DEVELOPMENT OF A PRIVATE REHABILITATION UNIT - AN EXPERIENCE Aphrodite Kastanos M Sc Physiotherapy Diana Speer M CSP INTRODUCTION Facilities available for specialised neu­ rological and orthopaedic rehabilitation, based on the principle of a multidiscipli­ nary approach, are very limited in South Africa. This type of specialised treatment has primarily been available at academic hospitals and those hospitals under the control of the mining industry. The re­ sources available in these sectors have been put under enormous strain, thus lim­ iting the quantity and quality of rehabili­ tation offered to the physically disabled. Barney Hurwitz Medical Institute In November 1991, the directors of a large group of hospitals agreed to convert an already existing hospital into a private rehabilitation institute that would cater for both in- and out-patients. A neurologist and therapists were involved in setting up the departments of physiotherapy, occu­ pational therapy, speech therapy and so­ cial work. Nursing staff were responsible for setting up the wards for in-patients. In February 1992, the establishment w as o p e n e d , a d m ittin g p o s t-a c u te neurologically impaired and poly-trauma .. .continued from page 42 10. Kigin CM. Chest physical therapy for the a c u te ly ill m e d ica l p a tie n t. P h y s T her 1981;61:1724-36. 11. King M, Phillips DM, Gross D et al. Enhanced tracheal m ucus clearance with high fre­ quency chest wall com pression. Am Rev Respir Dis 1983;128:511-5. 12. Mackenzie CF, Imle PC, Ciesla N. Chest Physiotherapy in the Intensive Care Unit. Sec­ ond Edition. Baltimore, Hong Kong, Lon­ don, Sydney: Williams & Wilkins, 1989:69- 88,146-8,241. 13. Mackenzie CF, Shin B, McAslan TC. Chest physiotherapy: The effect on arterial oxy­ genation. Anesth Analg 1978;57:28-30. 14. Marini JJ, Pierson DJ, Hudson LD. Acute lobar atelectasis: a prospective comparison of fibreoptic bronchoscopy and respiratory therapy. Am Rev Respir Dis 1979;119:971-8. 15. Newton DA, Stephenson A. Effect of physio­ therapy on pulmonary function. A labora­ tory study. Lancet 1978;2:228-9. 16. Pavia D, Thompson ML, Philliparos D. A preliminary study of the effect of a vibramat pad on bronchial clearance. Am Rev Respir Dis 1976;113:92-96. 17. Van Eeden SF. Notes on chest injuries for Intensive Care student nurses (in Afrikaans) 1990, University of Stellenbosch. 18. Wollmer P, Ursing K, Midgren B et al. Ineffi­ ciency of chest percussion in the physical ther­ apy o f chronic bronchitis. Eur J Respir Dis 1985;66:233-9. p a tie n ts for in te n siv e re h a b ilita tio n . Within six weeks it was recognised that the s ta ff e sta b lish m en t needed to be ex­ panded. By the end of May 1992, allied medical staff complement consisted of 2.5 physiotherapists, one occupational thera­ pist, one social worker, 0.5 speech thera­ pist, under a rehabilitation coordinator. A clinical psychologist was available on re­ ferral. On admission to the institute, patients w ere assessed by each speciality, after which the therapists would confer and contract with the patient/caregiver. This allowed the patient and therapist a specific time to reach predetermined goals, as well as preparing the home environment for discharge of the patient. The patients day was structured so that he was involved in a full day therapy pro­ gramme with therapeutic activities being carried over in the ward. The programme also included a day or weekends at home prior to discharge from the ward whereaf­ ter outpatient therapy could continue. In addition full day, half day or sessional pro­ grammes were available to out-patients. Liaison between disciplines included weekly ward meetings involving medical, nursing andallied medical staff as well as a vveekly outpatient meeting. Problems Financial Although the hospital charged medical aid tariffs, a significant number of patients' medical aids had reached the limit of bene­ fits while the patient was still in an acute care hospital. Representative Association of Medical Schemes (RAMS) refused to pay for serv­ ices rendered by the therapists in the em­ ploy of the hospital. Government gazetted codes as set out by RAMS for physiotherapy do not in­ clude a tariff for patients receiving ex­ tended periods of rehabilitation, or for as­ sistants carrying out supervised exercise programmes. Staff The hospital required specialists in fields of physiotherapy, occupational ther­ apy, speech therapy, social work and nurs­ ing. such specialists are scarce and re­ quired appropriate remuneration. Legislation did not allow physiothera­ pists to be employed by any organisa­ tion/person other than the state, the mines of an independent physiotherapist. Discussion The establishment of a private rehabili­ tation institute in South Africa is an inno­ vative and exciting concept. However, our medical resources do not provide for the comprehensive treatment and reintegra­ tion of the neurologically impaired indi­ vidual into society. In many cases, by the time the patients were medically stable and ready for rehabilitation, they had reached the limit of their medical aid bene­ fits and thus could not afford further treat­ ment. This resulted in patients being dis­ charged before reaching their maximal functional potential. G oing hom e still functionally dependent to a unprepared environment puts considerable emotional an d f in a n c ia l s tr a in on fa m ily and caregivers. Large institutions running on business principles cannot provide this type of serv­ ice without showing a profit. Specialised therapists providing a professional service need to be suitably remunerated. Thus a balance must be found between the needs of society and the financial practicalities of running a private rehabilitation institute. The cost of setting up a rehabilitation centre is substantial. Therefore, the bene­ fits to the patient and community need to be critically appraised. Literature has indi­ cated that reh ab ilitation in diagnostic groups is of maximal benefit predomi­ nantly due to the uniform approach to management (Flicker, 1989). This team ap­ proach should en g en d er high m oral, am ongst the m em bers and initiate re­ search which acts as a catalyst to improve patient care and standards of treatment. Literature indicates patients rehabili­ tated on stroke units/wards leave hospital sooner than those on general m edical wards (Millikan, 1979). This implies that hospital costs per patient may be less on a stroke unit’ (Stevens et al, 1984). Results indicate a higher proportion of patients discharged from stroke units were inde­ pendent compared with those from gen­ eral medical units (Garraway et al 1980). Garraway found the mean length of stay in the stroke unit was 55 days in compari­ son to 75 days in a general medical ward. However, at one year follow-up the stroke unit benefit was no longer evident. Ongo­ ing community follow-up is more likely to be utilised by those patients who received rehabilitation in a stroke unit (eg district nurses, physiotherapists and day centres) (Garraway et al 1981). Studies comparing formalised neuro­ rehabilitation with non-formalised treat­ ment in functional and cognitive skills have been undertaken. Results show those patients who took part in the formalised programme gained a greater functional ca­ pacity with implications for return to work and decreased cost to, society (Mackay). There is now clear evidence as to the bene­ fit to patients and cost effectiveness of skilled and appropriately delivered neuro­ rehabilitation (Brooks, 1991). Physiotherapy, May 1994 Vol 50 No 2 Page 43 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) A t th e B H M I a te n d e n c y to w a rd s the a b o v e re s u lts w a s e x p e r ie n c e d . U n fo r tu ­ n a t e l y b e c a u s e o f t h e a f o r e m e n ti o n e d p r o b le m s , c o m p le te d r e s u lts c a n n o t b e q u o te d . Suggestions: P rio r to o p e n in g a re h a b ilita tio n c e n tre w h ic h w ill p r o v id e th e n e c e s s a r y s erv ic e, all th e le g a lis tic a n d fin a n c ia l im p lic a tio n s m u s t b e c le a re d . T h is in c lu d e s p e rm is s io n b e in g g r a n te d fr o m th e r u lin g b o d ie s a l­ lo w in g th e ra p is ts to b e e m p lo y e d b y h o s ­ p ita ls . (P e r m is s io n c a n b e o b ta in e d if m o ­ tiv a te d - E d ito r). A p p ro v a l m u st b e g a in e d fo r a c o m p o s ­ ite fe e fo r a r e h a b ilita tio n p a c k a g e , th a t w ill b e c a rrie d o u t in a n a p p r o v e d re h a b ilita ­ tio n e n v ir o n m e n t th a t p r o v id e s a ll th e n e c ­ e s s a r y e q u ip m e n t. A p a c k a g e c o u ld b e w o rk e d o u t d e p e n d in g o n th e a m o u n t a n d ty p e o f th e ra p ie s re q u ire d . T h e a l l i e d m e d i c a l s t a f f s t r u c t u r e s h o u ld ru n p a r a lle l to th e n u r s in g s ta ff w ith its o w n h ie ra rc h y , th u s h a v in g a r e ­ h a b il it a t i o n c o o r d i n a t o r , s e n io r , ju n io r s ta ff an d a s sista n ts. C o n s i d e r i n g th e f a c i l i t i e s c u r r e n t ly WORLD CONFEDERATION FOR Sheena Irw in-Carruthers WORLD CONGRESS The m ost exciting new s at p resen t relates to plans for the 1995 C on gress and G eneral M eeting, to b e held in W ashington DC from 25-30 Ju n e n ex t year. V a r io u s t y p e s o f p r e s e n t a t i o n s a r e planned: • Research rep o rts o r special in terest re­ ports, both o f w hich m ay b e given either as platform p resentation s or p oster p res­ entations. • C om puter program s, w hich m u st b e origi­ nal d esigns and m ay not b e for sale com ­ m ercially. • M aterials d isplay tables, w hich m ay con ­ tain sm all p ieces o f equ ip m en t, m odels, graphic m aterial, booklets o r data form s. A gain these m u st h av e been designed by the presenter and m u st n o t b e available for sale. • A ud iovisu al p resen tation s o f videotapes, m o tio n p ic t u r e s , s y n c h r o n is e d s lid e - sound prog ram m es o r slides w ith an in­ stru c tio n a l leaflet. T h e s e m u st a lso be original designs and m ay n o t b e com m er­ cially prod uced. T he d ead lin e fo r su bm ission o f abstracts is 1 Sep tem ber 1994. In ad dition, invited sp eakers w ill take part in an international clinical lectu re series and in case conferences. M orn in g rou nd -tables (ov er continental break fast) and special interest m eetings are planned on a variety o f subjects. T h ere is a w id e ch oice o f pre- an d post-con g ress CPE cou rses an d there w ill also b e op portu nity to a v a ila b le a t th e B H M I, p a tie n ts a d m itte d fo r r e h a b ilita tio n c o u ld b e s e p a ra te d in to d ia g n o s tic g r o u p s . E a c h g r o u p d iffe r e n ti­ ated in to its o w n sp e c ia lis e d u n its / w a rd s a llo w in g fo r o p tim a l u s e o f th e s e a v a ila b le fa c ilitie s (eg h y d r o th e ra p y p o o l a n d A D L c en tre). Conclusions: D u e to th e se fin a n c ia l a n d p e rs o n n e l p ro b le m s , th e in s titu te h a s, o f n e c e ss ity , a d a p te d in o rd e r to c o n tin u e p ro v id in g th is s p e c ific s erv ic e. T h e in s titu te h a s e s ­ ta b lis h e d g e r o n to lo g y a n d g e n e r a l r e h a ­ b i li t a t io n w a r d s . T h e th e r a p is ts a r e n o lo n g e r e m p lo y e d b y th e in s titu te a n d a re re g is te re d w ith th e ir s p e c ific p ro fe s sio n a l b o d ie s as in d iv id u a l p riv a te p ra c titio n e rs . L ia is o n b e tw e e n te a m m e m b e rs h a s re ­ m a in e d h ig h , th e c o r n e r s to n e o f w h ic h is th e w e e k ly te a m m e e tin g d u rin g w h ic h g o a ls o f tre a tm e n t, s o c ia l a n d e c o n o m ic m a tte rs p e rta in in g to th e p a tie n t a re d is ­ c u s se d . It s h o u ld b e n o te d th a t w ith th e re s tru c ­ tu rin g o f m e d ic a l a id re g u la tio n s , in 1 994, p ro v is io n fo r th e e s ta b lis h m e n t o f r e h a b ili­ ta tio n u n its w ill h o p e fu lly b e m a d e , e ith e r PHYSICAL THERAPY visit renow ned health care facilities. Social activities ran ge from official cere­ m on ies and receptions to ja z z con certs and picn ics - all very tem pting! NOTE TO SASP MEMBERS If you are thinking o f presenting a paper or poster at C on gress, p lease en su re that the abstract is subm itted to the N ational E xecu­ tive C om m ittee b y 6 Ju n e 1994. This is stand ­ ard operating proced u re for W C P T m em bers, so that high standards m ay b e m aintained. T he N EC w ill n o t b e able to con sid er financial assistance to m em bers d eliverin g p a p e rs 'if their abstracts h av e not been seen. The "early b ird " registration fee o f $275, to b e paid by 21 A pril 1995, is surprisingly reasonable for a C on gress w hich w ill offer a ch oice o f over 1,000 presentation s and is e x ­ pected to attract no few er than 12,000 p artici­ pants. POLICY PAPERS T h e Standard T ask Force o f W C P T has circu lated a series of policy papers, requ est­ ing the com m ents o f m em ber-organisations. N EC w ill b e circu lating these to the Branches and to a p p ro p ria te G ro u p s, C o m m ittees, portfolio h olders and ind ividu als for their com m ents, and it is hoped that p lace w ill have been found for their discu ssion d uring C ou ncil. T h e p ap ers fall into tw o groups: Declaration of principle A D eclaratio n o f P rin cip le record s the C o n fed eratio n 's agreed stance on an issue affectin g the practice o f physical therapy in­ ternationally. A D eclaration o f P rinciple requ ires a two- thirds m ajority vote and should b eco m e pol- a s s e p a r a t e c lin i c s o r a s s p e c i f ic u n its w ith in e x is tin g h o s p ita ls . T h e r e c o g n itio n o f th e n e e d fo r s u c h u n its a n d a c k n o w ­ le d g m e n t o f th e b e n e fit to p a tie n ts w h o a re tre a te d in th e s e e s ta b lis h m e n ts m u s t b e b r o u g h t to th e a tte n tio n o f th o s e a t g o v e r n ­ m e n t le v e l a s w e ll a s th e g e n e r a l p o p u la ­ tion . References 1. Brooks N. The Effectiveness of Post Acute Rehabilitation. Brain Injury 1991;5:103-110. 2. Flicker L. Rehabilitation for Stroke Survivors - A Review. Aust N J of Med 1989;19:400-406. 3. Garraway WM, Alchtar AJ, Hockey L et al. Management of Acute Strokes in the Elderly: Follow Up of a Controlled Trial. Br Med J 1980;281(6244):827-829. 4. Garraway WM, W alton M S et al. The Use of Health and Social Services in the Manage­ ment of Stroke in the Community: Results fro m a C o n tr o lle d T r a il. A g e A g e in g 1981;10:95-104. 5. MacKay F. Stroke Rehabilitation: Is it W orth­ while? Arch Phys Med Rehab 1976;57:546. 6. Millikan CH. Stroke Intensive Care Units: Objectives and Results. Stroke 1979;10:235- 237. 7. Stevens RS, Ambler NR et al. A Randomised Controlled Trial of a Stroke Rehabilitation Ward. Age A geing 1984;13:65-75. icy for all member organisations. Declaration received to date are: • Education • Autonomy • Standards of physical therapy practice • Protection of title • Private practice • Support personnel for physical therapy practice • Quality care • The rights of the Patient/client • Validation of practice techniques and technology • Personnel resources planning • R elation sh ip s w ith o th er health p rofes­ sionals • Relationships with medical practitioners Declarations on Children, Torture, and Physical Therapy and Aged Care Services have already been adopted. The Code of Eth­ ics is being re-drafted at present, having pre­ viously been circulated to member-organisa- tions for comment. Position statement A Position Statement reflects the Confed­ eration's preferred opinion on an issue affect­ ing the practice of physical therapy interna­ tionally, recognising the fact that individual member organisations may be at different stages of development. A Position Statement requires a simple majority vote and may be adopted fully by a member-organisation or may be used when debating the issue at a national level. Two have been received" • Describing physical therapy • Curriculum guidelines for entry level physical therapy education. Bladsy44 . Fisioterapie, Mel 1994 Deel 50 no 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )