[Suitability of the SINGER as a tool for assessment in outpatient neurological rehabilitation]. / Eignung des SINGER als Assessmentinstrument in der ambulanten neurologischen Rehabilitation.

OBJECTIVE: The scales Barthel-Index (BI) and Functional Independence Measure (FIM) are the most frequently used instruments for measurement of outcome in neurological rehabilitation. Both instruments show appropriate psychometric characteristics but there are some limitations for their use in outpatient neurorehabilitation. The "Score of Independence for Neurologic and Geriatric Rehabilitation (SINGER)" was developed to compensate the weaknesses of the established instruments and to facilitate a direct connection to the ICF. The results of the original validation study of the SINGER in an inpatient setting recommended a test of the SINGER also in an outpatient setting. METHOD: The SINGER has been applied in a multicentric validation study. Patients of 17 outpatient rehabilitation centres were included consecutively. In this study patients with stroke or TBI were asked to fill in a questionnaire at 4 points of measurement. Additionally, medical staff were asked to rate the patients' status at admission and discharge. RESULTS AND CONCLUSIONS: SINGER-data could be collected of 429 patients. In sum, results recommend to use the SINGER in outpatient neurorehabilitation, though with some restrictions. In comparison to BI and FIM, the SINGER results show in any case considerably less ceiling effects. The further exclusive use of FIM and, above all, BI cannot be recommended. But for very weak affected patients SINGER is poor sensitive for change and because SINGER is not covering all relevant aspects of rehabilitation a combined clinical use of SINGER and other assessment instruments seems to be a constructive solution.

[Structures and processes in outpatient neurorehabilitation]. / Strukturen und Prozesse in der ambulanten Neurorehabilitation.

OBJECTIVE: Quality of structures, processes and outcome are commonly accepted as dimensions of quality management and quality assurance. Data of structures and processes are not published to date for German outpatient neurorehabilitation. Rehabilitative care and service providers are legally bound to apply concepts of quality management and quality assurance. The service providers pass recommendations, which have to be implemented by outpatient neurorehabilitation centres. Data analysis of existing structures and processes in outpatient neurorehabilitation centres are embedded as a part of a long-term multicentres outcome study. METHOD: 22 outpatient neurorehabilitation centres participated in an online survey with 227 items using the google tool "Docs" between September and December 2011. Following issues were asked: general information about the centres (e. g. date of establishment, number of therapy places, kind of patients, responsible organization), utility supply contracts with service providers, local cooperation and networking, staff and equipment and appliances, treatment concepts, processes of therapy (e. g. individual and group therapy, frequency, concentration, planning), team processes, goals and team development, quality management and documentation. RESULTS AND CONCLUSIONS: In the meantime outpatient centres of neurorehabilitation are well-established as care providers and commonly accepted by service providers. However a comprehensive availability does not exist. The results show comparable structures of the centres, what is mostly determined by the service provider audited regulatory framework. Different concepts result in different processes. There are a lot of hints with respect to different concepts in form and content to implement the legally obligated mandate. In general their work with context -factors is still a frequently unused potential. It can be countered by the therapeutic inclusion of the social and environmental living conditions of the patients.

[Community-based rehabilitation and outpatient care for patients with acquired brain injury and chronic neurological disability in Germany: continuing support for social participation and re-integration in the neurological care system?]. / Die neurologische Rehabilitations-Phase E: Nachgehende Leistungen zur sozialen (Re-)Integration und Teilhabe - ein Kontinuum?

In Germany a number of patients who are suffering from acquired brain injury and chronic neurological disability are either undersupplied or exposed to inappropriate care in their social environment. The number of these patients is increasing due to the changes in the procedures of care and due to demographic factors. While acute medical care and early rehabilitative treatment is accessible throughout the German health care system the necessary multimodal and competent care is rare or absent in the social participative sites such as life and occupational environments of the patients. The complex impairment of the brain, the central organ for sensorial, executive and other cognitive functions of human beings, renders the affected patient an exception in the system of medical and social care - this has only inadequately been considered in the past. The authors explain the necessity to disclose the status of a "human-with acquired-brain damage (Mensch-mit-erworbener-Hirnschädigung, MeH)" explicitly as severely disabled. The paper recommends a number of structural and procedural elements that have proven to overcome the insufficient or inappropriate support in integrating the patients suffering from acquired brain injury and chronic neurological disability in their social environment as well as for a demand-focused support with sustainable rehabilitative and ambulant follow-up procedures. Comparisons with other developed health care systems and international guidelines show that with organizing of early-supported-discharge, community-ambulation, shared-care and community-based-rehabilitation these problems have long since been identified elsewhere. Community-based and resident-oriented concepts have already been systematically implemented. In order to achieve the necessary support for the individual patient, a nation-wide development is necessary in Germany to perform the principles of the German social code and the principles of the Convention on the Rights of Persons with Disabilities of the United Nations: Goals of rehabilitation have to be more than functional treatment. Activation of the patient and supporting their coping and adaptive processes are necessary to achieve social participation and (re)integration into the community and in occupational life as implied by the standards of our society. Important elements of these are (1) identification of the individual patient and his/her burden during acute phase treatment or early rehabilitation (defined red-flag), (2) an individual clinical reasoning and planning of interventions and help, (3) general acceptance of the defined demands by all "players" in medical and social networks, (4) coordination and supervision of the medical and social interventions and of the assistive processes necessary in the individual environment. What seems to be needed is (5) systematic orientation to the goal of individual social participation at all levels of support, (6) cross linking, cooperation and development of the existing medical and social structures on site, (7) expansion of the legal framework and (7a) especially control of the implementation of the existing rights of social benefits and (7b) surveillance (transparency and quality management not only in the area of caregivers but also for the administration of social insurances!). The recommendations of the authors integrate systematically into the phase model of neurorehabilitation (VDR/BAR) in Germany. The focus of this work is the needs-appropriate programming of phase E, i. e., the transition between inpatient and outpatient care, between the clinical facility-oriented and the community-based (domicile-oriented, occupational-oriented) sectors, between welfare and independency.