LONG TERM HOSPITALIZATION

LONG-TERM HOSPITALIZATION

Hospitalization is based on a detailed multidimensional analysis of the patient and is designed to: assess the patient’s various different medical conditions with a careful analysis of co-morbidity, encourage autonomy, provide psychological support to them and their caregivers, and reduce/eliminate psychotropic treatment. The service combines condition-specific rehabilitation within an integrated plan and delivers multidisciplinary interventions dealing with multiple illnesses and associated disabilities. Socio-environmental, psychological and somatic problems are so closely interdependent in determining the aging person’s quality of life that intervening on any one of them singly would not lead to satisfactory results.  Specific rehabilitation procedures stimulate and support the person for the entire duration of their hospital stay. The tailored programmes also include treatment for patients who withdraw into themselves/become demotivated as such attitudes could nullify the rehabilitation results.

Hospital Care
Treatment is delivered during ordinary hospitalization

Waiting time
Based on bed availability.

Booking
Booking can be made either by phone or in person at the Hospital Admission office

Diseases and Conditions Treated
•    Internal diseases and conditions related to geriatric care
•    Malnutrition, dehydration
•    Immobilization syndrome
•    Central and peripheral vascular disease and strokes
•    After-effects of falls and fractures
•    After-effects of orthopaedic surgery

Admission
The rehabilitation team takes charge of the patient for the treatment of the case and prepares a tailored therapeutic-rehabilitation plan.
When the patient is admitted, a series of assessment tests is performed, using, wherever possible, scales validated and/or recognized by scientific communities, which enables the team to assess the patient’s cognitive status, emotional-affective balance, level of self-sufficiency and amount of nursing-care required so as to develop the best plan for them within the Hospital facility. The same tests are carried out during the hospital stay, in order to monitor the patient’s functional evolution, and again at the time of discharge when they will indicate the effectiveness of the rehabilitation treatment.

Main goals
The main goals of the interventions are for the patients to recover their functional abilities as much as possible. This is done through activities that enable them to recover from significant, reversible, disabilities and requires a high level of therapeutic engagement achieved by means of a tailored rehabilitation and healthcare plan that includes:
•    Comprehensive Diagnostic Evaluation and Interdisciplinary Assessment
•    Multidimensional Assessment
•    Nursing care
•    Rehabilitation therapy
•    Occupational therapy
•    Recreational activities
All these components are needed if the set goals are to be achieved.

Comprehensive Diagnostic Evaluation and Interdisciplinary Assessment
The comprehensive diagnostic evaluation, performed in the first days of hospitalization, analyses the patient’s clinical and care support variables as well as their rehabilitation and social variables. The patient approach is developed by the interdisciplinary team (geriatric physician, physiatrist, charge nurse, rehabilitation therapist, the Care Services Supervisor – known as RAA – and recreation workers), which carries out an initial assessment of the patient and regularly ascertains the work done and goals achieved. The geriatric physician will deal with the patient’s clinical examination, existing complications, therapies and recovery of their state health. Should he deem it necessary, he can prescribe further, specialist visits and non routine tests.

Multidimensional Assessment
The diagnosis is based on a detailed clinical analysis supplemented by a multidimensional assessment in order to:
•    Identify the patient’s different medical conditions and thereby determine the impact of each individual disease and condition on their psycho-physical balance
•    Determine their level of self-sufficiency in basic everyday living  activities and design tailored working plans to enable them to regain as many of their residual capacities as possible
•    Monitor, with the whole staff, the changes in the patient’s functional status using assessment tools specifically designed for functional monitoring purposes:
    −    Tinetti scale, for assessing balance and gait
    −    IADL-BADL, for assessing self-sufficiency in everyday living activities
    −    Mini Mental State Examination, for a basic cognitive assessment
    −    Geriatric Depression Scale, for an overall assessment of their emotional-affective state
    −    Braden Scale, for assessing the risk of pressure ulcer in bed-ridden or malnourished elderly persons

All the above assessments are performed when the patient is admitted as well as when they are discharged or as required.
In order to complete the patient’s clinical picture the following additional tests can be carried out:
•    NPI (Neuropsychiatric Inventory) to assess behavioural disorders
•    MNA (Mini Nutritional Assessment) to assess malnutrition
•    SII (Severity of Illness Index) to assess co-morbidity

Nursing care
The functions performed by nursing staff and care workers are essential in order to:
•    put into effect the intervention plans developed for the patient and related monitoring actions (prevention of healthcare-related infections, treatment/prevention of skin lesions, meeting primary needs, taking charge of concomitant needs-conditions and so on)
•    comfort and support the patient in tackling minor and major everyday challenges

Rehabilitation Therapy
The rehabilitation programme includes a variety of treatments, including:
•    PHYSICAL THERAPIES FOR PAIN RELIEF - T.E.N.S., Diadynamic Current, Faradic Current, Kotz Currents, Exponential Current, Iontophoresis, Infrared and Ultraviolet Rays, Ultrasounds
•    ELECTRICAL STIMULATION
•    MAGNET THERAPY
•    NEUROMOTOR RE-EDUCATION TECHNIQUES - Bedside treatment, Posture, Balancing exercises, Kabat-Bobath-Grimaldi-Perfetti treatment
•    ACTIVE-PASSIVE MOBILIZATION TECHNIQUES – Upper and lower limbs, Cervical-dorsal-lumbar rachis
•    FUNCTIONAL RE-EDUCATION TECHNIQUES – Group kinesiotherapy, Standing, Orthostatic exercises,  Physiotherapy table, Stationary bike, Fisioteck mobilizer
•    WALKING RE-EDUCATION THERAPY – Parallel bars, Weight-shifting, Posture changes, Walking frame, Walking frame with forearm support, Hurdle path
•    MASSAGE THERAPY
•    PROPRIOCEPTIVE RE-EDUCATION
•    GROUP MOTOR KINESIOTHERAPY

Occupational therapy
Rehabilitation is reinforced through Occupational therapy (OT). OT treatment is delivered through specific physical activities designed to help patients attain their maximum potential in terms of their functions and independence in all aspects of daily life. The tailored OT programme includes monitoring/adjusting the elderly person’s expectations to their real chances of recovery.

Recreation activity
The recreation service delivers a tailored programme of:
•    Motor activities: aimed at stimulating mobilization of the elderly person through psycho-physical engagement
•    Cultural activities: aimed at rediscovering values and traditions and boosting the importance of “individual life stories” and collective memories
•    Creative activities: designed to develop manual skills and creativity
•    Cognitive activities: using psycho-activating games in an effort to slow down intellectual decline in elderly persons
•    Games designed to bring out the person’s emotions through movement and rhythm
•    Religious activities: relational recreation based on methods intentionally designed to facilitate interpersonal communication and improve listening skills

Assessment of home environment and hospital discharge
At the discharge stage, the team assesses the motor skills and level of autonomy - self-sufficiency attained by the patient and the presence of architectural barriers in their homes so as to determine suitable solutions and/or prescribe any aids. The physician, together with the patient and/or their family, evaluates the need to discharge them under a continuing care scheme. He/she will deliver to the patient and/or their family the hospital discharge letter which sets out the attained level of functional recovery, the critical areas to be monitored, the drug therapy being administered and the rehabilitation procedures to be followed at home.