The Development of Rehabilitation Services in the Australasian Region John OLVER AM MBBS MD FAFRM (RACP) Director Rehabilitation Epworth Healthcare Professor Rehabilitation Medicine Department of Medicine Monash University The Asia-Oceania Region Grouping of countries holding 60% of the world s population (>4.5 billion) The region hosts a diversity of cultures, political environments, socio-economic development, religions and population sizes There has been a gradual evolution of Rehabilitation Medicine and associated programs and facilities throughout the Asia- Oceania region 1
1948 1960s 1990s 1993 1970s Asia-Oceania Region The Commencement of Rehabilitation Medicine The Australasian Faculty of Rehabilitation Medicine (AFRM) of the Royal Australasian College of Physicians was formed Followed by China, India, Indonesia, Korea, Taiwan, Thailand At a later stage, organisations were also formed in Malaysia, Singapore and Mongolia The Australian Association of Physical Medicine was formed First Asian National organisations formed (Philippines and Japan) Followed by Vietnam, Hong Kong and Laos Rehabilitation is still in the initial phase of development in some countries. In others, there are well established programs, research projects and advances in technology that are instigating changes for the discipline and projecting it beyond its current boundaries Han, 2007 History of National PMR Societies in Asian Countries Country or Administrative Region PMR Association Year of Establishment Number of Physiatrists PMR Training (years) Board Certification Examination Australia Australasia Faculty of RM a 1993 300 2 + 4 Yes Yes New Zealand Bangladesh Bangladesh Association of PRM 1995 25 3 Yes n/a Brunei n/a - 1 n/a n/a n/a China Chinese Society of PM&R b 1985 10000 5 In preparation Yes Chinese Association of RM 1983 Chinese Taipei Taiwan Academy of PM&R 1971 640 4 Yes Yes Hong Kong SAR Hong Kong Association of RM 1996 39 3 + 3 Yes Yes India Indian Association of PM&R 1972 416 3 Yes Yes Indonesia Indonesian Association of PM&R 1987 257 4 Yes Yes Iran Iranian Association of PRM 1972 250 3 Yes n/a Japan Japanese Association of RM 1963 1102 5 Yes Yes Korea Korean Academy of RM 1972 947 4 Yes Yes Laos Laos National RM Association 2005 4 n/a n/a n/a Malaysia Malaysian Association of RM 2004 15 2 + 4 Yes Yes Mongolia Mongolian Society of PRM 2005 130 1 n/a n/a Philippines Philippine Academy of RM c 1974 300 3 Yes Yes Singapore Society of RM Singapore 2005 16 3 + 3 Yes Yes Thailand CME /CPD Activities Royal College of Physiatrists of 1998 338 3 Yes Yes Thailand Thai RM Association 1988 Vietnam Vietnam Rehabilitation Association 1991 1400 3 n/a n/a The formation of regional societies has been pivotal for the development of the specialty in Asia and Oceania. It promotes Rehabilitation Medicine and sharing of knowledge across borders. Earliest regional professional meetings:- Thailand (1998), Joint Japan-Korean conference (2002) 2
Asia-Oceanian Society of Rehabilitation Medicine The largest step forward in regional communication (2007) Formed with the purpose of being a regional scientific and educational society for practitioners of Physical and Rehabilitation Medicine Aims to improve the knowledge, skills and attitudes of physicians in their management improving patients quality of life through successful community reintegration Broader mission: represent physical and Rehabilitation medicine from the Asian and Oceanian region to international health organisations Asia-Oceanian Society of Rehabilitation Medicine (AOSPRM) First congress was held in Nanjing, China (in 2008) and since this time, conferences are held on a biennial basis (Taiwan, Bali, Thailand and Philippines) This congress also formed the focus of Rehabilitation in China (Disaster Relief) as it occurred just after the Sichuan earthquake whereby Chinese delegates were in disaster relief roles The conduct of Regional meetings has introduced a global perspective of Rehabilitation (e.g. updates on the Society s relationship with the WHO and promotion of global concepts e.g. International Classification of Functioning, Disability and Health) 21 countries have National representatives in the Society including: (Australia, Bangladesh, Brunei Darussalam, China, Chinese Taipei, Hong Kong, India, Indonesia, Iran, Japan, Korea, Laos, Malaysia, Mongolia, Myanmar, New Zealand, Pakistan, Philippines, Singapore, Thailand and Vietnam) 3
Asia Oceania Region Regional Differences Examples Overall philosophy of rehabilitation medicine General, accepted understanding Improving activity and participation in society in individuals with impairment and consequent disability Alternative understanding Rehabilitation has the same connotation as recovery and is a natural outcome of the disease rather than an active process addressing it (China) Definition In Asia-Oceania, it ranges from RM, PRM or PM&R (Han 2007) Stage of Development For most Western countries (including Australia), Rehabilitation Medicine started after World War II to provide medical service and rehabilitation for veterans with spinal cord injuries or amputations. It started much later in Asia than in Europe or the United States Han, 2007 Rehabilitation in Australia Australian State Run Rehabilitation programs emerged within dedicated Rehabilitation Centres Diploma in Physical and Rehabilitation Medicine commenced (1970) to recruit doctors into the specialty. The National Specialist Advisory committee formally recognised Rehabilitation as a principal specialty (1977) 1948 1955 1970 1977 1996 Ministry of Post-War reconstruction became the Commonwealth Rehabilitation Service Transitioned previous serving servicemen back into the workforce (through Vocational Rehabilitation). No focus on improving personal independence. Services available in most States at the time little rehabilitation existed in state run public hospital systems Bruce Ford described the concepts of team-based, multi-disciplinary programs which extended beyond medical impairment and encompassed physical, psychological and social assessment of patients 4
Royal Australasian College of Physicians (RACP) The College introduced a Fellowship Training Program in Rehabilitation Medicine which grants doctors the right to practice as Specialists in Australia New Zealand adopted the same training program, initiating their own country branch of the college (holding its first meeting in 1989) In 1991, the College joined with the Royal Australasian College of Physicians (RACP) and became one of its faculties Post graduate education is modelled on the Royal College System from the UK rather than a University based qualification Rehabilitation Training Curriculum Module 1 Written Assessment Module 3 Clinical Research/ Research Project Module 5 Health Services Administration and Evaluation Module 2 Clinical Assessment Module 4 Clinical Neuropsychology Module 6 Behavioural Sciences Formalised curriculum for training 48 month program (at 2 nd or 3 rd year post graduate level) 6 modules to be completed during training Post Fellowship education is presently run by a newly formed Rehabilitation Medicine Society of Australia and New Zealand (RMSANZ) 5
Proportion of Rehabilitation Physicians in Australasia 567 rehabilitation physicians across Australasia 214 trainees 67 retired Fellows 14 honorary Fellows Australasian Rehabilitation Outcomes Centre (AROC) AROC is the national rehabilitation medicine clinical registry of Australia and New Zealand (established in 2002 as a not-for-profit centre) The Australasian Faculty of Rehabilitation Medicine (AFRM) is the auspice body and data custodian Australian Health Services Research Institute at the University of Wollongong manages AROC on its behalf and undertakes the day to day management of AROC AROC collects data from >96% of Rehabilitation Facilities in Australia and New Zealand for every episode of care on admission and discharge https://ahsri.uow.edu.au/aroc/whatisaroc/index.html 6
Purpose and Aims of AROC It provides an audit tool to allow for internal evaluation and comparison with national benchmark data for all impairment groups To produce information on the efficacy of interventions through the systematic collection of outcomes information in both the inpatient and ambulatory settings Rehabilitation physicians in our role as educators: Develop clinical and management information reports based on functional outcomes, impairment groupings and other relevant variables A set of benchmarking reports are prepared for individual facilities and payer organisations every 6 months that summarise the Australasian data against the submitting facility https://ahsri.uow.edu.au/aroc/whatisaroc/index.html Rehabilitation in Japan Rehabilitation practice preceded its formal establishment. In the 1920 s, it was focused on crippled children A certification system in Rehabilitation was started Following the certification system, this developed into a new organisation of Board-certified Physiatrists 1920s 1963 1980 1982 2003 The Japanese Association of Rehabilitation Medicine (JARM) was established Guidelines for post graduate training were created and the Fundamental Principles for Education of Rehabilitation Medicine were developed 7
Rehabilitation Curriculum in Japan Curriculum in Japan had similar objectives to the Australian model. Institutes were certified for education in Rehabilitation Medicine and courses developed by JARM An additional focus at present is leading the development of robotics in physical rehabilitation Electrodiagnosis was a key skill for physiatrists. Research methodology and interdisciplinary team management was also encouraged Rehabilitation in Malaysia Training program and development of Rehabilitation Medicine was championed by Professor Datuk Dr Zaliha Omar Training formally commenced in 1997 a four year post-graduate Masters course (University of Malaya). <2004 trainees spent 6 months training in Melbourne Examinations were conducted with external examiners (from USA, Europe, Australia) Rehabilitation has evolved over recent years with new facilities containing dedicated Rehabilitation beds First Malaysian Association of Rehabilitation Medicine Conference held in December 2004 8
Rehabilitation in China The evolution of Rehabilitation has embraced Traditional Chinese practices (massage, (acupuncture, herbal medicine) and Western medicine. This integration is particularly applied in stroke/chronic pain Evolution 85 million disabled Estimates people (with 90% having Rehabilitation needs). Many cannot access a Rehabilitation program. In response, pilot programs of integrated Rehabilitation were introduced in 2010 (46 cities and 14 provinces) 1980s: Modern rehabilitation was introduced to the Chinese health system. System needs restructure and increased financial input (as disassociation between the different grades of hospitals e.g. acute, Modern subacute) Policy With the recent National Policy on Health China (2030) and economic growth, Rehabilitation is an important aspect of healthy living and aging. There are now training facilities for doctors, therapists and nurses and partnerships to create new rehabilitation facilities Challenges in Delivering Rehabilitation Services Referral between tiers of management Rehabilitation medicine is often not well understood by the general public and other doctors. People who would benefit from rehabilitation are not being referred to the services Team-Based Specialty Rehabilitation operates most efficiently with good team communication rather than the delivery of individual therapy services. The treating Rehabilitation physician is best placed to take a leadership role in the coordination of treatment Locality Service gap exists between city and rural services. Rural services are under resourced. Difficult to access services in countries such as Australia with vast distances 9
Rural Rehabilitation Services 2009 Thailand study: 8.9% of the population had disabilities and majority lived in rural areas. No more than 2% were involved in Institution based Rehabilitation. Community-based Rehabilitation was introduced to address this service gap (1970 - early 80s) In China, there was a shortage of Rehabilitation resources which were unevenly distributed between rural, urban areas and in different regions Therapists require alternative training for roles - need to be aware of cultural, economic and religious differences of clients and be flexible in their approach and goal setting Challenges in Delivering Rehabilitation Services (cont.) Aging population Specialty focuses on minimising the effects of disability on activity and participation in society so will need to meet this demographic challenge. In Japan, 22% of the 128 million population are >65 years. In Singapore, by 2030, 20% of the population will be >65 years Prevention Preventative role in all phases of rehabilitation treatment (from acute to community) to oppose the vicious circle of immobility. Involves preventing further impairment after injury due to immobilization and sedentary lifestyles Resources Disability has been related to a high risk of poverty with some prejudice noted against people with disability. In Indonesia, 1.8% of the population have extreme problems and 19.5% have problems with daily living tasks. Across the region, the financial resources and available personnel to deliver services are low compared to the existing needs 10
It is hoped this report will provide a template to influence Governments in this region to allocate more resources to Rehabilitation to ensure the dignity of people with disability and help change the perception of them to active and equal citizens Epworth Monash Rehabilitation Medicine Unit Research Team Thank you Email: john.olver@epworth.org.au 11