The socio-family reintegration of people affected by a spinal injury, acquired brain damage or any other disability of neurological origin, is often a difficult situation as a result of the high degree of complexity that their care can represent for those people, relatives, caregivers and professionals, both health and social, unaccustomed to the specificities of this group.
The Neurorehabilitation Specialized Assessment and Support Team (EASE) allows acting at any of the different levels of care in the health and social care networks with the objectives of improving the effectiveness of the patient’s reintegration into their usual environment, guaranteeing suitability and the continuity of care, favor the quality of care, comprehensive and personalized, and provide an agile and effective coordination system with the specialized referral hospital for the transfer of knowledge and skills specific to the neurorehabilitation process to all professionals in the different networks.
– Comprehensive assessment in person prior to possible admission to the Institut Guttmann, this program established by the EASE allows to assess, in person and at the hospital of origin of the demand, the Indication to enter our center. In case of not proceeding, specialized accompaniment and support is also offered to the patient, her family and the hospital professionals. We have received 79 evaluation requests, most of them made in acute care hospitals.
– Post discharge support program for people affected by brain damage and their families in the community setting, the community program aimed at people with DCA has been continued. During 2019, a total of 55 requests were attended. The origin of these requests has come from our organization and other specialized network resources, either from associations of people affected by acquired brain damage or from other social and health resources. Of these 55 requests, after establishing a first interview, 37 people have been linked to the program. Along with the previous program, the Community Mental Health Program for patients with acquired brain damage (DCA) and their families is also carried out with 31 new applications in 2019; these added to the prevalent cases of 2018, make a total of 53 patients attended.
– The Fragile Patient program aims to coordinate with the entire therapeutic team to intensify the work of preparing for discharge in patients who are in a very vulnerable situation, with high healthcare complexity and needs for resources and care at home.This year 24 users have been included in this program.
Regarding healthcare activity:
During 2019, 637 cases have been attended and 942 calls have been made and registered, 689 home visits by all the professionals of the team, 224 visits to other centers and 335 face-to-face interviews with patients and / or relatives in our center. Talks and training sessions have also been held for families, professionals, universities and other institutions.
ASSISTANCE ACTIVITY EASE 2016-2019
Regarding home care activity:
During 2019, 26 home services have been performed, with a total of 462 hours.
The Home Care Service is a program that includes a set of services aimed at meeting the social and health needs of people with a disability or other type of dependency and their families, with the aim of promoting personal autonomy and contributing to promote their quality of life within their own socio-emotional environment.