Rehabilitation may require only one discipline, but usually it draws on the coordinated efforts of more than one. When a complex problem requires expertise from several disciplines, a rehabilitation team can develop a program to coordinate therapy.
Usually, rehabilitation programs are organized around a particular type or set of problems. For example, a program may be designed to help patients recover from hip fracture, stroke, myocardial infarction, or heart surgery. The program can coordinate the needed services in an environment designed to facilitate recovery. Also, persons with similar conditions can work together (oward a common goal, encouraging each other and reinforcing the rehabilitation training.
Rehabilitation programs for geriatric patients include medical care that would not be needed for younger adults. Nurses and therapists can more easily adjust goals and the intensity of care to older patients when they arc not integrated wilh younger ones, who usually can handle more intensive, demanding therapy. Also, in segregated programs, older pa¬tients will not compare their progress wilh that of younger patients and thus become discouraged. Moreover, the social work needed to provide postdischarge care can be more readily integrated into the program.
Many different settings have geriatric rehabilitation programs, and the extent, aggressiveness, and duration of treatment varies from pro¬gram to program. Although rehabilitation may begin in the hospital, organized rehabilitation programs rarely exist there. Rehabilitation hospitals usually provide the most extensive and aggressive care and should be considered for patients who have the most potential and who can participate in aggressive intervention. Patients in rehabilitation hospitals must receive and be able to tolerate at least 3 h of therapy daily. Many nursing homes have programs as well, but they arc far less intensive. Generally, these programs are limited to 1 h daily and fewer than 5 days a week. Services may be delivered in outpatient settings or at home, but these alternatives cannot deliver the two or three daily

treatments and the variety ul services supplied in institutions. Provid¬ing care lo a disabled elderly person at home is most desirable, but it can be physically and emotionally taxing to a caregiver. The spouse may not be physically able to help, and the children may be too busy with their own families. I lome health aides are available in some com¬munities but usually cannot provide round-the-clock care. Thus, when the disability is severe, institulionalization may be necessary. Nonethe¬less, creative home care may be possible, especially for those with sub¬stantial financial resources.
At the star! of treatment, the duration of therapy must he considered and discussed wilh patients and their families because not all persons can invest the lime needed for optimal results. For example, after a hip fracture, complele rehabilitation may take 6 or 8 wk; after a stroke, it may take several months. For patients unable or unwilling to remain in a rehabilitation facility that long, the goals must be altered. Determin¬ing the goal of rehabilitation helps determine how and where lo accom¬plish it.
Rehabilitation is initialed by a physician who writes a referral con¬taining instructions lo an allied health professional. Like any prescrip¬tion, this referral is a legal document. Without it. the allied health pro¬fessional cannot treat the patient.
Because the allied health professional is carrying out (he physician’s orders, the physician establishes the goal of therapy and is responsible for the efficacy and side effects of treatment. Therefore, referrals should be appropriately detailed, including all relevant information and some initial directions. An appropriate referral would be: “Indepen¬dent in ambulation I mo poststroke. Please evaluate and (real for stabil¬ity and strength” or “3 wk posl-hip fracture. Please continue therapy for independent transfer and gait.” Although many therapisls accept vague orders such as, “Physical therapy lo evaluate and treat,” this type of order is not adequate. Physicians who are unfamiliar with writ¬ing orders to therapists should consult with senior therapisls, physia-trists. or orthopedic surgeons.
Before prescribing any exercise program, the physician should deter¬mine that the patient is medically stable and advise the (herapisl about any chronic cardiac, pulmonary, neurologic, or musculoskeletal limita¬tions. Older patienls may have several problems, and treatment must often be priorilized. Physicians should work closely wilh therapists lo decide which problems to work on first and when lo move on lo others.
A physiatrist, a physician who specializes in rehabilitation medicine, treats patienls wilh disabilities, coordinating a learn of physicians and allied health professionals, and helps puticnls develop and implement a comprehensive treatment plan. I his plan is not limited to the hospilul but extends lo Ihe patient’s community, family, friends, occupation, and lifestyle.