Continuum of care refers to an integrated, highly coordinated system of care and services designed to meet a patient’s needs at any point in their health care journey. It is a holistic approach that guides patients through a comprehensive network of services spanning different levels and intensities of care. Studies show that care coordination across the continuum improves outcomes, increases patient satisfaction and reduces the overall cost of care.1
Baylor Scott & White Institute for Rehabilitation (BSWIR), has redefined its continuum of care making it a model for meeting the unique, increasingly complex needs of patients at any point in their post-acute journey. This commitment to individualized recovery serves as the foundation for the hospital’s growth from a single inpatient facility to one of the nation’s largest networks of comprehensive inpatient and outpatient programs and services. It also provided the impetus for innovation.
A New Look at Neuro
In the fall of 2020, a new initiative focused on not only improving neurorehabilitation service lines but also aligning those services to provide optimal continuity of care. This Neuro Continuum model combines a strong, evidence-based approach to neuro rehabilitation with access to medical, psychology, case management and other critical support services. The Neuro Continuum has become a vital component of BSWIR’s care delivery, helping to create a seamless, well-coordinated alignment of services for patients and families across inpatient, outpatient and home-based services.
Making Rehabilitation REAL
The Real Life Rehab program is a key example of how neuro-rehabilitation has evolved at BSWIR. A first of its kind program in the U.S., Real Life Rehab brings neuro therapy into the home setting, helping patients adapt to their home environment while actually in their home. The program focuses on three main challenges facing neuro patients following discharge from inpatient rehabilitation: acclimation to change, adaptation to home and community and reinforcement of skills. This critical step leads to a more successful transition to the next level of care and recovery.
Real Life Rehab therapists begin working with the patient and family the day they leave the hospital or shortly thereafter. They help both the patient and family/caregiver understand the challenges they may face and provide the training, techniques and education to help ensure the comfort and safety of everyone involved. Ongoing restorative skill-building is also incorporated into daily activity routines to further support patients and families as they adjust to life ahead. By establishing a new, predictable routine within the home, patients and families are better prepared physically, functionally and emotionally to move forward.
Interim short-term services may also be provided by the Real Life Rehab team when a patient demonstrates difficulties carrying over critical skills from the hospital, day neuro or outpatient programs to home. Changes in living arrangements or location, caregivers, support systems or other factors can readily disrupt a patient’s ability to focus on reinforcing or acquiring new skills. By shifting to Real Life Rehab for a short period, the individual will work to with their team to address these issues, improve or stabilize their functional abilities and allow for the successful return to the primary rehab program.
In addition, Real Life Rehab may provide final generalization and application of skills learned when special circumstances warrant. This final transitional service helps verify that the patient is functioning at the highest possible level within their home and community, while also identifying any additional skills training the patient may need. Patient outcomes are measured across in three domains -- participation, supervision/assistance needed at home, and supervision/assistance required for community activities. This data is carefully analyzed to support ongoing program development, best clinical practices and measurable functional gains.
Guiding Neuro Recovery
Successful neuro-rehabilitation requires all care providers to consider the impact of the transitional challenges for patients who have had to abruptly adapt to physical, cognitive and psychosocial changes in their lives and enter into the often unfamiliar world of medical rehabilitation. At BSWIR, patients and families rely on our neuro continuum to understand and overcome the often difficult, real life changes and challenges they face. Providing a well-integrated, carefully coordinated and effectively aligned neuro continuum that provides the right services at the right time is essential in a successful rehabilitation journey. The Real Life Rehab program is one element that helps achieve that goal.
1.) ConsensusHealth. 2019