Post-Discharge "Continuum of Care" Clinical Pathway for persons with severe Neuro-Disabilitiesqualitative research to assess its concept and practicality after implementation

Stephanie Reichl^1*Romy Pletz¹Aukje Bartsch-de Jong²Nuria Vallejo³Tatjana Groß⁴Andreas Bender^4,5,6Thomas Platz^1,7

• ¹Universitätsmedizin Greifswald, Greifswald, Germany
• ²Schön Klinik, Bad Aibling, Germany
• ³Therapiezentrum Burgau, Burgau, Germany
• ⁴medbo Zentrum für Neurologische Rehabilitation am Bezirksklinikum Regensburg, Regensburg, Germany
• ⁵University Augsburg, Medical Faculty, Department Neurorehabilitation, Augsburg, Germany
• ⁶Ludwig-Maximilians-Universität München, Medical Faculty, München, Germany, München, Germany
• ⁷BDH-Klinik Greifswald, Institute for Neurorehabilitation and Evidence-based Practice, An-Institut University of Greifswald, Greifswald, Germany

While nervous system diseases are among the main causes for lasting neuro-disabilities and are increasingly affecting people in the societies globally, and while neurorehabilitation can help to prevent disabilities, improve functioning and participation, such services are mostly available as inpatient services and mostly early on, i.e., in the acute and subacute phase of diseases affecting the brain. But even with the best inpatient neurorehabilitation service available a substantial number of people will return to the community with an ongoing need for rehabilitative care. In the community, specialized neurorehabilitation services and expertise are, however, available only to a limited extent. This is especially true for neurologically severely affected patients, e.g. when patients with tracheal cannulas and/or mechanical ventilation are discharged from the inpatient setting. To guarantee the required care for these patients in the community, home-based specialized intensive care nursing (HSICN) services are available in Germany. Yet, no specialized community-based neurorehabilitation service is set up in parallel. This is where this project offers and investigates an innovative care solution: Expert teams from neurorehabilitation centers stay in contact with patients and HSICN members in charge for one year after discharge. To support this activity, a guideline-and evidence-based clinical pathway (CP) for the co-care of severely neurologically affected patients was developed and its appropriateness and practicality evaluated with this qualitative research project after it had been implemented. The CP itself was reflected as appropriate by those who implemented the co-care based on it suggesting its suitability for the purpose and hence its potential usefulness for other contexts. The insights gained further illustrate the potential and the implementation prerequisites for such an innovative inter-sectoral care approach linking center-based expertise with community care. Healthcare policy makers are informed that a hybrid collaborative centreand community-based healthcare approach for a clientele with highly specialized healthcare needs can be a model to address specific needs with a potential to promote health and optimize healthcare utilization.