Abstract
This study aims to carry out a specific action on the rehabilitation path, with the support of the service of social work and housing, systematizing a thorough analysis of each long-term hospitalization situation. An integrated global management in a rehabilitation pathway can only be conceived by a better identification of the factors of complexity and variables likely to change, an organization regularly readjusted, and collaborative work between relevant departments. Extra-hospital facilities play an essential role in the prospects of exits, which requires that the care system be equipped with a rapid relay capacity towards a readmission, that the care accompaniment be efficient and that the patient's care project be adapted to his needs. The closure of intra-hospital rehabilitation units may result in many hospitalized patients no longer having access to the specialized rehabilitation services they need.
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