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Table 2 Overview of the mechanisms and definition of each mechanism

From: Development of an evaluation tool for geriatric rehabilitation care

Mechanism Definition
Client-centeredness During the entire rehabilitation: - GRC professionals are continuously in conversation and agreement with the client - Goals are determined together with the client and suit the vulnerability of the client - The MDT regularly evaluates the rehabilitation plan with the client and the informal care givers - Preferably, the client is present during the MDT-consultation about his rehabilitation (process)
Client satisfaction during rehabilitation - The client is continuously involved in his rehabilitation process and all involved GRC professionals listen carefully to his input - Client knows which GRC professional he can ask questions of or share worries about his rehabilitation - The client is regularly asked about his satisfaction - Client feels safe and treated with respect
Information provision to client and informal care givers - Before admission, the client is well informed about what he can expect during GRC and what is expected from him concerning the therapeutic climate - During admission, information is given by one GRC professional and it suits the vulnerability of the client - The client is continuously informed about the progress and/or decline of his rehabilitation - Elderly care physician and client regularly talk about (the progress of) the rehabilitation process - Informal care givers are involved in the therapy - Client knows when therapy sessions takes place (even if the date and/or time of the therapy session changes) - The provisional discharge date is determined and communicated as soon as possible - Client is informed about the ‘things to organize’ concerning discharge
Consultation about rehabilitation (process) - Client and involved GRC professionals subscribe the rehabilitation goals - The progress of each rehabilitation process is regularly discussed - Registrations in the Electronic Client Dossier (ECD) are always up-to-date and all involved GRC professionals are aware of the up-to-date situation of a client - All MDT-consultations contribute to (1) the rehabilitation (outcome) of an individual client, or (2) the process of GRC, or (3) mutual cooperation
Cooperation within MDT - All involved GRC professionals can consult each other easily - The elderly care physician is in charge of the rehabilitation process - Expertise of all MDT professionals is taken seriously and all GRC professionals are equal to each other - MDT professionals work in mutual respect and they trust each other; there is a pleasant way of working together - MDT professionals can learn from each other. Feedback can be given and received in a constructive and safe way
Therapeutic climate - Each client trains 24/7 according to the principle ‘everything is rehabilitation’ (=therapeutic climate) - All involved GRC professionals stimulate the self-reliance of each client - Prior to admission, the client is aware of the therapeutic climate in GRC and he has a positive attitude about it - Rehabilitation goals are continuously coordinated with the client - Informal care givers are explicitly involved in the therapy and are aware that they can practice with the client
Professionalism of GRC professionals - GRC professionals are enthusiastic and motivated to work in GRC - GRC professionals proactively suggest which education, which contributes to their GRC-professionalism, they would like to follow - At MDT level, there is insight into what expertise is needed and which expertise is (not) present
Organizational aspects Admission: - For referrers to GRC (mostly hospitals) it is clear which clients are able to rehabilitate and can be referred to GRC - The elderly care physician has the final judgment whether a client can be rehabilitated and can be included in GRC During rehabilitation: - All involved MDT professionals have enough time to gain insight into the health situation of the client and to deliver the right care, appropriate to the goals and resilience of the client - One GRC manager decides for GRC and the MDT, even if more managers are involved. Decisions are made with the aim of realizing a good rehabilitation outcome and a satisfied client - New initiatives and innovation that can improve GRC can be tried Discharge: - At discharge, the client is referred to a living situation that suits him best; home, a nursing home, or a home that combines independent living with care