Text: Kari Anne Dehli, Indre Østfold municipality, photo: Indre Østfold municipality

 

The municipality can thus take increased responsibility for rehabilitation and more rehabilitation can take place in the home. The service strengthens individuals’ ability to maintain and / or regain their physical and / or mental coping ability. Cost-benefit analyzes show that the overall service helps to prevent and postpone the need for compensatory services.

Society-based rehabilitation has contributed to a holistic approach and emphasizes the person and society perspective. The personal perspective as a core value has increased user participation, provided more person-centered goals and measures, and contributed to increased participation from the person in their own rehabilitation process.

Interdisciplinary assessment team (TVT) ensures that more interdisciplinary rehabilitation with high intensity can take place in the home. TVT ensures coordination and contributes to good transitions in the process. TVT connects relevant actors from the health service and the local community and supports coping and participation. Speech therapist, job specialist, services for mental health and substance abuse, nutritional physiologist, and resources in the local community, are examples of actors we can now ensure access to and connect to in a rehabilitation process. Collaboration with the GP has been strengthened through increased use of electronic messages and participation in collaboration meetings.

The people who have been followed up by TVT will have an increased level of function. Retests 3, 6 and 18 months after the end of the course, show that the functional level is maintained.

Everyday rehabilitation (HVR) has been initiated and is still being tested. HVR also connects resources in the local community and uses technology. TVT and HVR’s role vis-à-vis other existing services has been clarified. TVT and HVR have a joint team coordinator who participates in a weekly case meeting with Coordination & Admissions, and admission meeting in the unit Rehabilitation, Learning and Healthy living.

Beds for intensive rehabilitation will be established in June 2021, and the day care (individual services and learning and mastery groups) will be continued. The day, learning and coping services now provide services to groups that previously did not have satisfactory services, such as people with long-term pain.

New innovative technologies relevant to rehabilitation have now been implemented. These support the rehabilitation and contribute to increased intensity, motivation and increased self-effort.

The interaction with the specialist health service and other actors has increased. Competence among employees in Indre Østfold municipality in rehabilitation has been strengthened. Knowledge-based measures have been implemented and have ensured increased quality of the measures.

The project has delivered annual follow-up evaluation reports and shared experiences and results in many arenas over five years.

Rehabilitation works, provides benefits for the person himself and for the service. A future correct dimensioning and prioritization of rehabilitation will contribute to a sustainable health service, where people are enabled to improve their level of function and master everyday life in the best possible way.

The project was a collaboration between organizations, researchers and academia, user organizations, key personell in the municipalities (Indre Østfold consisted of several municipalities when the project started), hospitals and industry. Norway Health Tech had a coordinating role in the project.