Patientenorientierte Rehabilitation – komplexes Management an der Schnittstelle zwischen Erkrankung und Funktionalität – eine Fallstudie

Abstract

The rehabilitation of geriatric and multimorbid patients poses an increasing challenge. To a major extent, the illnesses involved imply chronic musculoskeletal complaints and pain of the musculoskeletal system due to chronic degenerative processes. Here, the feasible aim often is not to heal the illness, but to achieve the best possible performance of the ill person while assuring the least possible degree of psychological discomfort. Thus, an optimally coordinated rehabilitative concept is necessary to maintain the patient's autonomy and his ability to participate in daily living to avoid care dependency, and to minimize the degree of psychological distress. An early definition of therapeutic aims set together by the patient and the health professionals allows for an effective, resource-saving collaboration which will be satisfactory for both the health professionals and the patient. Such collaboration will lead to the best possible outcome concerning the patient's functioning and quality of life. It must be realistic for both the patient and the health professional to achieve the therapeutic aims. The necessary steps to do so should be part of a manageable time schedule containing several stages which should ideally be predetermined and verifiable. A multidisciplinary collaboration and a multimodal approach focusing on the superordinate individual therapeutic aim are essential for a successful therapy. Personal as well as environmental factors have to be taken into account in order to develop a sustainable treatment concept. The International Classification of Functioning, Disability and Health (ICF) and its bio-psycho-social model of functional health provide a conceptual framework for therapy planning. Moreover, the ICF classification system offers an equipment for the documentation of health problems as well as therapeutic aims and therapeutic successes that can be used by all professions involved in the therapeutic process. A possible approach to rehabilitation and the demands placed on the health professional leading the team are described by means of a case study.