Integrating rehabilitation into health systems

Where should rehabilitation be directed?

The health interventions, both curative and preventative, implemented during the past two centuries⁹ have resulted in a shift towards individual lifestyle and behaviour, as well as broader social determinants. However, the existing health plan is not a viable solution for the majority of high-burden of NCDs or geriatric concerns, as it fails to address future challenges. On the other hand, the WHO asserts that mitigating primary behavioural risk factors such as tobacco consumption, physical inactivity, excessive alcohol intake, and poor dietary habits can prevent a significant proportion of NCDs¹⁰. The persistent influence of NCDs on population health and the health challenges associated with ageing necessitates a comprehensive ‘retooling’ of the healthcare system and workforce to tackle multiple, coexisting, and interrelated health issues. Health policies should focus not just on extending NCD preventive programmes but also on enhancing rehabilitation strategies aimed at optimising functional levels across the lifespan. The recent COVID-19 pandemic has revealed that an acute respiratory infection requires a comprehensive range of healthcare services. The absence of rehabilitation has adversely impacted individuals with disabilities and has led to various mental health issues, thereby underscoring the need for integrated rehabilitation services capable of addressing the entirety of a patient’s challenges within a single framework.

The way forward

Rehabilitation professionals need to modify their health strategy in accordance with the WHO’s International Classification of Functioning (ICF)⁹, which has established the framework for rehabilitation within the healthcare system. Utilising the conceptual model and information reference system offered by the ICF, it is now feasible to elucidate the correlation between rehabilitation’s aim to optimise functioning and the epidemiological trends that will affect the global population. Recently, the WHO has provided a detailed account of the global expansion of rehabilitation programmes¹¹, based on the premise that optimising functionality is the WHO’s third health indicator, after mortality and morbidity. The future of rehabilitation would be more promising if health professionals regarded it as an interdisciplinary partnership rather than a means to encroach upon the others’ clinical domain expertise. Frølich et al¹² reported a project that integrates and implements rehabilitation programmes for four chronic conditions namely, chronic obstructive pulmonary disease (COPD), type 2 diabetes, chronic heart failure, and falls among the elderly, integrating a geriatrician, an internal medicine specialist, a physiotherapist, and a nursing expert. The project utilised established organisational frameworks, incorporating a steering committee and four chronic illness working groups to deliver comprehensive treatment, from initial consultation in an outpatient clinic to follow up. Nurses and therapists underwent training to enhance chronic disease management, whereas educational programmes facilitated patient self-management. The internal and external project evaluations indicated that the rehabilitation treatment enhanced patients’ physical functioning beyond expectations for a similar population.

Despite the increasing demand for rehabilitation, there is a deficiency in its awareness, its significance and the extent of its unmet needs. This presents a significant obstacle to the advancement of the rehabilitation sector, necessitating aggressive advocacy for rehabilitation services as essential for meeting the population’s demands in the future. Rehabilitation users, providers, and civil society play a crucial role in enhancing rehabilitation advocacy.

Integrating rehabilitation into different models of care

Incorporating quality rehabilitation into service delivery paradigms is essential as countries progress towards integrated person-centred care. While all health services, such as promotion, prevention, treatment, rehabilitation, and palliation, contribute to long-term care, we must intensify our initiatives to integrate rehabilitation into policy and implementation. Countries must engage in a systematic process of situation assessment, planning, implementation, and evaluation to adequately address the rehabilitation requirements of their citizens¹³. National health strategies and financial allocations must incorporate rehabilitation, thereby advancing the objective of universal health coverage. There should be effective service delivery models, encompassing referral systems across various levels of the health system and between community and hospital-based services. Further, the substantial deficiencies in the evidence basefor rehabilitation necessitate a major enhancement of research support. Significant shortcomings in the evidence for rehabilitation policy and planning, including the elucidation of cost-benefit analyses, the identification of facilitators and barriers to rehabilitation access, the determination of the severity of unmet demands, and the establishment of a standardised measure of rehabilitation impact, require additional study.

This objective necessitates that health providers evaluate each patient comprehensively, assigning equal importance to all facets of an individual’s illness. All disease stages should have access to specialist services for management. Care transfers must not impede any rehabilitation or other objectives and processes. To accomplish this, each healthcare organisation requires four specialised teams to address disease (medical), disability (rehabilitation), distress (mental health), complex symptom management, and end-of-life care (palliative care). Rehabilitation (or disability) teams may predominantly handle the intervention for certain existing illnesses, such as learning disabilities and chronic pain management. Collaboration with other healthcare sectors would be mutually beneficial¹⁴. It is reiterated that all individuals should have access to rehabilitation services, regardless of ‘disabilities’. For example, cardiac rehabilitation is recommended following coronary bypass surgery or angioplasty, which is considered a class 1 indication¹⁵ (i.e., a strong recommendation); nonetheless, there is no explicit disability linked to heart diseases that may occur in conditions like a stroke. Rehabilitation is a crucial component of the patient’s care continuum to attain optimal health. This need not incur significant economic costs, as existing resources just require consolidation to enhance efficiency and effectiveness. For instance, the majority of medical and surgical ward teams incorporate therapists—specialised nurses and therapists who frequently assist patients with particular conditions (e.g., Parkinson’s disease) or issues (e.g., incontinence). Additionally, hospitals should proactively gather and publish data on health and well-being rather than solely focusing on disease. The involvement of a physician specialising in rehabilitation will facilitate the assessment of many rehabilitation facets, including the probable prognosis, potential complications, and emerging medical issues, along with referrals for mental health services or palliative care as necessary. Healthcare organisations could contemplate the collaborative distribution of responsibility with other services for measures pertaining to areas beyond health, particularly the social functioning of their patients. Rehabilitation must be a part of any healthcare programme that aims to improve health and well-being, promote mental and physical wellness, aid in illness recovery, and, when full recovery is not possible, maintain optimal health until the end of life. The long-term effects of rehabilitation may manifest when rehabilitation enhances someone’s safety and independence, a decrease in hospital and nursing care admissions, and the capacity to return to employment or other responsibilities.