Community programs


The domestic and social reintegration of people affected by a spinal cord injury, acquired brain injury or any other disability that is neurological in origin is often difficult as a result of the high degree of complexity that their care represents for the patients themselves, their family, carers and health and social care professionals who are not used to dealing with the particular needs of these patients.

The Assessment and Support Team Specialised in Neurorehabilitation (EASE) acts in all levels of care within the health and social care networks for the more effective reintegration of patients in their own social and domestic context.

The team works to ensure that they are receiving the correct continuing care, favour the highest quality comprehensive and personalised care, and provide flexible and effective coordination with the specialist reference hospital, transmitting specific knowledge and skills in the neurorehabilitation process to all professionals from the different networks.

During 2022, Institut Guttmann carried out 477 interventions, distributed as follows:

Home assessment98
Other professional training in exchange for SSP10
Connexió amb recursos68
Comprehensive PU management34
Education for the family and/or carers30
Specialist comprehensive assessment57
“Fragile Patient” programme14
Advice on support products2
Training of other professionals in specific techniques 4
Unit for Minority and Neuromuscular Diseases11
Treatment of neurogenic bowel34
Social information and guidance8
Specific programmes107

Some of the specific programmes developed throughout the year are as follows:

  • Community occupational therapy programme for people affected by acquired brain injury, and their families.

This is a community-level programme to accompany people who have suffered a severe brain injury and who have difficulties generalising learning in Activities of Daily Living (ADL) and carrying out a routine of meaningful activities in their home environment.

  • Community mental health programme for patients with acquired brain injury and their families.

The main aim of this community programme is improving quality of life, favouring reintegration into the home environment and social life, and optimising opportunities for full occupational participation as wanted by the person. It is aimed at adult patients (between 18 and 70 years old) who are affected by moderate/severe acquired brain injury, and who present behavioural, emotional or mood disorders and difficulties in occupational participation.

  • Neurorehabilitation hospitalisation programme at home for patients with spinal cord injury.

This programme started with a pilot in 2021 and was launched on a regular basis during 2022. This is an individualised programme of neurorehabilitation hospitalisation at home. Its intensity is adapted to the clinical and functional characteristics of the patient, and the programme is clearly person-centred. It is aimed at patients with an acute spinal cord injury and who cannot follow intensive treatment on a hospital admission basis.

  • During 2022, 31 requests were received from participants, who have received different intensities of treatment for an average of 4 months, with an expert team of occupational therapists, nursing and physiotherapy staff and social workers, among others.
  • The service avoids transfers, prolonged and/or unnecessary hospitalisation, emphasising the human dimension of the patient. 100% of users gave the experience a score above 8.

After a spinal cord injury, the stay in hospital is not just for physical rehabilitation. Psychological aspects are also addressed and the patient is prepared for what is to come after discharge. A whole team of professionals works to help people resume their lives as soon as possible, but there are cases in which, for various reasons, users need a more personalised intervention that could not be carried out in the best way through hospital admission.

Very satisfactory results

The results of users’ rating scales indicate a very high degree of satisfaction. 100% of participants rated their experience above 8 – 50% gave it a maximum score of 10 – and stated that they would recommend the programme to other people in their situation.

The programme has also achieved very positive results in rating scales for different aspects of patients’ lives. In the case of the FIM, which measures the degree of functional independence, there has been an average increase from 72 to 88 points (12.7%), with a more notable increase in personal care, mobility, locomotion and sphincter control.

In the 5 patients who maintained the ability to walk, the Functional Ambulation Categories (FAC) scale has shown progress from grade 1 – in which the person needs the permanent help of another to move to grade 3, in which the patient walks alone and outside the home under supervision. ”Self-care, sphincter control and personal mobility are generally the most significant goals for patients with spinal cord injury”.


Post-Discharge Support programme for people affected by acquired brain injury and their families in the community setting.
Community mental health programme for patients with acquired brain injury and their families.38
Neurorehabilitative hospitalisation programme at home for patients with spinal cord injury.31