[Improvement of rehabilitation aftercare through long term follow along of the patients--results of a pilot study].

Abstract

BACKGROUND: The population grows older, patients suffer from chronic diseases more frequently, and working life will be longer. Against this background, medical rehabilitation becomes more important. However, various studies indicate that rehabilitation lacks in sustainability beyond positive short-term outcomes: After three to six months there are hardly any detectable effects. For some time now the answer to this lack of sustainability is seen in an increase of aftercare. But here too, the situation seems rather deficient as in-patient treatment that usually lasts for three weeks is still predominant in the minds of many rehab patients and physicians. METHOD: In a multicentre research project a new strategy and organisation of aftercare was developed and tested by orthopaedic clinics and patients with chronic low back pain. The main emphasis was put on changes in physical activity and mobility. The central item was higher personal activity of rehab patients and an aftercare plan for doctors and therapists that can easily be realised. Therefore numerous means of implementation (checklists, information material, patient documentation) were developed. Six rehab clinics and 77 rehab patients tested the new credo. RESULTS: On the whole we received positive reactions from clinical staff and rehab patients. The mobility diary during rehabilitation was greatly accepted and accurately filled-in by patients. After rehabilitation two-thirds of them returned the mobility diary they had completed at home. In general it had also been filled-in reliably. Starting points for supports to be offered by clinics are readily identifiable. CONCLUSION AND PERSPECTIVE: Results of the pilot study showed that the concept is practicable and promising. Yet, long-term follow-along of rehab patients can only be realised by supplementary personal contact. Should the now starting controlled longitudinal study reveal that the concept contributes to securing the longer-term rehab effects, the time and expense for appointing an aftercare contact would be more than justified.