1. 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

2. 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

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

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

5. 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

6. 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

7. 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

8. 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.

9. 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).

10. 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…

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

12. 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)

13. 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.

14. 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.

15. 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

16. 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

17. 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

18. 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)

19. 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

20. 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

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

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