The future of rehabilitation for older Australians

We urgently need a national strategy to reduce overreliance on hospital services for functional recovery treatments

In this issue of the Journal, Soh and colleagues report their study of the outcomes of inpatient rehabilitation for older people.1 Their findings can be interpreted in a variety of ways. Most participants (396 of 618, 60%) recovered pre‐admission levels of functional performance (as measured with the Activities of Daily Living [ADL] scale), but cognitive impairment (64% of participants) and frailty (the median Clinical Frailty Score at admission was 6 = “moderately frail”) were confirmed as negative prognostic factors. Within three months of discharge from inpatient rehabilitation, 160 of the 618 had been newly institutionalised (26%) and 75 of the 693 initially included patients had died (11%). Recovery of ADL function was, as expected, more frequent than recovery of the more complex functioning assessed by the Instrumental Activities of Daily Living scale (35%). But 110 of the 192 people living at home prior to admission who made no functional gains on the ADL during rehabilitation (57%) were still at home at the three‐month follow‐up and had probably received some benefit from the coordinated rehabilitation program. While the investigation by Soh and colleagues was a single centre study, their findings are broadly similar to those of an older Australian multicentre study.2

The authors are clear that cognitive impairment and frailty should not exclude participants from inpatient rehabilitation, but rather alert treating practitioners to consider rehabilitation strategies appropriate for patients with these conditions. Unfortunately, at least after hip fracture, there is currently no agreement on the rehabilitation of people with cognitive impairment,3 but some alternatives have been described.4 It is important to note that most people in the study by Soh and his colleagues had cognitive impairment or frailty, but many nevertheless achieved functional improvement.

The rehabilitation of people with frailty takes time,5 and hospitals are under pressure to reduce patients’ stays in hospital (the median rehabilitation length of stay reported by Soh and his co‐authors was 20 days1). As our population ages, the demand for frailty rehabilitation will increase, and the question arises as to how much should be delivered in hospitals. Ambulatory (or community) rehabilitation is not widely available in Australia. Instead of universal access to rehabilitation, as urged by the World Health Organization (WHO) in 2017,6 rehabilitation is largely delivered in hospitals as a specialised health strategy for the few, and older Australians leaving hospital do not always have access to rehabilitation services. Providing frail older people discharged from hospital with multidisciplinary rehabilitation over several months reduces their frailty and improves their functioning,7 and is associated with fewer re‐admissions to hospital and transfers to residential care, keeping people in their own homes longer.8

Almost half the frail patients in the study by Soh and his colleagues1 (49%) were admitted with musculoskeletal conditions, probably after falls or fall‐related fractures. Falls by older adults in Australia lead to 1.2 million days of hospital care and cost at least $1 billion each year.9 There is some evidence that the number of falls an individual suffers can be reduced by rehabilitation care,10 but inadequate funding of allied health services and community rehabilitation means many older people at high risk have access to rehabilitation services only after they are admitted to hospital, after a fall. Similarly, inadequate support for rehabilitation physicians and geriatricians to participate in community case conferences on complex cases restricts their work outside hospitals.

Inpatient rehabilitation is not the only option for older people. The NSW Rehabilitation Service Model of Care11 delineates four ambulatory rehabilitation settings: home‐based, outreach, outpatient, and day hospital. Relevant programs currently include home‐based rehabilitation and outpatient or day hospital rehabilitation (supported by state health departments), and the Transitional Aged Care (in the home or in a residential aged care facility)12 and Short Term Restorative Care programs13 (supported by the Australian government). It is very difficult for an older person to find their way to the service that will best fit their needs, and the difficulty is compounded by multiple descriptors for rehabilitation, including “restorative care” and “reablement”. Some health services have worked through these intersectoral problems and have articulated a model that could be implemented broadly in Australia.11

Australia urgently needs a national rehabilitation strategy to reduce overreliance on hospital services for functional recovery and rehabilitation treatments. It needs to be consistent with the WHO Rehabilitation 2030 strategy,6 which recognises that function is the third major health indicator (after mortality and morbidity) and is a cornerstone of any aged care strategy. Key priorities are to build the capacity and competence of primary health services to provide general rehabilitation services to older people, and to improve networking of and collaboration between primary care and specialist rehabilitation units.