The development of European Union of Medical Specialists (UEMS) physical and rehabilitation medicine programmes of care (PRMPC) and of physical and rehabilitation medicine care pathways (PRMCP) in France is a good example of the positive interaction between European and National organizations. PRMPC were defined at the European level to offer a robust template for the description and assessment of physical and rehabilitation medicine (PRM) clinical activity in various fields and contexts. An accreditation procedure has been organized and has started to provide very informative documents.
In France, discussions on this topic began in 2000 in Marseille, at the 2nd International Symposium on Health Accreditation (Boulanger, 2000), with several subsequent experiences at a local level. At the end of the same decade, the European approach fostered the interest of French PRM organizations in a period of struggling with public authorities about two crucial issues: (i) the specifications required for reimbursement of functional instrumental assessments and (ii) funding of PRM care in postacute and chronic facilities. After a series of preliminary works, the French Society of PRM (SOFMER) decided to publish a systematic description of PRM activities using a similar template as PRMPC. These synthetic documents were called ‘PRMCP’.
A brief description of the European and the French background will be provided before detailing each approach.
The UEMS is a nongovernmental organization consisting of national professional organizations that represent medical specialists in each European country (De Korvin and Delarque, 2009). Full members are countries participating in the European Community or the European Economic Space. Other countries have an observer status.
The UEMS Council in Brussels represents 50 specialties altogether. In addition, every discipline can manage its own specialized section and board. Thirty-one countries participate in the UEMS PRM Section. There are two delegates per country. The PRM Section is organized in two committees: (i) the Committee for Professional Practice, which deals with fields of competences, and (ii) the Committee for Clinical Affairs, focused on quality of care. Furthermore, the UEMS PRM Section is tightly linked to the European Board of PRM, which works on European harmonization of specialists’ pregraduate and postgraduate education in PRM. All delegates are volunteers and the UEMS PRM Section is a non-profit-making organization.
PRM delegates had a long preliminary debate about the best way to address quality of care at a European level. Quality of PRM care reflects a combination of influences, including scientific foundations, medical knowledge, skills and leadership, relevant procedures and adequate team and equipment. These conditions must be consistent with patients’ needs and realistic goals.
European PRM doctors share a common scientific culture and medical philosophy on the basis of a patient-centred approach, mutual aid and social progress. Nevertheless, there is a huge variety of national contexts throughout Europe, with different public rules, care organizations and funding procedures, cultures and religions. Medical care is at the border of European Union’s legal competency and remains under the umbrella of national policies. Therefore, there is no official incentive to organize a quality system at the European level and no funding for this purpose.
Despite this, the Clinical Affairs Committee (CAC) decided in 2004 to set up a voluntary based accreditation system to bring up original information from PRM activities ‘in real life’ as a starting point for further developments (De Korvin Krokowski et al., 2009; De Korvin et al., 2010). As a working unit for the description and assessment of PRM clinical activity, CAC defined the ‘PRMPC’ by the following elements: (i) fundamental concerns – pathological and impairment considerations, disability and handicap issues, social and economic consequences, programme principles; (ii) objectives – target population, programme goals and targets in terms of ICF (WHO, 2012); (iii) contents – assessment (diagnosis, impairment, activity and participation, environmental factors), intervention (programme timeframe, PRM specialist interventions, team interventions), follow-up and results (discharge plans, long-term follow-up); (iv) environment and organization – clinical setting, clinical programme, clinical approach, facility; safety, patient rights, advocacy; role of the PRM specialists in the programme, team management procedures; (v) information management – patient records, information management system, programme monitoring and results; (vi) quality improvements – identification of the programme’s strong and weak points, action plan to improve programme quality; and (vii) references – scientific references and guidelines cited in the above description, details about national documents.
After some attempts to set up a semiautomatic algorithm of programme validation, CAC decided in favour of a peer review by national delegates and associated experts. This new procedure proved to be more flexible and more efficient for achieving a double objective: (i) to check the consistency of each programme with scientific evidence and guidelines for clinical practice and (ii) to help express the local context and how the programme had been designed to cope with those specificities.
As a result of several years of voluntary work without any external funding or sponsoring, more than 20 PRMPC have gained the UEMS PRM Section accreditation. All of them are displayed on the website www.euro-prm.org. Every PRM specialist who runs a programme of care in Europe is welcome to submit it to CAC accreditation, which is free of charge.
Describing a PRMPC is a ‘smart’ way to start an improvement approach. Every programme can be a good basis for a wide range of assessments: (i) about overall aspects, such as patients’ satisfaction (Delanian Halsdorfer et al., 2011), programme effectiveness and efficiency (De Korvin et al., 2001; Rousseau et al., 2001), cost/effectiveness ratio; (ii) about specific aspects, such as the value of any intervention or the influence of any contextual parameter. There is a wide perspective ahead for future works, with a strong link between scientific methodology and daily implementations.
Developments in France
There are about 1850 PRM specialists in France. Two-thirds of them are employees of institutional facilities: public hospitals or rehabilitation centres run by NGOs or private corporations. One-third of PRM doctors are private practitioners settled either in the community or in private hospitals.
PRM is represented at the national level by three main bodies: (i) the Board of PRM Academic Professors (COFEMER, 2012), focused on initial teaching and training; (ii) the SOFMER, dealing with research, scientific matters and continuing medical education; and (iii) the French Union of PRM (SYFMER), which is responsible for professional issues. All three are major components of the National Council of PRM, established by a recent law as a consultant of public authorities.
PRM specialists working in a private practice are paid by the patients, who are reimbursed by the National Union of Health Insurance (UNCAM). Registration to the National Health Insurance is mandatory both for patients and for physicians. The payment system is based on an official list of clinical and technical acts [Union des Caisses Nationales d’Assurance Maladie (UNCAM), 2012], which results from tough negotiations between UNCAM and medical unions. No alternate funding, even by additional insurance, can be obtained for any activity outside of this official list.
Because of economic restrictions since the 1990s, UNCAM has become very reluctant to add any kind of ‘new’ medical activity, which would risk enlarging the scope of reimbursements. This hindered the development of instrumental functional assessment in PRM practice, whereas early return back home was increasing the demand for PRM follow-up and guidance of postoperative patients and other disabled individuals. Isokinetic dynamometry (ID) came up as the first issue at stake. UNCAM feared that allowing the reimbursement of ID would result in the payment for serial strength assessments of healthy sportsmen and women and that would foster an uncontrolled increase of isokinetic devices.
The deadlock was broken when SYFMER suggested to link each reimbursement to a specific PRMPC; PRM follow-up after knee cruciate ligament replacement offered a convenient example to test this concept, as it represented a significant part of ID indications and illegible patients could be easily traced by their operation code in UNCAM’s database. The agreement started to be applied in Spring 2012. Hopefully, this should open the gate for further negotiations on the reimbursement of other techniques, especially for spinal disorders and posture analysis.
Institutional PRM facilities for inpatients and outpatients are controlled by the Ministry of Health within the general framework of postacute care settings (Ministère des Affaires Sociales et de la Santé, 2012). Cardiologic, pulmonary, geriatric postacute care and even general postacute care without specialists also belong to this sector, which used to be managed on the basis of an overall day cost. This system was suspected to have an inflationary effect and public authorities wanted to replace it by an activity-based funding. This was actually applied to acute care settings, but conflicting issues were raised in postacute care settings.
Patients with high morbidity and comorbidity level will require intensive nursing care and often expensive drugs, but will need rather few physiotherapy and other rehabilitation techniques. The main goal is to help them pass through life-threatening situations and/or bring them a comfortable and respectable end of life.
Individuals applying for intensive rehabilitation should fulfil the criteria for expecting a functional improvement or coping with an adapted environment, hopefully their previous home, school or working place. The cost of drugs and nursing may be much lower, except for early rehabilitation care, but effective rehabilitation will require a wide range of professional skills and equipment, and sometimes expensive techniques; for example, spasticity treatments.
In the past decade, French PRM organizations issued standards for rehabilitation facilities (FEDMER, 1999), followed by admission criteria to PRM care (Groupe Rhône-Alpes et FEDMER, 2008; Calmels et al., 2010). In 2010, SOFMER started to publish a systematic description of PRM activities, using a similar template as PRMPC (Yelnik et al., 2011, 2012). These synthetic documents were called ‘PRMCP’ and aimed to emphasize what PRM care can offer patients in a comprehensive perspective from their pathology to their life project. PRMCP was designed to provide to decision makers proper information about patients’ needs in terms of PRM care and a basis for relevant organization and funding.
Each PRM pathway is outlined by a team of PRM experts in the field, with respect to available scientific evidence and to the French care system. This draft is widely circulated among PRM specialists and other professionals and comments are taken into account for the final version.
Depending on the complexity of the situation, PRMCP descriptions adopt two different patterns:
Type 1 refer to severe deficiencies: Patients after stroke (Yelnik et al., 2011), traumatic brain injury (Pradat-Diehl et al., 2012) and spinal cord injury (Albert et al., 2012). Four categories of differing severity have been proposed for stroke, three for traumatic brain injury and five for spinal cord injury.
Type 2 refer to more simple deficiencies: Patients after rotator cuff tear surgery (Ribinik et al., 2012a), knee ligament replacement (Calmels et al., 2012), hip arthroplasty (Ribinik et al., 2012c), knee arthroplasty (Ribinik et al., 2012d), shoulder stabilization surgery (Edouard et al., 2012) and after proximal humeral fracture and shoulder hemiarthroplasty (Ribinik et al., 2012b). Two or three categories have been considered according to the medical complexity of the case.
As an example of type 2 pathways, patients after rotator cuff tear surgery (Ribinik et al., 2012a) have been classified into four care sequences and two clinical categories, taking into account personal and environmental factors that could influence patients’ needs: (i) stage 0: preoperative care; (ii) stage 1: up to 6 weeks after surgery; (iii) stage 2: from week 7 to week 12 after surgery; and (iv) stage 3: from week 13 after surgery.
As an example of type 1 pathways, stroke patients (Yelnik et al., 2011) have been divided into four categories according to the severity of their impairments:
Only one type of impairment, independent walking, no need for ecological evaluation; for example, arm paralysis, isolated language disorder without any comprehension deficit, vision disorder, isolated and incomplete sensitivity disorders.
Several impairments (e.g. complete hemiplegia or aphasia or spatial disorientation or transitory swallowing disorders) or motor deficit of the lower limb preventing the patient from walking; there is a potential for recovery and a probable independence project.
Several impairments with at least some cognitive disorders (memory, language or executive functions disorders) or behavioural disorders, limited recovery potential, partial or impossible independence project.
Extremely severe accident; multiple associated impairments (profound paralysis, disorders of consciousness and communication, respiratory deficiency), implying no possibility of regaining. These clinical states include locked-in syndromes and vegetative or minimally responsive states (EVC-EPR).
Each category has been addressed according to the same six parameters with respect to the International Classification of Functioning, Disability and Health (WHO): (a) impairments without any added difficulty; (b) need to adapt the environment (equipment related only); (c) inadequate or insufficient medical network; (d) social and psychosocial difficulties; (e) associated medical pathologies having a functional impact; and (f) associated psychiatric pathologies having a functional impact.
Several of the our most important partners, such as the Ministry of Health, the Management Council of French Social Insurance Facilities and the French Federation of Public Hospitals have shown much interest in the SOFMER PRMCP approach. Independently from SOFMER’s action, the concept of care pathways was also promoted by the French Authority for Health (HAS) in May 2012 to improve coordination of professional interventions for chronic disorders, such as obstructive chronic bronchitis or Parkinson’s disease.
PRMCP can help to define homogeneous groups of patients with respect to their impairment, associated disorders, environment and stage of recovery. This should help to schedule appropriate care organization and funding in a prospective way, rather than on the basis of past activity, as it had been done so far in France. A pilot study is now in project.
PRMPC and PRMCP share a common approach focused on the best response to patients’ needs. The first approach is the description of a local organization with respect to scientific evidence and local conditions. The second is an outline of PRM intervention related to a multidimensional pattern of patients’ situations. Both enhance the role of PRM doctors, whose expertise is necessary for making a synthesis of medical diagnosis and functional assessment, for setting up a patient-centred care strategy and for supervising the rehabilitation team’s intervention.
The increasing interest of decision makers in SOFMER PRMCP in France is a strong incentive to pursue the UEMS Section accreditation of PRMPC at the European level. This is an inspiring example of a fruitful interaction between European and national initiatives.
Conflicts of interest
Georges de Korvin is the president of the French Union of PRM (SYFMER); Alain P. Yelnik was the past president of the French Society of PRM (SOFMER); Patricia Ribinik is the Secretary General of the French Society of PRM (SOFMER); Paul Calmels is the vice president of the French Society of MRP (SOFMER); Francis Le Moine is the president of the French Federation of PRM (FEDMER); Alain Delarque was the past president of the PRM Section of the European Union of Medical Specialists and vice president of the French Union of PRM (SYFMER). Apart the above-mentioned positions of the coauthors, there are no conflicts of interest.
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