Both the rehabilitation team and the patient should plan for when the patient leaves the service at all stages. Just as students in education eventually leave an educational environment, there comes the point when the rehabilitation patient must start to live outside a rehabilitation environment. But, just as education often continues as a part of life in some form for many, further involvement of rehabilitation experts should remain an option after leaving. Full-time rehabilitation is a stage, and even within that stage, the person may move from one service to another just as students move from one school to another. (See discussion of analogy with education (here.)
This page focuses on the process of transfer from a rehabilitation service, either transfer to another service or care placement, or discharge from active involvement with any rehabilitation service. This process is not always carried out very well. The key points are shown in this graphic.
The team responsible for a patient must consider a transfer from the first day, even if initially it is uncertain precisely what transfer may be needed. In the great majority of cases, only two or three possible transfers will be likely, and work may need to start in preparation long before the actual time of transfer arrives.
Needs: rehabilitation, medical, care, social
The team should consider four classes of need for the patient whenever contemplating a transfer or discharge.
The first is the patient’s rehabilitation need. This need covers direct, face-to-face therapeutic practice and learning (i.e. therapy as usually understood). More importantly, the requirement covers having unimpeded access to the rehabilitation team expertise over time. The patient may need rehabilitation expertise to resolve a new problem, monitor for avoidable complications, train carers in the specific care and support required, or advise on practical activities and many other matters.
The second is their care need. This need covers, obviously, the nature and extent of direct assistance with, or undertaking of, all personal activities of daily living such as washing, feeding, toileting and dressing. It is less obvious but equally important. It includes assistance with domestic, community, and social activities as appropriate. It also covers advising on and, sometimes, organising a suitable environment. Rehabilitation teams usually consider the physical environment, but the social and temporal environments (routines and structures, and availability of activities to fill time) also need consideration.
The third is their medical need, the need for medical expertise to manage the disease, any ongoing rehabilitation medical input, such as drugs, and support the care and rehabilitation teams when new potential medical problems arise. Although much of this will be well within a General Practitioner’s range of practice, not all will be.
The fourth is their social need, their need for the level of social contact and interaction that they want. Some people wish to have much social. Others do not necessarily want any. Tailoring social connection to a person’s preference is essential, particularly but not only when considering a transfer to a long-term care home or new accommodation in the community. It concerns loneliness, which is discussed in more detail here.
The critical question to consider initially is, “What will this patient’s continuing rehabilitation and care needs be when they have progressed as far as they can in our service?“
The next question to ask is, “What service or services might be able to meet the needs identified?”. The clinical team should, before the transfer occurs, ask two more specific questions,
- “Can the proposed next service meet the patient’s rehabilitation needs adequately (not necessarily perfectly)?” and,
- “Can the proposed service meet their care needs sufficiently to maintain the safety and well-being, which includes both bodily well-being and psychosocial well-being?“
The answer to the final question will determine the timing of transfer: “Will the next service meet the patient’s needs at least as well as the current service, if not better?“
Sharp-eyed readers will notice that money has not been mentioned, but it is a factor. Moreover, equity (justice) also has to be considered. In summary, this means asking, “Is it just or fair to continue with this patient, given that other patients might benefit from using our service?” For example, if another four weeks might, or even definitely would, give the existing patient a 3% increase in something, it might not be fair to someone who would gain a 10% increase over the same four weeks.
In general, though not always, the next service will cost less. Moreover, as time progresses, increasing priority should be given to a patient’s social engagement and social activities. These are usually limited in a predominantly rehabilitation setting. The problem that arises most often is that the funding organisation will not fund adequately for social engagement and activities to be met in the community or even in long-term care.
The primary transfer destinations to be considered are as follows:
- An inpatient medical setting. This is relatively rare, and will usually only occur from an inpatient rehabilitation unit. Moreover, this is rarely the planned transfer, and it usually arises as an urgent transfer. Nevertheless, the process of transfer should follow the principles outlined later, as far as possible and usually after the event.
- Another more specialised rehabilitation setting. This is also relatively rare, but does arise in two circumstances. A patient already in an inpatient unit, and a sudden-onset usually neurological disorder may become both more mobile, and also more emotionally or psychiatrically disturbed such that neither the care needs nor the rehabilitation needs can be met. Second, a patient with a progressive, also usually a neurological disorder, being managed in the community may develop needs (care and/or rehabilitation) that can no longer be met there.
- Another less specialised rehabilitation setting. There are relatively few inpatient rehabilitation settings, so this transfer is also relatively rare. One important consideration would be whether the inevitable disruption in and associated prolongation of rehabilitation can be justified by other benefits.
- A long-term care setting. This is not uncommon, both from inpatient units and from community rehabilitation services. The usual large deficit is the provision of any access to rehabilitation expertise once the transfer is complete. This lack is iniquitous. Social support is often limited.
- A community setting, usually the patient’s own home but sometimes with someone else. This might involve:
- with planned rehabilitation, given in an out-patients department or day hospital, or given at home by a community rehabilitation team;
- no planned rehabilitation, but under the care of the general practitioner and with usual access to community services.
When a team arranges a transfer, it is essential to ensure a complete and proper transfer of information and, if necessary, training of the following service in the management of any clinical problems which require an approach tailored to the patient. This training includes practical matters, such as how to transfer a patient into their wheelchair or position someone at night, and behavioural issues, such as responding to aggressive or socially inappropriate remarks.
The distinction between discharge with easy availability of further rehabilitation input and ongoing so-called ‘slow stream rehabilitation is arguable. Funding organisations usually require it. The patient and the care team should be able to access rehabilitation advice and expertise when needed without any difficulty. Further, if they think it necessary, the rehabilitation team should monitor the patient’s situation and care provision at intervals.
The artificial distinction between a patient having or not having rehabilitation is similar to the manager’s situation. The manager attends continuing professional development activities and is appraised regularly, and both are educational activities, but the manager is no longer ‘in education’. The patient is no different concerning rehabilitation: they need an appraisal from time to time, and they may benefit from intermittent rehabilitation input.