Methods and tools of the rehabilitation process in a case of acute disseminated encephalomyelitis (ADEM) in the evolutionary age: continuity hospital-territory

Background: An analysis of the situation of the Piedmont Region and Italy shows a lack of continuity of care due to the difficulties of communication, the fragmentation and incorrect timing of the interventions, the development of ultraspecialized skills and a lack of organizational models. However, program sharing and coordination of interventions are essential for the practical implementation of the rehabilitation, especially in pediatric physiotherapy. Purpose and Objective: Aim of the study is the continuity of care (hospital-territory) for children with acute disseminated encephalomyelitis, in order to achieve a good individual and family compliance in the rehabilitation programme and greater levels of autonomy. This study uses a figure to link the two realities and telerehabilitation. Methods: The project was divided into a first phase, the intensive hospitalization and a second phase, the return to the home withrehabilitation, trainingeducational and organizational interventions. The graduand student has been identified as a point of reference and a “bridge” between the two realities. A web page with “Google Forms” customized for children was created in order to increase compliance and motivation of patients and family. Questionnaires were administered to families, children and healthcare to check the methods and tools used in the study. Results: At the end of the study the rehabilitative intervention was assessed by scales and test scores, and improvements have been achieved. The organizational intervention (web page and hospital and communuty continuity mode), evaluated through questionnaires, has been postively assessed by those who took part in this project. Hospital-Territory continuity is a crucial and important moment for patients: having a physiotherapist who acts as a trait d’union is essential as is the use of telerehabilitation for monitoring and maintaining the autonomy of these children. Conclusions: Continuity of care is still operator-dependent; in rehabilitation this is a crucial and important time, as evidenced by the project. In order to support patients and their families and facilitate positive outcome it would be really important to have a reference organizational model and a referent physiotherapist who represents an interface between the various players in the socio-medical system The problem remains open and each route has its own story.