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Rehab + cbr + ibr


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Rehab + cbr + ibr

  1. 1. P a g e | 1 Dr. Nithin Ravindran Nair (PT) REHABILITATION + INSTITUTIONAL BASED REHAB. + COMMUNITY BASED REHAB. Definition: Rehabilitation is defined as the coordinated use medical, social, educational and vocational measures for training and retraining the individuals to the highest possible level of functional ability. Delivery of Rehabilitation Care: The Team • Patient with disability • Family members of PWD • Community members TEAM MEMBERS Medical • Physiatrist • Surgeon – Orthopedic, Neuro, Cardiac, Plastic, General • Neurologist • Psychiatrist • Pediatrician • Obstetrician • Geneticist • Neonatologist • Rheumatologist • Cardiologist • Oncologist • Urologist • Ophthalmologist • Otorhinolarngologist • Physician – General, Family Paramedical • Physiotherapist • Occupational Therapist • Prosthetist – Orthotist • Rehabilitation Nurse • Speech Therapist • Psychologist • Biomedical Engineer
  2. 2. P a g e | 2 Dr. Nithin Ravindran Nair (PT) Socio-vocational • Social Worker • Vocational – counselor, evaluator • Skilled Instructors • Placement officers • Child development specialist • Special educator • Employment agencies • Industries • Banks and Funding Agencies • NGO Types of Rehabilitation: Medical Rehabilitation: restoration of function. Vocational Rehabilitation: restoration of the capacity to earn a livelihood. Social Rehabilitation: restoration of family and social relationship. Psychological Rehabilitation: restoration of personal dignity and confidence. Models of Rehabilitation: (Ref: Alhadi Jahan et. al, 2017) Six conceptual rehabilitation related model were identified. The components on which the models are built were linked to the domains of the International Classification of Functioning, Disability and Health (ICF) Model. TYPES MEDICAL VOCATIONAL SOCIAL PSYCHOLOGICAL
  3. 3. P a g e | 3 Dr. Nithin Ravindran Nair (PT) Biomedical: o It focuses just on medical therapeutics. o There is complete ignorance to the psychological, social and environmental factors. o It limits the selection of the outcome measures and tools especially - chronic disease management (external factors significantly important in treatment development and planning) Social: o It presents disability as a result of a socially created problem, not the medical factors. o It proposes that systemic barriers, negative attitudes and exclusion from the society are ultimate factors. o It suggests that all people are equal in terms of functional ability and participation, and everyone can participate successfully in life if environment is appropriate. o Great focus on environment (society) but ignores the characteristic of the individual that might participate in the disability process. MODELS BIOMEDICAL SOCIAL BIOPSYCHOSOCIAL ICIDH CBR HEALTH RELATED QOL NORMAL STATE DISABLED STATE DISEASE, TRAUMA OR HEALTH CONDITION NORMAL STATE MEDICAL INTERVENTION
  4. 4. P a g e | 4 Dr. Nithin Ravindran Nair (PT) Biopsychosocial: o Combination of 3 dimensions – Biomedical + Psychological + Social. o Biomedical – Biological component (medical), Psychological – cognition, emotions, attitudes etc., Social – economic, environmental, and cultural. o Currently practiced model. ICIDH: o In this model 3 main concepts were recognized – Impairment, Disability and Handicap o Unidirectional (Linear model) o Focused on disease and related conditions and ignored the effect of individual and the environment in disability. o Same limitations like biomedical model. CBR: o CBR is a strategy within the community development for the rehabilitation, equalization of opportunities and social integration of all the people with disabilities. BIOMEDICAL HEALTH SOCIAL PSYCHOLOGICAL DISEASE OR DISORDER IMPAIRMENTS DISABILITIES HANDICAP
  5. 5. P a g e | 5 Dr. Nithin Ravindran Nair (PT) o Principles of CBR revolves around these 5 ideas – Equality, Social Justice, Solidarity, Integration and Dignity. o Models of CBR: ✓ WHO model: Uses trainers, booklets on health-conditions. ✓ Neighborhood model: A resource center in the community adopts another center, trains personnel and in due course this becomes another resource center. ✓ DRC model: Launched by Government of India in January 1985. It surveys disabled population and works on all aspects of their rehabilitation – prevention, early detection, medical intervention etc. HRQOL: The Ferrans and colleagues revised version of Wilson and Cleary model Symptom status Physiological variables CHARACTERISTICS OF INDIVIDUAL General health perception Overall QOLFunctional health CHARACTERISTICS OF ENVIRONMENT
  6. 6. P a g e | 6 Dr. Nithin Ravindran Nair (PT) ICF MODEL CONTEXTUAL FACTORS Approaches of Rehabilitation: The delivery of rehabilitation care is done through the following approaches: ✓ Institution Based Rehabilitation (IBR) ✓ Community Based Rehabilitation (CBR) ✓ Homes ✓ Day Care Centers ✓ Out Patient Clinic ✓ Camp Approach Institution Based Rehabilitation Characteristics Advantages Disadvantages • Urban Based • Large number of rehab personnel available • Excellent infrastructure • Referral center for all diseases and conditions • Research Programs • Statistics Generated • Rigorous Program • Rare conditions can be treated • Costly • Patients admitted – cut off from society • No follow-up • Late identification, intervention HEALTH CONDITION BODY STRUCTURES AND FUNCTIONS ACTIVITY ENVIRONMENTAL FACTORS PERSONAL FACTORS PARTICIPATION
  7. 7. P a g e | 7 Dr. Nithin Ravindran Nair (PT) Community Based Rehabilitation Characteristics Advantages Disadvantages • Community Based • PWD and their family members are decision maker • CBR workers or semi- professionals are service providers • Economical • Guaranteed Follow -up • Early identification, intervention • Difficulty to tackle complicated problems • Skilled personal care not given Homes Characteristics Advantages Disadvantages • Cater to patients of a homogenous group • Patients stays in campus • Limited – rehab professionals • Empathetic approach • Low cost nursing care • Patients admitted – cut off from society • Very little medical care • Family responsibility – limited to monetary Day Care Centers Characteristics Advantages Disadvantages • Patients of a homogenous group brought daily to center • Some medical rehab work is undertaken • Integrated with special schools • Holistic approach • Family members get to interact – rest of the day • Difficult task to get the patient to the center • All rehab team members not present Outpatient Clinic Characteristics Advantages Disadvantages • Caters to a large group • Medical / Therapy advice – case to case basis • All rehab team members present • Useful in developing countries • All services provided at a cheaper cost • Can’t cater to moderately to severe disabled • Hardly any follow up of patients
  8. 8. P a g e | 8 Dr. Nithin Ravindran Nair (PT) Camp Approach Characteristics Advantages Disadvantages • Single contact with large numbers of rehab professionals at the same time • Many people can be evaluated on the spot • Organized by local organization for people from lower strata of society • Statistics can be obtained – incidence and prevalence • Community awareness • Some management can be given free of cost. • Depends entirely on sponsors • No follow up of patients Rehabilitation Strategies (Ref: WHO Guidelines) ✓ Identify needs and priorities ✓ Facilitate referral and provide follow-up ✓ Facilitate rehabilitation activities: Provide early intervention activities for child development, encourage functional independence, facilitate environmental modifications, link to self-help groups ✓ Develop and distribute resource materials ✓ Provide training Present Rehabilitation Services in India 1) District Rehabilitation Center (DRC) Project started in 1985 2) Four Regional Rehabilitation Training Centers (RRTC) have been functioning under the District Rehabilitation Center (DRC) scheme at Mumbai, Cuttack, Chennai and Lucknow. 3) National Information Center on Disability and Rehabilitation 4) National Council for Handicapped Welfare 5) National Level Institutes – o National Institute for Mentally Handicap (NIMH) -Secunderabad o National Institutes for Hearing Handicap (NIHH) - Mumbai o National Institute for the Visually Handicap (NIVH) – Dehradun o National Institute for Orthopedically Handicap (NIOH) – Kolkata o Institute for the Physically Handicap (IPH) – Delhi o National Institute of Rehabilitation Training and Research (NIRTAR) - Cuttack, Odhisha.
  9. 9. P a g e | 9 Dr. Nithin Ravindran Nair (PT) o National Institute for Empowerment of Persons with Multiple Disabilities (NIEPMD) - Chennai o Indian Sign Language Research and Training Center (ISLRTC) - Delhi 6) Ministry of Social Justice and Empowerment has set up Composite Regional Centers for Skill Development, Rehabilitation and Employment of Persons with disabilities in various states to provide preventive and promotional aspects of rehabilitation. 7) The Government of India formulated National Policy for person with Disabilities, 2006 which deals with physical, educational and economical aspects of rehabilitation. Recent Advances: Rehabilitation in health systems: Guide for Action / Rehabilitation 2030 o It is initiated by WHO which helps governments to strengthen their health systems. o 4 phase process and 12 steps PHASES STEPS 1) STARS – Systematic Assessment of Rehabilitation Situation 1) Prepare for situation assessment 2) Collect data and information 3) Conduct assessment in the country 4) Write, revise, finalize report and communicate findings. 2) GRASP – Guidance for Rehabilitation Strategic Planning 5) Prepare for strategic planning 6) Identify priorities and produce first draft of plan 7) Consult, revise, finalize and complete costing of plan 8) Endorse and disseminate strategic plan 3) FRAME – Framework for Rehabilitation Monitoring and Evaluation 9) Develop monitoring framework with indicators, baselines and targets 10) Establish evaluation and review processes 4) ACTOR – Action on Rehabilitation 11) Establish a recurring implementation cycle 12) Increase capacity of rehabilitation leadership and governance.
  10. 10. P a g e | 10 Dr. Nithin Ravindran Nair (PT) DIFFERENCE BETWEEN CBR AND IBR HEADINGS CBR IBR Definition CBR is a strategy within the community development for the rehabilitation, equalization of opportunities and social integration of all the people with disabilities. IBR is the rehabilitation of PWD at or through institutions often away from their home. Location Anywhere and community based Urban and institution based Decision maker PWD and their family Service providers Service providers CBR workers and semi professionals Mainly professionals Services At door step (Holistic) Far (Medical) Accessibility of services Accessible to all Only few institutions are accessible Extension of services Can be done Not possible Quality of service Not good Good Social rehab Possible Not possible Psychological rehab Possible Not Possible Skilled personal Care Not given Given Socioeconomic status Considered Not considered Action Proactive Responsive Active participation Possible Not possible Awareness / Promotion Yes Not
  11. 11. P a g e | 11 Dr. Nithin Ravindran Nair (PT) Identification Early Delayed Intervention Early Delayed Follow up Guaranteed Not Guaranteed Complicated problems Difficult to tackle Easy to tackle Cost of treatment Economical Costly Physiotherapy o Indirect service provision to client o 1 therapist to a given population o Service receiver addressed as client o Often works in group o Therapy time allocated as per population need o Direct service provision to client o 1: 1 - therapist to patient ratio o Service receiver addressed as patient o Rarely works in group o Therapy time allocated as per individual need CBR and IBR should be viewed as dynamic continuum (the two can operate interdependently THE CONTINUUM Acute care and specialist facility Outreach services Home care programme Social services Community workers Volunteers Family / Caregiver PWD IBR CBR
  13. 13. P a g e | 13 Dr. Nithin Ravindran Nair (PT) ✓ Assessment of the needs of the PWD and their family ✓ Homebased or Neighbourhood based programs ✓ Parental involvements ✓ Playgroups and integrated schooling for children ✓ Organization for and by the PWD OBJECTIVES OF CBR: ✓ Provide all rehabilitation services needed ✓ Reducing or eliminating environmental barriers ✓ Promoting social integration and self-actualization ✓ Protective and ensuring security of disabled ✓ Empower disabled people ✓ To raise awareness in the community (sensitization and education) BASIC PRINCIPLES OF CBR: ✓ Shifting services from institutions to homes of the disabled people CBR PRINCIPLE SOCIAL JUSTICE SOLIDARITY INTEGRATIONDIGNITY EQUALITY
  14. 14. P a g e | 14 Dr. Nithin Ravindran Nair (PT) ✓ Shifting the services from professional to trained community or family members ✓ CBR should be flexible so that they can operate at local level, using locally available resources ✓ Ensure that PWD is involved in planning and managing the program. ✓ CBR enables PWD to live independently through training in ADLs, education, skills development, employment opportunity, accessibility and social interaction. ✓ CBR should concentrate on changing people’s attitude to disability and disabled people. COMPONENTS OF CBR PROGRAM: ✓ Creating a positive attitude towards people with disability ✓ Provision of functional rehabilitation ✓ Provision of education and training opportunities ✓ Provision of care facilities ✓ Prevention of the causes of disabilities ✓ Creation of micro – and macro – income generation opportunities ✓ Management, monitoring and evaluation of CBR projects APPROACH TO COMMUNITY / STRATEGIES TO INITIATE CBR ACTIVITIES: Step 1: Understanding the community ✓ Knowing the community: Meet a group of disabled people to understand their QOL, problems. Retrospective study – previous census book of revenue district / gazetteer of district / survey reports of PWD / records of AWW, NGO and rehabilitation workers. ✓ Communication: Communicate with health worker, district disability officer, social welfare officer, child development project office, directorate / commissionerate of disability to know the available and utilized government schemes. ✓ Visit: Visit a couple of village/ slums / tribes and meet formal and informal leaders including women’s group and youth groups to understand the prevailing situation of the disabled people.
  15. 15. P a g e | 15 Dr. Nithin Ravindran Nair (PT) Step 2: Resource identification and mobilization ✓ Resource mapping: Find out following information o No. of schools (Primary / Secondary) o No. and type of vocational training schools in the proximity o No. of special schools for children o No. of PHC, subcenters, CHC, district and private hospitals o Available nearest support – PT / OT o Details of religious leaders, formal and informal leaders, AWW, health workers, teachers etc. o Details of officers – education officers, district disability officers, child development project officer, district officer for employment and labor etc. o Details of occupations, sub-occupations, industrial training centers o Details of community-based groups working for self-help, education, health etc. o Formal meetings with district / taluka / village level government and functionaries Step 3: Write a plan / proposal ✓ Background, rationale and situation analysis o Why the effort is proposed? o What is the present scene in the area? o Who are the major players? o What are the available resources? o What is the magnitude of the problem? o What is your vision, mission and goals? ✓ Approach and methodology o How it is planned for implementation? o How vocational needs are met? o How parents / family members of PWD are approached counselled, trained, organized? o How aspects of Disability Act and available government resources accessed? ✓ Organizational structure o Risk factors anticipated
  16. 16. P a g e | 16 Dr. Nithin Ravindran Nair (PT) o Expected outcomes/budget o How monitoring / evaluation done? o What and how records will be kept? o Acknowledgement of people who helped in the development of proposal. Step 4: Start helping people simultaneously o Holding awareness program o Counselling o Assessment camps o Workshops on disabled people o Helping with medical and surgical treatment o Getting scholarships o Providing bus pass Step 5: Get support and mobilize resource ✓ One may like to broach the topic with – o Panchayat members o PHC staff o Local community groups o Management of your institutions o Directorate of disabled welfare at state and center level o National and international level organization Step 6: Start systematic work once resource support is assured. Till then help people ad hoc. o Monitoring and recording systems o Records for individuals with disabilities o Records at village, group of villages, PHC area, field practice area o Minutes of the meetings held o Monthly / Quarterly reports o Field visit reports o Special camp reports
  17. 17. P a g e | 17 Dr. Nithin Ravindran Nair (PT) REFERENCES: ❖ Community Based Rehabilitation – Malcolm Peat ❖ Community Based Rehabilitation of PWD – S Pruthvish ❖ Textbook of Rehabilitation – S Sunder (3rd ed) ❖ Essentials of Community Based Rehabilitation – Satya Bhushan Nagar ❖ Physiotherapy in Community Health and Rehabilitation – Waqar Naqvi (1st ed) ❖ WHO CBR Guidelines ❖ Textbook of Preventive Practice and Community Physiotherapy – Dr. Bharati Vijay Bellare (1st ed)