REHABILITATION SERVICES

BASIC CONSIDERATIONS

Rehabilitation services are an integral part of the services provided at the primary level. This constitutes a reorientation of rehabilitation from mainly institution-based services to community oriented and community based services. Communities and particularly people with disabilities should be involved in designing, implementing and monitoring services for people with disabilities. This precludes a disability service from being seen narrowly as a therapy service provided only by a certain category of staff. All health personnel in co-operation with all other sectors and the communities/people themselves are responsible for making society inclusive of all people including people with disabilities.

The clinic is the first point where people with disabilities, their family members or caregivers meet health staff. Clinics need to become creative in their approach to the problems experienced by these patients.

SERVICE DESCRIPTION

The purpose of rehabilitation at clinic level is to provide a service to prevent disabling conditions, to detect disabilities early so to prevent complications and the worsening of the effects of a disability on a person’s functional ability, to treat disabling and potentially disabling conditions and to provide access to rehabilitative services for people with disabilities, making them appropriate and acceptable.

The pivotal person at the clinic, through whom people with disabilities will access the rehabilitation service, is the PHC Nurse. The Therapy Assistant (Community) is the person providing the rehabilitation service at this level, in consultation with the visiting Therapist. The visiting generalist doctor is important in providing access to treatment of potentially disabling conditions, which would otherwise be difficult for people to access on a regular affordable basis.

Specific rehabilitative services include a basic assessment of people with disabilities e.g. stroke, spinal injury, cerebral palsy, developmental delay, blindness, communication problems, arthritis, amputations, backache, followed by an appropriate treatment programme, in consultation with the disabled person and his family. Consumable assistive devices e.g. continence devices, rubber ferrules and other aids to daily living are prescribed, provided and people trained in their use. Management of continence problems of patients with spinal cord injury, spina bifida, mental retardation, traumatic conditions and the elderly includes the supply of continence devices and devising continence programmes.

Patients are assessed for disability and care dependency grant applications.

NORMS
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  1. Improve access to comprehensive health services for the disabled. (National: Year 2000 Goals, Objectives and Indicators.)

  2. Have a responsive and area-specific disability information system in place, which will feed into the general information system of the district and clinic.

  3. Institute a functional referral system between the community-clinic-district hospital, as well as other relevant sectors.

  4. Institute a system of obtaining, repairing and maintaining essential assistive devices for rehabilitation at clinic level.
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STANDARDS
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  1. Reference, Prints and Educational Material:

1.1 A register of all local, regional, provincial and national resources for referral for rehabilitation, education and training.
1.2 OT reference pack.
1.3 "Disabled village children" by David Werner, as reference book

  1. Equipment:

2.1

  1. Medicines and Supplies:

3.1 Consumables such as axillary rubbers, rubber ferrules and cane tips.
3.2 Ready-made packs on order per specified patient:

  1. Competence of Health Staff

Clinic Staff are able to:

4.1 Use of standardised questionnaire for the detection of hearing loss.
4.2 Identify and refer patients requiring rehabilitation.

The Therapy Assistant is able to

4.3 Teach prevention of pressure sores and pressure sore care.
4.4 Identify and implement techniques in a walking re-education programme.
4.5 Construct simple aids for daily living from locally available materials and teach the patient how to make and use them.
4.6 Teach mobility and daily living skills to a blind person.
4.7 Identify articulation, language and fluency disorders.
4.8 Plan, implement and monitor language stimulation programmes.
4.9 Use augmentative and alternative communication methods with appropriate patients, construction of simple communication boards, and teach the family how to use them.
4.10 Plan, implement and monitor basic programmes for the rehabilitation of people with neurogenic disorders of communication.
4.11 Counsel the family and teachers of a person with hearing impairment on simple measures to improve communication.
4.12 Have knowledge of available resources for rehabilitation.
4.13 Construct and instruct in the making of corner chairs with table, standing frames and walkers out of Appropriate Paper Technology.
4.14 Construct and instruct in the making of toys out of locally available waste materials and plan, implement and monitor play and stimulation activities to facilitate development.
4.15 Teach basic maintenance of wheelchairs, hearing aids, callipers and crutches.
4.16 Teach an exercise programme for the prevention and treatment of backache.
4.17 Instruct on back care and joint protection principles to decrease pain and maintain the range of movement in the treatment of back pain and other conditions involving joints.

Visiting Therapist are able to

4.18 Design treatment/rehabilitation programmes for people with stroke, spinal injury, spina bifida, cerebral palsy, barriers to learning, sports injuries, backache, arthritis, amputations, blindness, to be implemented by the therapy assistant or family members of the person with a disability.
4.19 Assess people with disabilities for the need for Specialised Assistive Devices, and prescribe and order these from the District, Regional or Tertiary Hospital.
4.20 Assess patients with burn scar tissue, and prescribe and order pressure garments.
4.21 Assess scholars with barriers to learning
4.22 Guide doctor in assessment of degree of disability for applications for disability and care dependency grants.
4.23 Design and direct needs driven awareness raising, education and prevention programmes.
4.24 Assess the need for surgical release of contractures and other corrective procedures.
4.25 Supervise and arrange the continuing education of community therapy assistants.

The visiting PHC doctor is able to

4.26 Assess continence problems, and advise suitable continence management in consultation with the therapist or therapy assistant, patient and family.
4.27 Manage spasms related to spinal injury with drug treatment and/or detection and treatment of stress factors.
4.28 Assess persons for disability grants and care dependency grants.
4.29 Use a Schiotz Tonometer.
4.30 Diagnose disabilities as early as possible, and develop a system of referral. (National Year 2000 Goals, Objectives and Indicators.)
4.31 Clinics are accessible to wheelchairs and trolleys and have toilet facilities for people on wheelchairs.
4.32 People with disabilities are given preference when queuing for services and, where feasible, appointments are given to patients to reduce waiting times.

  1. Referrals

5.1 From district hospital to clinic:

5.1.1 All patients with newly acquired disabilities, who have completed the acute phase of their rehabilitation for follow up by the therapy assistant.
5.1.2 All newly detected patients with disabilities, who have been assessed by a therapist, doctor or specialist, for follow up and rehabilitation at the nearest clinic.

5.2 In the clinic to the rehabilitation service:

5.2.1 All children detected with a developmental delay for assessment.
5.2.2 Patients with healed burns that cover a joint surface for the prevention of contractures and treatment of scarring.
5.2.3 Patients with disabilities for alleviation programmes and rehabilitation.
5.2.4 All patients with chronic deforming arthritis.

5.3 Referral of patients to doctor or multidisciplinary team:

5.3.1 Patients with spinal chord injury with troublesome spasms.
5.3.2 Patients with continence problems for institution of an adequate continence programme.

5.4 From clinic for specialist assessment or treatment:

5.4.1 Patients with physical disabilities amenable to corrective surgery, assuming that a therapy follow-up service is available.
5.4.2 Patients with chronic disabling rheumatoid arthritis for assessment and monitoring.

5.5 From clinic to hospital:

5.5.1 Patients requiring intensive daily rehabilitative therapy.
5.5.2 Patients with extensive bedsores.
5.5.3 Patients in need of more assistive devices not available at district level.
5.5.4 Complicated burns (facial, perineal, burns involving a joint or over 10% of body surface).
5.5.5 Patients with spinal injury and sudden increase in spasms, temperature and high blood pressure.

5.6 From clinic to other sectors:

5.6.1 Children with sensory loss to LSEN schools.
5.6.2 Patients with disabilities who are capable of working, to department of labour for employment opportunities.
5.6.3 Patients with disabilities for training in suitable occupational skills.
5.6.4 Patients with disabilities that are not suitable for the open labour market, to community groups for disabled people, self-help groups, or protected workshops.
5.6.5 Any other sectors which are deemed useful for the development of social and economic independence of the disabled person e.g. training centres for the blind.
5.6.6 Peer support groups.
5.6.7 Patients with disability who are not acceptably cared for in the community to the welfare department.
5.6.8 Severely disabled children, who are not accepted at schools to community day care centres.

  1. Patient Education

6.1 Prevention of bedsores in debilitated patients and patients with sensory loss.

  1. Records

7.1 Data collected at clinics to be used for development of a district data base on disability for use for programme planning
7.2 Patient information recorded using the SOAP Format.
7.3 Initial assessment and follow up forms standardised for the district, and kept in the chronic file of the patient at the clinic.
7.4 A summary note of the diagnosis, referral and treatment is in the patient held record.
7.5 The visiting therapist ensures that data and information, and records are accurately and consistently maintained.
7.6 Data fields for clients referred for rehabilitation are included in the clinic register.

  1. Community and Home Based Activity.

8.1 Refer patients to community monitoring programmes, mobilise community support, where indicated by the patients’ social circumstances to ensure compliance with treatment.
8.2 Needs analysis for rehabilitation in the community, to plan appropriate and effective intervention programmes.
8.3 Home visits on patients to gain insight into their social situation.
8.4 Devise home based rehabilitation programmes for people requiring extended rehabilitation, in collaboration with the disabled person, his family, and/or community.
8.5 Maintain contact with clients through follow up visits.
8.6 Identify and mobilise community resources for groups and peer support, skills training and income generation.
8.7 Supervise, advice and assist community therapy assistants.
8.8 Recommend and assist with implementation of adaptations to client’s homes, communities, work areas, or schools.

  1. Collaboration

9.1 Develop a responsive disability information system and database in consultation with PHC Nurse, Generalist Doctor, Disabled People’s Organisations and Community

NB : IN COLOR THAT WILL REPEAT ITSELF TROUGHOUT PART 2 PREFERABLY A DIFFERENT COLOR FROM PART 1

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