Process of rehabilitation

Rehabilitation is a process, not an action, and this page introduces the section on the process of rehabilitation. The process does include giving specific treatments. Although I do not cover treatments in detail in this section, I review the essential characteristics of successful treatments. The process is a typical problem-solving process, no different from the process in other healthcare areas except in two ways. The focus is on disability, not disease. And more importantly, rehabilitation undertakes its diagnostic analysis and formulation using the biopsychosocial model of illness, not the biomedical model. Several other features distinguish rehabilitation from many other healthcare processes. Rehabilitation includes a much broader range of treatment interventions, and rehabilitation is generally a slower and longer-term process. This feature leads to a much bigger focus on planning and coordinating treatments. Rehabilitation will often involve professionals not only from other healthcare services but also from other organisations outside health.

Context

All they do in rehabilitation is to assess you, to find out what you can’t do“, and “Rehabilitation is when you see a physiotherapist, isn’t it” or “All they do in rehabilitation is to have meetings”. These views of rehabilitation, commonly expressed by patients and other healthcare staff alike, show that we must describe the process more thoroughly. Each captures a part but misses the whole. To explain the process, I will start at the beginning and then consider the end goal (described in more detail in another part of this site) before going through the process in more detail.

The patient will present to healthcare with a problem that concerns them and has not been or cannot be resolved by identifying a disease and successfully treating it. Occasionally, if unconscious or confused, the patient does not actively present a problem to the service. Rarely the presentation is by family, friends or concerned professionals who notice a problem the patient is unaware of or is unwilling to be seen about. Suppose the problem exposes the patient or others to risk. In that case, a rehabilitation service will consider the situation after considering the legal and ethical aspects, the degree of risk, and the extent of active refusal by the patient.

The patient hopes rehabilitation will enable them to overcome the problem and achieve their desired goal. The hope may be to return to a pre-illness state or, in the case of longstanding illness, to achieve a better quality of life. The process of rehabilitation is just a specific example of problem-solving in healthcare. (here)

The patient is not the only person with an interest in the process of rehabilitation. Everyone needs to recognise this fact. Others who have a legitimate interest include:

  • family, friends and acquaintances. They may be concerned about the patient’s welfare, but they may also have other concerns, such as whether they are able or willing to provide ongoing support if needed.
  • the funder. Few people pay directly and personally for their rehabilitation. The funding organisation, usually the state or an insurance company, will wish to know whether the patient is eligible for rehabilitation and what benefit will accrue.
  • the rehabilitation team. The team may have several interests, both positive and negative. They get income to pay them and gain satisfaction from success, but they may also be threatened or harmed by the patient or family.
  • the service organisation. The rehabilitation team will be part of a healthcare (usually) organisation. An organisation will manage the team and have concerns about reputation, safety, interactions with other services and, crucially, financial performance. These concerns may translate into pressure to discharge someone; see this blog post, for example.
  • long-term care services. Many patients receiving rehabilitation will be in or return to the community or care home who will be responsible for delivering support and, sometimes, recommended opportunities to practice and improve activities. These groups will also have an interest in the rehabilitation process.

Thus many factors entirely separate from the patient’s clinical state and wishes influence the rehabilitation process, and the rehabilitation team cannot ignore them. They often have a significant effect, usually restricting the procedure.

Problem-solving process

One can break the problem-solving process down into a series of steps, as I shall. These steps are helpful when analysing or describing the process, but they are artificial, and people simultaneously undertake two or more aspects of the process. In each contact with a patient, you will be doing all stages. We will now review the process, broken down into the steps described in more detail on other pages.

Before doing this, I wish to emphasise one crucial point. Each part of the process has an immediate goal, and for each component to succeed, the clinician must remember the overall plan. In other words, a clinician must undertake each step of the process, aiming for the next step and a satisfactory resolution of the patient’s problem. Each step is not part of a standard production line; the clinician needs to adapt each step as it progresses and new information or understanding arises.

Data collection.
Data collection starts immediately from the first contact. You will have information in letters and emails; you will make assumptions about where the patient is (e.g. in an intensive care unit or at home). You will have much other contextual information you will use even before first meeting the patient. Your first sight of the patient – how they walk or move – and your first social interaction – whether they acknowledge or greet you – will provide vital data.

Most professionals then move on to a more formal process of taking a history and undertaking an examination while additionally observing natural behaviours. During this more formal process, a skilled clinician focuses on confirming or, more importantly, refuting early hypotheses. In other words, they are not simply collecting information but formulating and trying to narrow down the diagnostic possibilities.

Formulation.
At some point, often early on, the person or team must undertake a formal, preferably structured, review of information collected to understand the nature of the problem. What are the ‘real difficulties’? What are the proximate and more distant causes or factors influencing the difficulties? What else might be having an effect?

The formulation does not occur in isolation; it has a purpose, and the goal is not simply to understand. The goal is to identify what actions might help resolve, even sometimes remove, the problems.

Planning.
The team will use the formulation to plan what to do. The plan depends upon very many different and sometimes conflicting influences and facts. The program needs to start with an idea of the expected long-term outcome, which must be related to the patient’s wishes as far as the team can meet them.

However, to a greater or less extent, many other factors will affect the plan. They include:

  • the prognosis and expected future
  • availability of resources, both in rehabilitation and in the wider world
  • the degree to which family and the patient can and do participate to reach the goals

The planning process must be flexible and include contingency plans if matters progress better or worse than expected.

Action.
Action is the most specific part in many ways. Still, most other people consider the activities of rehabilitation and the preceding and following steps unnecessary ‘fluff’, and often will consider it a waste of time. The reality is that preparation before acting will usually determine the success of the action, and the critical part of preparation is to have the best information available.

The range of potential actions a rehabilitation team will undertake is extensive. In broad terms, they include:

  • Teaching the patient something and helping them to learn for themselves
  • Teaching family members and others something and helping them to learn for themselves
  • Liaising with other people to ensure they act as required
  • Collecting more information
  • Providing or arranging the care someone needs to maintain safety and well-being.

Evaluation and reiteration.
The last step in the problem-solving cycle is evaluating progress with, if necessary, reformulation and resetting plans. In other words, you see whether your initial plan is working; if not, you review the situation and devise new strategies. Eventually, when there are no further plans for improving the problem, you make a plan for a longer time of stasis or slow change.

Terms used in rehabilitation.

Rehabilitation has devised its terminology. I will explain it here briefly.

Assessment.
Rehabilitation professionals almost universally use the word assessment for the first phase. Traditionally the term has referred primarily to collecting data using specific measures. For example, a physiotherapist will measure the range of motion at a joint, strength of a muscle, speed of walking, etc. Each profession has its own ‘assessments’, referring to a standardised questionnaire or measures.

Until recently, many people have overlooked the importance of a formulation, and most people considered going from ‘assessment’ to ‘goal planning’. This lack of awareness does not mean that formulation did not occur. Instead, each person had their interpretation of data and understanding of the situation derived primarily from their professional assessment.

Thus, the term included formulation but only by each individual; team formulation was still rare. Unfortunately, the lack of discussion of the analysis and interpretation of all the data known at the team level often leads to misunderstandings and mistakes.

Goal-planning.
Team meetings such as goal-planning, goal-setting, case conferences, family meetings, discharge planning, initial assessment meeting, etc., have been a feature of rehabilitation for many years. This variation may arise from the different focus of different meetings.

It is likely that the formulation also occurred in an unstructured way, arising from joint discussions about goals and prognosis.

I am unaware of much research into the purposes of team meetings for individual patients in rehabilitation. They likely satisfy a variety of functions:

  • discussion about data and sharing of other information to improve understanding
  • consideration of patient and family expectations and goals
  • review of prognosis and what might be achieved
  • negotiation within the team and also with the patient and family about realistic goals and time scales
  • agreement on actions needed
  • collaborative planning about who will do what with whom and when

Therapy.
The word therapy is shorthand for rehabilitation activity, but many crucial actions are not therapy, nor are they undertaken by therapists. The general failure to recognise that nurses (and doctors, dieticians, orthoptists etc.) undertake many necessary rehabilitation actions may follow the lack of any generic word for rehabilitation activities.

A more accurate expression is an intervention. It is better not to specify the profession because all professions carry out many interventions, such as providing emotional support or educating a patient or family member. I have previously illustrated the considerable range of actions a rehabilitation service may undertake or organise. (Figure 1 here)

Review (meeting).
The last step has no commonly-used term. Review is probably the most commonly used word, either alone (‘the review meeting’) or alone (‘a review’). Some review meetings do have specific titles. In inpatient services, the team may use a ‘discharge planning meeting’ or ‘a six-week review’.

Details on the rehabilitation process

The remaining pages in this section cover the rehabilitation process, as shown in the figure below (download here). The process is seamless and different components may co-occur. Nevertheless, separation into stages helps in the analysis of the process. For example, a meeting will often consider formulation and planning simultaneously as the two are inextricably linked.

Each of the five stages has pages associated with it, exploring specific issues more deeply. The accordion below introduces identified step with a link to the pages.

Data collection

This part concerns assessment. This is perhaps the easiest part of the process to understand. The page will also explain the similarity and differences between assessment and measurement. It will consider the importance of understanding aspects of diagnostic testing and using tests to predict prognosis. (Here)

Formulation

This is the part of the process where I suspect current practice is weakest. I rarely see any formal or informal recording of formulation in a patient’s notes or letters. This is a great weakness. The team collects much information, yet considering all the information and how each part relates to other parts is rarely undertaken. (here)

Therefore, this part has additional pages on the process of analysis. (here)

Planning

This part considers more than just setting goals, though it does inevitably and correctly discuss setting goals. It emphasises the need to use the biopsychosocial model of illness to remain patient-centred and considers a model which may help a team remain patient-centred. (here)

Multi-professional team meetings span the formulation-planning divide. Therefore, there is a separate page about meetings. [not yet written]

Actions

This part will consider the huge variety of interventions possible, pointing out that many depend upon people and organisations outside the rehabilitation service. It considers the evidence on what we know works to demonstrate that our research is, inevitably, limited. Nonetheless, we know that the process is successful and that the effectiveness of complex interventions is difficult to prove. (here)

Evaluation

This is the last step in the cycle. The professional or the team need to make a decision: should we continue or not? If not, where should we transfer the patient’s care, or do they no longer need care. This is a complex decision because the decision is constrained by what is available. Often, in rehabilitation as in all other matters, the service may be the most suitable one available, not perfect but better than any available alternative. (here)

Conclusion and summary

Although I stated that breaking the process down into steps was artificial and that all stages occurred simultaneously, I hope that identifying stages helps improve the process by focusing attention on the goal of each step within the whole process. The following pages should illustrate how this process dissection can enhance its effectiveness.

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