Geriatric Rehabilitation Network – Patient in the Lead: Aiming for personalised, efficient, and effective geriatric rehabilitation

Abstract

Background: Elderly patients admitted to the hospital after a stroke, joint replacement or trauma can recover at a geriatric rehabilitation setting. Ideally, geriatric rehabilitation considers the individually varying complexity of recovery, depending on for example degree of resilience, severity of multimorbidity, and extensiveness of social support system. During their rehabilitation, patients and their caregivers prepare for the patients’ return to home at the most optimal functional level. To accomplish this, it is imperative to centralize the rehabilitation around the personal needs and wishes of patients and caregivers. We as the Geriatric Rehabilitation Network – Patient in the Lead observed that this centralization is not common practice and the patient is rarely in the lead. An exploratory study among patients, caregivers, and healthcare providers confirmed our observations. We found three striking leads that should be pursued in geriatric rehabilitation: 1 Patients and caregivers strongly indicate a lack of a personal approach based on their needs and desires as well as a lack of continuous involvement and communication during their rehabilitation process; 2 Healthcare providers indicate a lack of alignment within and between disciplines and a lack of knowledge on the proper tools and measures based on the variety of complex disorders they encounter; and 3 Patients and caregivers indicate a suboptimal level of information management about transition and continuation of rehabilitation at home or another care setting. These three leads form the reason for our call for more personalised, efficient, and effective geriatric rehabilitation, with patients truly at its heart. Aims: The aim of this presentation is to inspire the audience to assign a central role to the patient. It is a well-known and common pitfall to overlook the patients as well as their caregivers: with our tools, measures, and experiences the audience can overcome this pitfall and improve geriatric rehabilitation from the beginning to the end by involving patients and caregivers continuously and effectively. Format: In this presentation we will discuss how to: 1 Tailor geriatric rehabilitation to the needs and desires of patients and caregivers, taking into account their diversity in past and current live events with effective skills in communication, Shared Decision Making, and Advance Care Planning; 2 Improve the mutual communication within and between the various disciplines involved in geriatric rehabilitation; and 3 Arrange optimal information management about transition and continuation of rehabilitation at home or another care setting. Target audience: We welcome any professional who wishes be more effective in geriatric rehabilitation, and evidently, anyone with personal experiences in geriatric rehabilitation, either as a patient or caregiver, as together we form a learning community. Learnings: Tools to effectively communicate with patients and caregivers to truly involve them in their own rehabilitation process. Tools to apply shared decision making and advance care planning in geriatric rehabilitation. Tools to measure and evaluate the progress of geriatric rehabilitation.