08 | Community Reintegration

Evaluation

Shortly before discharge to the community, Martin’s functioning status was re-evaluated, a final rating of the intervention targets based on the evaluation was given and compared to the rating given in the first assessment to determine Martin's goal achievement.

The evaluation at the end of Martin's Rehab-Cycle® showed that Martin and his rehabilitation team were successful in achieving the majority of his goals.

Goal Achievement in Cycle Goal 1  – Vocational Reintegration

In the course of phase 2 (the clarification phase) of vocational rehabilitation (VR), Martin made significant advances, often due to his own initiatives. For example, he pushed for conducting a cognitive evaluation with the hope that it would reveal new vocational avenues. His hopes were later justified as the results revealed cognitive resources of which he had not been previously aware. Based on the results of the cognitive evaluation, the VR counsellor encouraged Martin to return to school in order to meet the prerequisites for attending university  – an option Martin had never before considered. The encouraging results gave Martin's self-esteem a great boost.

In contrast to the first Rehab-Cycle®, Martin had become pro-active in his rehabilitation. He took the initiative and reached out to his network of friends and colleagues. Discussions with a friend sparked an idea for a new career  – becoming a vocational coach for others who are dealing with similar issues. Martin also contacted his former employer to explore possible employment options. This resulted in a chance of returning to this employer on the condition that Martin clearly defines the position he would like to enter and makes a proposal for reintegration. Both of these prospects  – vocational coach and returning to the previous employer  – were very promising.

During the course of VR phase 3 (the integration phase) Martin and his VR counsellor discussed and acted on these new vocational options. Despite the positive results of the cognitive evaluation, Martin made clear that he had no interest in returning to school. Regarding the offer from his former employer, a plan was developed in which Martin committed to start working at a 30% full-time equivalent six weeks after discharge from the rehabilitation centre. At the same time, Martin also applied to take a basic course on vocational coaching. This 6-month training would enable him to provide peer coaching to those, like himself, who are facing obstacles to employment either due to disability or social circumstances.

Martin had come a long way since his first Rehab-Cycle®. His decision-making capacity had increased tremendously, as evident in his pro-active approach and the choices he made in the current Rehab-Cycle®. Sparked by new vocational opportunities, Martin was in a very good position to begin a new life in his old community.

Goal Achievement in Cycle Goal 2  – Independent Housing and Mobility

Prior to his accident, Martin had lived in a shared 5th floor apartment with a friend. Without an elevator, this apartment was not wheelchair-accessible, and it was clear that he would need to move. He thought of two possibilities  – finding a new wheelchair-accessible apartment with his friend or looking for a place for himself alone. While Martin took responsibility for his apartment search, he had difficulties making a decision on which path to follow. After much discussion with the social worker and psychologist, Martin decided on the option of living alone. His search, though time consuming, was successful, and he found a wheelchair-adapted three-room apartment that needed very few modifications.

Regarding his goal of independent mobility, Martin required both a driver’s license and an adapted car. Martin successfully completed his driver’s training and passed the driver's examination shortly before his discharge. At the beginning of the Rehab-Cycle® Martin's car had been ordered, but insurance coverage for the adaptations had not been confirmed. By the end of the Rehab-Cycle® the insurance payment had been confirmed and his car was adapted to his needs.

Issues of insurance coverage for the purchase of a Swiss-Trac™, the device that Martin needed to increase his wheelchair mobility in the hilly and forested area where he and his parents resided, remained unresolved at the end Rehab-Cycle®. While an order had been placed, the insurance company denied payment, presenting Martin with a financial burden that also limited his community participation. Without the Swiss-Trac™, the choice of community activities that he would be able to participate in was reduced. Fortunately, the Swiss Paraplegic Foundation agreed to subsidize the purchase of the device.

Goal Achievement in Cycle Goal 3  – Recreation and Leisure

During the course of Martin’s rehabilitation, he was exposed to a variety of sporting activities that included swimming, team sports and hand-biking. Given that his swimming skills had already been underdeveloped prior to the accident and a fear of the water developed after his injury, Martin showed little interest in swimming. Hand-biking, on the other hand, thrilled him. Martin's interest in hand-biking was so fervent that he began training on his own to improve specific muscle and movement functions necessary for the sport. He considered purchasing a hand-bike, and upon his return home, he planned to contact a local wheelchair club to further pursue the sport of hand-biking.

Goal Achievement in Cycle Goal 4  – Optimized Motor Functioning

Despite tremendous improvements in Martin’s physical functioning, he continued to suffer from pain and spasticity at the end of his Rehab-Cycle®. Although the location of pain shifted from his shoulder to a location closer to his spine, the manual therapy intended to alleviate the pain proved to be ineffective. Likewise, neither aquatic physical therapy, hippotherapy nor acupuncture was able to significantly reduce Martin’s spasticity. Cycle goal 4 was therefore not achieved.

The results of the evaluation can be seen at a glance on the ICF Evaluation Display prepared at the end of Martin's Rehab-Cycle®. The ICF Evaluation Display is a visual depiction of the change between Martin's functioning status before and after intervention, showing whether the goal values set for each intervention target were reached. See table 4.

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Table 4: ICF Evaluation Display; ICF Qualifier: rate the extent of problems (0 = no problem to 4 = complete problem) in the components of body functions (b), body structures (s), activities and participation (d) and the extent of positive (+) or negative impact of environmental (e) and personal factors (pf); Goal Relation: 1, 2, 3, 4 refers to Cycle goal 1, 2, 3, 4; SP refers to Service-Program goal; G refers to Global Goal; Goal value refers to the ICF qualifier to achieve after an intervention; Goal achievement: + means achieved, - means not achieved.

ICF Research Branch CoordinatorICF Research Branch in cooperation with the WHO Collaborating Centre for the Family of International Classifications in Germany (at DIMDI)

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