The structures of rehabilitation

Donabedian’s framework for analysing healthcare had three components: structures, processes, and outcomes. This page introduces the importance of the structures of rehabilitation. Structures are not just buildings and other physical features. The rehabilitation structures include many contextual frameworks, such as how local commissioning is organised, the model of illness used by the team, and the organisation of services. The nature of rehabilitation is defined and influenced by these structural factors. I show the range of structural elements that may influence rehabilitation in a MindMap here. Three structures have a significant and direct impact on the process of rehabilitation: the biopsychosocial model of illness, the multiprofessional team, and the patient-centred problem-solving model of the process. These are the focus of this and subsequent pages in this section. The other factors significantly impact the process and outcome for an individual patient or, more generally, the nature and availability of services. This page gives an overview of structures influencing rehabilitation to place the three most essential structures in an overall context.

Table of Contents

Context - what are the structures of rehabilitation?

A structure is “the arrangement of and relations between the parts or elements of something complex” [OED]. Rehabilitation is undoubtedly complex. For rehabilitation to succeed, one needs:

      • a team of experts coming from many professions and often from several organisations

      • any specific equipment that team members may need professionally

      • a place for that team to work in, if only for team meetings, keeping equipment and records etc

      • funding to allow the team to work

      • an agreed model of illness that all team members agree on and use when analysing and managing a patient

    Rehabilitation services are usually part of larger systems, such as:

        • a host organisation (hospital, social services, not-for-profit organisation etc.)

        • a local, regional and national set of laws

        • the different cultures of the other parties involved, both individuals and organisations.

      In other words, as I have said elsewhere on this site, “no rehabilitation service is an island, each is a part of a greater whole.” One must be aware of all the different frameworks that will impact the availability of rehabilitation, what type of rehabilitation is on offer, how much is available, what the patient and others will receive, and many other aspects of the process.

      In summary, when considering rehabilitation, a structure is any conceptual framework or system and the actual physical environment that rehabilitation works with and works within. The rehabilitation structures include systems, conceptual frameworks, buildings, and objects, all of which may influence the rehabilitation process. They may facilitate and improve it, constrain or limit it. The effect may be large or small, but it will be rare that structures have no impact.

      Context - what influences do structures have?

      Everything is part of a structure and may be influenced by other systems. For example, the universe’s nature and behaviour are determined and controlled by a variety of apparently fixed relationships determining, for example, how strong the force is between two masses (gravity) and how energy can transfer from one form to another (E = mc2 ). Rehabilitation is no different. It is part of many systems, and delivery occurs within a physical environment. The people involved use models in analysing situations and deciding what to do.

      Influence on outcome

      Donabedian’s health quality model suggests that improving rehabilitation structures may improve the rehabilitation process, increasing its effectiveness, efficiency, patient availability, safety, and other aspects of the process or outcome. For example, how rehabilitation services are commissioned and how an organisation provides the service will influence availability. Suppose a multi-professional team with a suitable range of expertise undertakes the rehabilitation. In that case, the process will be more effective than the same group acting as individuals but not as part of a team.

      Structures may constrain rehabilitation, reducing some aspects of the process and outcome. For example, a provider organisation that considers the length of stay the only meaningful measure will prevent some patients from gaining the benefit they could. A team that lacks input from a clinical psychologist will be less effective.

      Many structures have a less definite, ‘good’ or ‘bad’ influence instead of a modulating influence, requiring the process to be adapted or altered. They may also affect the outcome, efficiency, or effectiveness through the alterations required. For example, if a patient comes from a cultural background where disabled people are over-protected and discouraged from becoming more independent, their outcome may worsen. In contrast, someone who has limited or no support may achieve a greater than expected degree of independent function.

      Influence on process

      One can also classify the influence by the aspect of rehabilitation affected. Broadly these can be classified as:

          • the process itself, at the level of the patient

          • the nature and availability of rehabilitation at the level of the population

        The following structural factors probably have a significant influence on the patient’s process and outcome:

            • the model of illness used by the service

            • the relationships between the people providing the rehabilitation (the ‘team’)

            • the model of rehabilitation used

            • the availability of suitable equipment and environments for the minority of patients who need specific equipment and/or environments (e.g. a secure environment to preserve safety)

          The following structures probably have a significant influence on the population’s ability to access and receive rehabilitation:

              • the model of illness used by organisations responsible for commissioning and for providing the rehabilitation services

              • the relationships, contractual or determined externally, between all organisations involved with patients needing rehabilitation

              • the understanding of and knowledge about rehabilitation of the public and politicians, affecting the priority given to rehabilitation

            The eight classes of structures influencing rehabilitation are shown below and can be seen in a separate table by pressing the link in the next section.

            Eight classes of structure

            I will now consider, briefly, the eight classes of the structure shown in the MindMap above or in a separate tab.  (here).

            Model of illness

            Models of illness are compelling, a power that is not recognised. The biomedical model is o ingrained that it is considered a given, like gravity. However, there is an alternative, better model – the biopsychosocial model of illness.

            This model is arguably the central structure of rehabilitation and the basis for the other significant systems. This framework emerged over 20 years, first formally published in 1977: Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977; 196: 129–136. (here) It grew from developments in many fields such as sociology, psychiatry, and psychology. Even in his original paper, Engel used chronic back pain to illustrate its application in rehabilitation.

            The biopsychosocial model of illness is the first vital structure needed for successful rehabilitation. In my review of research that found rehabilitation effective, I noted that almost all interventions were based on this model. (here) Peter Halligan and I highlighted its importance in reviewing its status 40 years after the first paper. (here) It is described extensively in other pages in this section, starting here.

            Model of process

            Rehabilitation aims to resolve, reduce or lessen the problems generated by an illness. Someone, usually but not always the patient, will seek help for the problems caused by disease, damage, or dysfunction in the context of an illness. Just as in all healthcare, rehabilitation uses a standard problem-solving process. In brief, this includes:

                1. Identifying the problems and the factors that are causing or related to those problems
                      • In rehabilitation, this is termed assessment.

                  1. Using the data collected to analyse and understand the problems
                        • In rehabilitation, this is called formulation.

                    1. identifying potential actions, deciding on which to undertake, and planning a course of action
                          • In rehabilitation, this is usually called goal planning (or similar)

                      1. undertaking the actions
                            • In rehabilitation this is usually called rehabilitation treatment.

                        1. evaluating the situation after the actions are complete and returning to step (1) if needed, otherwise stopping.
                              • There is no standard term known to me, but evaluation is a good term

                        The traditional medical process used in almost all healthcare uses the same process; it is universal. Within the biomedical model process, the words usually used are:

                            1. Diagnosis, which covers both
                                  • Collecting the data (clinical examination and investigations), and

                                  • Analysis sometimes referred to initially as the differential diagnosis

                              1. Management plan, which covers both
                                    • Further analysis and

                                    • planning a course of action

                                1. Treatment usually only refers to disease-specific actions, not care.

                                1. Review (or similar word)

                              The problem-solving model of the healthcare process is the second vital structure needed for effective rehabilitation. More details are given on other pages. (here)

                              Service model

                              Each service will have its structure: admission criteria, rules on length of involvement and when to discharge, degree of professional autonomy, etc. I will illustrate two aspects, each having a spectrum between two ends.

                              The first aspect concerns one of the crucial features characterising effective rehabilitation: multi-professional teamwork. The holistic nature of the biopsychosocial model of illness requires a broad assessment of the situation. Though one person can take an overview and identify areas of interest, one needs people from many professions to gain sufficient detailed information about the patient to understand the situation. Additionally, the range of potential interventions is broad, necessitating a wide range of professions.

                              The sharp reader will have noticed I refer to multi-professional, not the more usual multi-disciplinary team (MDT). It is possible to have several disciplines within a profession, and the range of expertise needed is beyond the scope covered by one profession.

                              Many people use the term team to refer to individuals who work with a specific patient but do not work with other patients. This use is an incorrect use of the term in this context. As is made clear later (here), a rehabilitation team work together towards shared, agreed goals not simply with one patient but with many patients. Further, they work together towards broader, team-based service goals and share many other aspects of their work.

                              The multi-professional team is the third vital structure underlying successful rehabilitation. More details about this are available here.

                              A second feature of the structure of the rehabilitation process also needs emphasis. How flexible is it? Do the team and service offer fixed, inflexible service packages such as a “fatigue management programme” and a “spasticity service”, or does it treat each patient as an individual constructing a programme around their needs? This service aspect is relevant because one other essential feature of effective rehabilitation is tailored to an individual patient’s needs. (here) Tailoring the input to a patient’s needs is only possible if the service structure allows unique programmes tailored to the patient’s needs.

                              Physical structures

                              Most people will interpret the structure used by Donabedian to refer to buildings and equipment and, possibly, personnel. Surprisingly, for much rehabilitation, this is relatively less important. However, some patients will need specific physical structures.

                              Many patients will need care and support to maintain their safety and well-being. Though this is not necessarily an integral part of rehabilitation, the patient’s safety and well-being must be maintained whilst the patient receives rehabilitation. Some patients need much hands-on care to feed, clean, dress and so on, while others may lack safety awareness and need close observation and, sometimes, restrictions on movement. Some patients can only be cared for in residential placements. Some patients require equipment to facilitate care, such as a hoist or maintain life, such as a ventilator.

                              Sometimes, an effective treatment package may comprise transcutaneous electrical stimulation (TENS) to control pain, a hydrotherapy pool, a treadmill, and a smartphone to monitor activity and give feedback. As a proportion of the resource needed in rehabilitation, the physical structures are minor but vital for some patients.

                              The third physical structure is integral to the team. A team can only be effective if it has a dedicated space to have team meetings, store shared records, meet informally to discuss shared problems, etc.

                              Commissioning and funding

                              Someone must pay for each service. The structure of the funding system has a significant impact on rehabilitation, often dictating (not too strong a word) who can receive rehabilitation, what the patient can receive, and how much they can receive. This structural feature applies to a population but influences individual patients.

                              The funding system has its influence in several ways, depending partly on the national funding system. The system may be based around patients paying through an insurance scheme or healthcare organisations deciding what is needed and how it should be provided, with providers meeting their requests.

                              The commissioning system may determine or influence service design and organisation, nature and extent of collaboration with other services, degree of flexibility in meeting the needs of patients, the incentives to continue or stop rehabilitation and so on. The rules governing what is paid for and the calculated amount will greatly influence services.

                              The fundamental difficulty in the UK arises from the dominance of the biomedical model of illness and its associated model of the healthcare process. The model is unsuitable for patients with multifactorial problems requiring many different interventions over time, with less certainty of the effect than in some medical situations.

                              Other serivces

                              Rehabilitation has no clear boundaries. (here) Patients with a disability often receive input from many other agencies such as social services, the local housing department, the department of employment, and educational organisations. Each will focus on their area of expertise, working within their constraints and formulating what is needed. The rehabilitation service will often call on these complementary services for help.

                              These other services influence the effectiveness of rehabilitation in two ways.

                              First, there are differences between areas as to what is available. The structure of the local organisations will influence the patient’s process and possibly their outcome.

                              Second, each of the other services will have its own culture, understanding of rehabilitation and disability and so on. These structural characteristics will also influence how rehabilitation is carried out.

                              Laws and regulations

                              Laws and other regulations apply to organisations providing rehabilitation and those working within rehabilitation. Most of these laws apply generically across all healthcare and society. A few have a specific effect on rehabilitation.

                              For example, the Mental Capacity Act 2005 (in England and Wales) and its equivalent legislation in the other countries of the UK have a significant impact on rehabilitation, especially neurological rehabilitation, because it guides clinical practice when a patient lacks mental capacity. Similarly, laws concerning discrimination and driving may impact upon advice given. Many patients are vulnerable and come under the aegis of safeguarding legislation.

                              Professional standards set by the professional bodies also affect rehabilitation, though they rarely limit actions or decisions. Nevertheless, they should be recognised as having an influence,

                              Societal structures

                              Laws and regulations are published, fixed structures made by society. Equally influential are the unpublished but robust systems that fall within the rubric of culture. Culture encompasses “the ideas, customs, and social behaviour of a particular people or society” [OED]

                              Ethical standards are a part of a culture, not legislated but much written about and the basis for many professional standards and some laws. The boundary between being ethical and being polite or respectful is debatable – is it unethical to ignore a patient’s wishes, or does that show a lack of respect and courtesy?

                              In healthcare, including in rehabilitation, many situations require the professional person to balance different interests and possibilities and to balance them without a reasonable estimate of the consequences because outcomes are unpredictable. Each healthcare worker needs to have or develop a framework (i.e. a structure) to help them decide on the most appropriate course of action when faced with contrasting options and uncertainty.

                              Other social structures that may influence rehabilitation include religiously-determined rules, such as day-time fasting during Ramadan, and the often unspoken rules of small support groups that might be appropriate for a patient.

                              Conclusions and summary

                              When I first thought of Structures in Rehabilitation, this page was only supposed to introduce you to the biopsychosocial model (here) and the multi-disciplinary team (here). It made me think of a third important structure, the patient-centred problem-solving approach. Furthermore, as I wrote this page, I realised that the ideas gave me another perspective on rehabilitation and some of the problems faced daily. I hope it has interested you. I am not sure whether the insights offered will have practical consequences.


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