A network-based rehabilitation model for frail elderly people: development and assessment of a new model

Living independently at home promotes the well-being of people aged 65 and over. In Finland, the municipalities are responsible for providing social and health services, including rehabilitation of the elderly. Rehabilitation is in practice carried out by independent rehabilitation centres. The Social Insurance Institution of Finland is a national agency responsible for financing and developing rehabilitation. Combining the efforts of these three agencies, a new network-based inpatient rehabilitation model was established to support the community living of frail elderly persons at high risk of institutionalization. This article describes the new model and evaluates the cooperation within the rehabilitation network, as well as the contents of the rehabilitation.

The new model was evaluated in two phases using diverse methods. First, the networks were assessed as they were being established in 2000, and secondly, when they were operational in 2002. The first phase involved 53 networks operating in 46 municipalities and 12 rehabilitation centres, and the second 44 networks in 41 municipalities and seven rehabilitation centres. The data were collected by questionnaires, interviews and reports.

The rehabilitation networks were functional, although constant development and search for better working practices was time consuming. Two different approaches in the networks were found: the 'networks of creators' were able to carry out the new tasks highly successfully, while the 'networks of followers' only managed to do the minimum as instructed. Motivated network members and adequate resources appeared to be essential for a successful rehabilitation process.

It is possible to create a functional rehabilitation network involving different agencies. Further development work is necessary to make the network-based rehabilitation model more efficient.