Health and social care activity and EASE

In May 2020, the Specialist Neurorehabilitation Assessment and Support Team (EASE) celebrated 20 years since its creation as a pioneering service in Spain with the vocation of facilitating and helping patients and their families return home after hospitalisation as the result of an acquired disability.

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.

EASE makes it possible to act in all levels of care within the health and social care networks for the more effective reintegration of the patients in their own context, 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.

For 20 years, EASE has continued to grow in terms of the number of patients attended and in the profile of programmes that it develops to become consolidated as a benchmark post-hospital care service, not only at home but also as inspiration for similar programmes in other hospitals.

Care activity during 2020:

EASE has also been one of the hospital services that has carried out outstanding work in care and monitoring of patients and their families during the months of lockdown as a result of the Covid-19 pandemic, having carried out over 850 interventions on patients, relatives and other key professionals.

During 2020, 451 cases were seen and 1,127 calls and video calls were made. There were 381 home visits by all the professionals in the team, 71 visits to other centres and 137 video-call interviews with patients and/or relatives. Talks and training sessions have also been given for families, professionals, universities and other institutions.

A total of 1,080 telematic contacts were made during the period of strict lockdown, including follow-up calls, video calls, information via email, etc.


2017201820192020Variation 20-19Variation 20-17Annual average
calls and video calls *
Telematic contacts during the lockdown period1.080
Home visits587715689381-80,8%-35,1%593
Visits to other
Details of the different programmes:

Comprehensive assessment in person before possible admission to the Institut Guttmann; this programme, set up by EASE, allows us to assess patients who intend to enter our centre in person and at the hospital where the request is made. Seventeen requests for evaluation have been received, the majority from acute care hospitals. This amount of face-to-face activity is considerably lower than in previous years due to the consequences of the Covid-19 pandemic, given that access to hospitals was restricted.

– Within the Post-Discharge Support programme for people affected by brain damage and their families in the community setting, during 2020 a total of 25 requests were made. They have originated from our organisation and from other specialist resources in the network, either from associations of people affected by ABI or from other social and health resources. Of these 25 applications, after an initial interview, 23 people joined the programme.

– Within the Community Mental Health Programme for patients with acquired brain injury (ABI) and their families, during 2020 15 new requests were received which, added to the prevalent cases of 2019, make a total of 43 patients seen.

– The aim of the Fragile Patient programme is to coordinate with the whole therapeutic team to intensify the work of preparing for discharge in patients who are in a very vulnerable situation, with highly complex care and the need for resources and care at home. In 2020, 14 users were included in this programme.

With regard to the home care activity: In 2020, 12 home care services were carried out, with a total of 261 hours. The Home Care Service is a programme that includes a number of services designed to meet the social and health needs of people with disabilities or other forms of dependency and their families, in order to promote personal independence and help increase their quality of life within their own social and domestic context.