From the previous cycle, it was clear that the next phase of rehabilitation would need to focus on community reintegration. Martin’s Global Goal remained unchanged: independent living. A new Program Goal was determined as transition to community. Note that the previous Service Program Goal was defined as independence in daily living (in the rehabilitation facility). Martin had achieved this in the last Rehab Cycle.

Both the healthcare team and Martin himself then identified four areas that they felt needed to be addressed:

  • Mobility — To be independent when using the wheelchair in any location, as well as in the use of means of transportation (car, public).
  • Recreation — What options existed and what were Martin’s interests, especially to find opportunities for sporting activities?
...thoughts of the future caused him stress, both with regard to housing and a profession – key aspects of community reintegration.
  • Employment — Building on the vocational counseling already begun, what were Martin’s prospects and potential avenues for work?
  • Accommodation — What type of housing was possible and desirable?

Based on these areas of concern, the following Cycle Goals were defined:

  1. Vocational reintegration
  2. Independence in transportation and housing
  3. Development of recreation and leisure activities
  4. Movement-related functions

Determination of intervention targets

For each of the Cycle Goals, intervention targets were established:

  • To advance vocational reintegration, Martin’s decision-making competencies needed to be improved, suitable careers needed to be identified and employer support needed to be ensured in order to develop a concept of Martin’s future profession.
  • Achieving independence in transportation and housing required further wheelchair training on a variety of terrain and the ability to drive an adapted car including securing an appropriate driver’s license. Assistive devices needed to be ordered, including a car adapted for disabled-access and a Swiss Track™, a motorized device for increasing wheelchair mobility. Lastly, Martin’s decision-making competencies and his stress regarding the future needed to be focused on finding a solution to his housing problem.
  • The development of recreation and leisure activities, primarily sporting activities, were achieved through improving exercise tolerance, muscle and movement functions, the ability to maintain a sitting position, exploring specific athletic activities and initiating contact with a local sports club for the disabled.
  • Intervention targets regarding movement related functions were focused on Martin’s insufficient immune response (manifested for example, in Martin’s recurring urinary tract infections which increased his muscle spasticity and stiffness). Pain management would increase Martin’s range of motion and allow for more intensive training. Also emphasized was improving Martin’s relationship with his body which, it was hoped, would contribute to increased movement functions.

Box 2 | Organization of Transition to Community

A patient’s transition from a hospital or rehabilitation center back to his or her community marks a major development in the rehabilitative process, and in the life of the individual. Extended hospital stays and service discontinuity contribute to difficulties for patients making this transition.7In order to adequately address these issues in a context of continuing care, transitional rehabilitation programs have been developed. Such rehabilitation is intended to bridge hospital-based primary rehabilitation and secondary or tertiary community rehabilitation. It aims to reduce the time spent in the hospital, increase a patient’s control over the rehabilitation environment and enhance community reintegration.7

Once a transitional rehabilitative approach is decided on, the patient and healthcare team will together negotiate the areas to be addressed and the corresponding objectives. This should be a flexible and individual process that will cover goals, a program plan and timing.7 Program flexibility will help to ensure that the goals remain relevant to the patient, that appropriate staff and resources can be made available and that supporting links to community resources can be established.7Examples of issue areas that are often addressed through transitional rehabilitative interventions include housing, mobility, transportation, equipment, relationships and vocation.

The complex and multidisciplinary nature of interventions focusing on reintegration necessitates that each stakeholder in the process be invested and actively involved.7 The patient must formulate the process, engage in community links and, in the end, take the lead in reestablishing his or her familial and social roles. The patient’s family needs to be adequately prepared and included in the rehabilitative process. A core team of healthcare professionals with corresponding expertise and role autonomy need to ensure care and service continuity and maintain an understanding of a patient’s lifestyle and community issues. Finally, from a systems perspective, efforts must be made to focus on the process and both immediate and long-term outcomes, along with an emphasis on early discharge.

Figure 2: ICF Categorical Profile

Figure 2: ICF Categorical Profile: Illustrates the aspects of the functioning status which are relevant for this patient. * ICF Qualifier rates the extent of problems (0 = no problem to 4 = complete problem) in the components of body functions (b), body structures (s), activity and participation (d) and from -4 = complete barrier to +4 = complete facilitator in the environmental factors (e). In personal factors (pf), the sign + and – indicates to what extent a determined pf has a positive or negative influence on the individual’s functioning. C1, 2, 3 mark the relation to Cycle Goals 1, 2, 3; SG is related to Service Program Goal, G related to Global Goal.