The Institut Guttmann’s Specialist Assessment and Support Team (EASE) is a multidisciplinary health and social care team that specialises in neurorehabilitation under an agreement with the Servei Català de la Salut, supported by the Institut Guttmann Neurorehabilitation Hospital. Its services are offered wherever the person is, whether at home or in a health centre, health and social care centre or social services centre.
EASE’s mission:
- To facilitate social care and family reintegration and professional social and health care for people affected by a spinal cord injury, acquired brain injury or other neurological conditions that cause a disability.
- To provide support to families.
- To train professionals from primary health care and other centres to attend to and monitor patients, by training their workers or providing direct care.
- Within the Neurorehabilitation Hospital, to coordinate with other professionals to prepare for the discharge of patients who are more vulnerable, have greater care complexity or have special circumstances. To facilitate, therefore, getting people back home and continuing their care. EASE acts as a liaison team to ensure the best conditions.
Support programmes for patients with highly complex needs when returning home and managing complications
The purpose of the home assessment is to offer advice on removing architectural barriers, and offering adaptations and support products to promote people’s autonomy and help get them home.
This programme offers a comprehensive approach to the management of pressure injuries in neurological patients, establishing contact with the teams of professionals who offer care in the patients’ home environment to guarantee continuity of care and transmit specialist knowledge in treating this type of injury in people with neurological sequelae.
It is mostly carried out by nursing professionals. In some cases, when the injuries are secondary to sitting, the occupational therapist also intervenes by doing an analysis and intervention on the different elements (chair, pillow, activity carried out).
Specialist and personalised intervention for people affected by neurogenic bowel with serious intestinal continence problems where treatments used to date for their management have not been effective, limiting their quality of life.
This intervention is aimed at people included in EASE community programmes. It is put into place upon the request of the referring teams in the area when the patient is at home or in a health centre, social services centre or health and social care centre.
Its main purpose is to use a brief intervention to respond to aspects of the social sphere that concern the person or their family. The main actions are to guide, inform and advise on:
- Current socioeconomic protection.
- The rights of people with disabilities.
- Useful resources.
- Support for the management of administrative procedures derived from disability.
- Referral to primary health care or specialist care resources.
The purpose of this intervention is to facilitate coordination and support at any time on the care continuum. The team makes contact with professionals from the health, health and social care, and social services network to transmit information regarding the person’s individual care needs.
These are educational interventions on specific neurorehabilitation techniques. The demand can be generated from the hospital itself, from other health services, health and social care services and social services, or from patients themselves who are aware of the programme. The most common techniques are:
• Transfers and postural changes. Use of the electric hoist, transfer table, etc.
• Handling an electric wheelchair in the urban environment.
• Manual evacuation: digital evacuation, alternative devices.
• Changing and caring for a tracheostomy cannula.
• Preventing skin injuries.
• Intermittent catheterisation.
These specific educational interventions are aimed at professionals who care for people with neurological impairment across different services. They refer to specific neurorehabilitation techniques such as: management of breathing devices, orthoses and specific support products, management of neurogenic bowel, complex care of skin lesions, management of neurogenic bladder, medication for spasticity/pain, etc.
The Institut Guttmann and Hospital Germans Trias are working together in the Comprehensive Care Unit for Neuromuscular Diseases.
Support programme for people affected by acquired brain injury and their families in the community environment
The support programme for people affected by acquired brain injury is a professional, systematic and personalised intervention and support programme, carried out by occupational therapists. It is carried out directly in the daily life of the ABI patient, influencing significant and everyday activities and situations. The purpose is to teach, consolidate or generalise learning in daily activities, promoting autonomy and supporting the family in managing relationships and situations, thereby helping reduce the level of stress on the family caregiver.
Community occupational therapy programme in mental health for people with acquired brain injury and their families
This programme was created to support reintegration and normalisation in the home, personal, social and work life of patients affected by acquired brain damage who present behavioural disorders and/or other mental health disorders. It is intended to offer tools to the patient, main caregiver or primary health care provider to be able to take the step from hospital discharge after an intensive neurorehabilitation process to a normalised and autonomous life in the community. This programme is mainly carried out by occupational therapists.
Home-based neurorehabilitation hospitalisation programme for patients with spinal cord injury
The intensity of this individual home-based neurorehabilitation programme is adapted to the clinical and functional characteristics of the patient, and is clearly person-centred. Its purpose is to allow patients to achieve maximum personal autonomy, provide management tools to their caregivers and connect with local resources to promote their quality of life and avoid complications.
The team devises an individual therapeutic plan that is carried out through home sessions and in-person/online follow-up. Other departments of the Institut Guttmann such as Urology and Traumatology are involved as consultants on the plan, as with patients admitted to our centre who are undergoing intensive treatment.
EASE Team
Personalized rehabilitation at home
Episode 3 of Beines de Mielina, the Institut Guttmann podcast