[Concept for a functional status and handicap-adjustment treatment and rehabilitation service chain in neurologic and neurosurgical management in Germany ("phase model")]

Abstract

The German medical service and social support network for patients with neurological diseases and disabilities are publicly criticized as inadequate. However, the German social laws give everybody the legal right to be admitted not only for acute medical treatment but also for rehabilitation measures if they are going to be disabled and at risk of becoming dependent on care or of losing the ability to work. Rehabilitation beginning in the early stage of illness is required. Institutions are now being built up to close the gap between acute medical treatment and the beginning of comprehensive rehabilitation, especially in those neurologically severely disabled patients who need "rehabilitation before care". As a basis for planning to improve the situation, a study group set up by the German Pension Insurance Association (Verband Deutscher Rentenversicherer) has developed the following concept of phases in neurological and neurosurgical treatment, rehabilitation and care. The aims and tasks of each phase are defined by the patient's functional status and requirements for recovery: 1. Acute medical treatment and care in intensive care units or normal clinical wards; 2. Early rehabilitation of patients who are not really conscious or cooperative and need intermediate care services should complications arise ("early rehabilitation"); 3. Rehabilitation of patients who are conscious and able to cooperate but depend upon care for functions in activities of daily living (ADL) ("comprehensive" or "post-primary rehabilitation"); 4. Rehabilitation of patients who are independent in ADL functions but need comprehensive treatment for further recovery ("medical rehabilitation" in a traditional sense); 5. Institutional or outpatient rehabilitational aftercare for vocational and/or social reintegration ("aftercare"); 6. Private or institutional care aimed at maintaining the patients' functional status ("permanent care"). Patients with severe traumatic brain injury or cerebral hypoxia often require phase B care, while those who have had a stroke and those with some other neurological diseases (e.g. multiple sclerosis) often require institutions offering phase C rehabilitation. Acute treatment, rehabilitation, care and aftercare must be connected as a chain of services. Problems of sharing the costs among the different parts of the German social insurance system has hitherto led to gaps in that chain.