Physical Medicine and Rehabilitation care delivery system in France Conference on the development of PMR services in Albania Tirana – June 19th 2006 Dr Pascal GRANIER Handicap International

PMR services in Primary Health Care PMR services in Secondary Health Care PMR services in Tertiary Health Care Education of PMR professionals Financing PMR services On going reforms & cross-cutting approach

Specificities of French (EU) system Aging population Progresses of reanimation care Social context (family structure) Shortening hospitalisation length  Need for post acute care facilities

Medical Care Channels Health problem Acute care facility Post-acute care facility Home Long-term care facility Home

Admission criteria for PMR facilities ACUTE MEDICAL CARE PHYSICAL MEDICINE AND REHABILITATION * IMPAIRMENTS * SOCIAL ENVIRONMENT *PHYSICAL ENVIRONMENT *PSYCHOLOGICAL FACTORS Daily specialised medical care At least 2 rehabilitation technics : Physio, OT, speech therapy, neuropsychology, physical retraining Complex multidisciplinary rehabilitation Need for social rehabilitation HOME MEDICAL POST ACUTE CARE

Admission criteria for Medical post-acute care facilities ACUTE MEDICAL CARE PHYSICAL MEDICINE AND REHABILITATION * IMPAIRMENTS * SOCIAL ENVIRONMENT *PHYSICAL ENVIRONMENT *PSYCHOLOGICAL FACTORS HOME Simple rehabilitation MEDICAL POST ACUTE CARE Medical follow up Difficult environment

Admission criteria for Medical post-acute care facilities ACUTE MEDICAL CARE PHYSICAL MEDICINE AND REHABILITATION * IMPAIRMENTS * SOCIAL ENVIRONMENT *PHYSICAL ENVIRONMENT *PSYCHOLOGICAL FACTORS HOME Simple rehabilitation MEDICAL POST ACUTE CARE Ambulatory medical follow up Social & physical obstacles

PMR in Primary Health Care PHC is mainly provided by private health professionals in France (general practitioners, nurses, physiotherapists, speech therapists, OP technicians…). Subsidised by Social Security (SS). Patients need a medical prescription to get physiotherapy. Physiotherapists are entitled to make assessment and training program.

Primary Health Care - Children Mother and Child Centres (PMI) Centres for Early Medico-Social Intervention (CAMSP) for children with development problems Respiratory physiotherapy network (bronchiolitis).

CAMSP - Role The mandate: prevention, detection, early intervention and orientation of children (aged 0-6) with developmental problems. Ambulatory diagnosis, medical and social follow-up and rehabilitation. Support integration in educational system. Networking with kindergardens, schools, delivery centres, PMI, hospitals…

CAMSP – Interdisciplinary team PMR Doctor, neuropediatrician, pedopsychiatrist. Physiotherapists, Occupational Therapists Speech therapist Special educators, psychologists Psychomotricity therapist Social worker Child nurse

PMR in Secondary Health Care PMR services in Hospitals Physiotherapy at the bed of the patient Multipurpose inpatients and outpatients consultations and interdisciplinary rehabilitation care Day care hospitalisation General Rehabilitation Centres (public and private)

Quality requirements for PMR in Secondary Health Care (1) Defined by Regional Hospital Directorate : Provide 3-4 hours multidisciplinary rehabilitation care (at least 1 PMR doctor + physiotherapists + 1 other PMR professional). Admission criteria (complex medical care and/or severe dependency). Specialised equipment.

Quality requirements for PMR in Secondary Health Care (2) Minimum staff : 1 PMR doctor / 30 inpatients 1 Physiotherapist for 10 inpatients 1 OT for 20 inpatients 1 chief physiotherapist or OT Speech therapist, social worker, OP technician, psychologist 5 nurses + nurse assistants / 30 inpatients.

Quality requirements for PMR in Secondary Health Care (3) Minimum equipment : Physiotherapy equipment (verticalisation table, bicycle, treadmill…) Hydrotherapy pool Occupational Therapy room equipped. Casting room and orthoses rooms. Electrotherapy and ultrasound Accessible bathroom

Tertiary Health Care Highly specialised PMR services Specialised posture and movement laboratory. Specialised treatments (Botulinum Toxin, pluridisciplinary spasticity management…) Part of comprehensive multidisciplinary teams in very specialised referral centres (muscular dystrophy, ALS, MS, …) Brain Injury and coma care

Education of PMR professionals PMR Doctor (Physiatrist) : 6 years + 4 years specialisation Physiotherapy: 3 years Occupational Therapy: 3 years OP Technicians : 3 years Speech Therapists: 4 years Psycho-Motor therapist: 3 years Neuro-psychologist : 5 years

Financing of PMR services Social Security system (income taxes) finances most of expenses. PMR services (Inpatients and outpatients) Drugs, prosthesis, orthosis, wheelchairs, crutches List of subsidised appliances (LPPR) Co-payments (alleviated if chronicle disease) Complementary insurances Extra needs : special procedures (SVA)

Current financing problems Deficit of Social Security System Solutions? Gate keeping role of general practitioners Payment of hospitals according to activities Increased co-payments Decrease hospital stay and number of beds Develop day hospitalisation and home hospitalisation Increase number of downstream facilities

Cross-cutting approach and networking Promote Educational and Professional Integration Networks (with DPOs, PHC professionals, social and educational facilities) Partnership agreements Quality Standards Social and medical work

Reform trends Gate keeping role of GPs Accreditation Evaluation of professional practices PMR services regional maps

Conclusion Interdisciplinary work Importance of education of professionals Networking involving facilities in primary, secondary and tertiary level, but also associations, social and education facilities.