an hour before departure.
The trip is booked with Service trips 0775-77 77 00.
Parking
The rehabilitation clinic offers free parking close by. There are 7 handicap parking spaces around
campus.
For questions about the content of the guide, please contact the rehabilitation clinic in Växjö, at
the front desk: 0470-592250.
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