European consensus on core principles and future priorities for geriatric rehabilitation: consensus statement

The consensus statement about core principles and future priorities of geriatric rehabilitation has the aim to help healthcare providers which need strategies to support older people who have experienced functional decline. Geriatric rehabilitation is now defined in a way that is compatible with existing service models across Europe. This consensus statement can provide a starting point for further development of geriatric rehabilitation. In response to the growing recognition of geriatric rehabilitation and to support healthcare providers which need strategies to support older people with frailty who have experienced functional decline, we developed a consensus statement about core principles and future priorities for geriatric rehabilitation. We used a three-stage approach to establish consensus—preparation, consensus and review. The consensus statement is grouped under 11 headings from (1) “Definition of GR” to (11) “Effective strategies to develop GR in Europe”, which define geriatric rehabilitation in a way that is compatible with existing service models across Europe. Additionally future goals around research and education are highlighted. The definitions of the consensus statement can provide a starting point for those wishing to further develop geriatric rehabilitation in their jurisdiction and help to develop strategic alliances with other specialties, serving as a basis for a pan-European approach to geriatric rehabilitation.


Introduction
The Geriatric Rehabilitation (GR) Special Interest Group of the European Geriatric Medicine Society (EuGMS) was established in 2018 in response to the growing recognition of geriatric rehabilitation across member states. Population ageing means that healthcare providers are increasingly challenged by the need to develop strategies to support older people with frailty who have experienced functional decline [1,2]. Geriatricians and older persons care physicians need to be ready to lead and advise on the development of such services. To support such work, we present here a consensus statement about the definition of GR, the type of patients who should receive GR and about the core principles and future priorities for GR.

Methods
We used a three-stage approach to establish consensuspreparation, consensus and review.
The preparation stage comprised two Delphi studies, one about the definition and organisation of GR in Europe [3], and one about the structures for GR across Europe [4]. These are reported in detail elsewhere. The findings were used as the basis for the second consensus stage.
For the consensus stage a group of 11 experts in GR from 5 EUGMS member states (Netherlands, Germany, UK, Switzerland, Italy) were invited to attend a face-to-face meeting in Heidelberg, Germany on the 18th and 19th May, 2019. Each participant was sent the outputs of the structural survey as well as the Delphi exercises and asked to return suggestions on text for a consensus document in advance of the meeting. These suggestions were presented at the meeting and discussed and edited until consensus was achieved.
In the review phase, the text of the consensus document was sent to all members of the EUGMS GR Special Interest Group, comprising representatives from (insert countries here), final comments were invited and approval from the EuGMS Executive Board obtained.

Results
The consensus statement is grouped under eleven headings: (1) definition of GR; (2) definition of GR patients; (3) resources for GR; (4) GR team structure; (5) rationale and limits of standards and guidelines in GR; (6) rationale and limits of a systematic evaluation system in GR; (7) definition of facilitators and barriers for further development of GR across Europe; (8) the rehabilitation process, (9) treatment principles, (10) education in GR, (11) effective strategies to develop GR in Europe.

Definition of geriatric rehabilitation
Geriatric Rehabilitation (GR) is defined as a multidimensional approach of "diagnostic and therapeutic interventions, the purpose of which is to optimise functional…," capacity, promote activity and preserve functional reserve and social participation "in older people with disabling impairments." This definition is based upon the ICF-framework of the WHO and the WHO rehabilitation cycle. It focuses upon patient-centred goals which reflect individual preferences established through co-operation with the patient and his or her caregivers.
Depending on different national policies, reimbursement structures and local availability, geriatric rehabilitation is offered in widely different settings. Moreover, it can be ambulatory, hospital-based or nursing home-based.

Definition of geriatric rehabilitation patient
GR is recommended for patients affected by multimorbidity and geriatric syndromes, who have the potential to improve their experience and/or outcome of functional performance. They should be participants in the rehabilitation process. Chronological age, place of residence and the presence of cognitive impairment should not be used to exclude patients from GR, but might have an impact on tailoring rehabilitation to specific patient`s needs.

Resources for geriatric rehabilitation
The available resources for GR with respect to facilities and beds vary a lot between the EuGMS member states. In most countries the available resources are insufficient, resulting in unmet needs. Rising demand reflecting demographic change, the ageing in place policy and development in treatments for chronic diseases across Europe means that an increase in available capacity across all forms of GR is required. Urgent attention should be given to mapping intrinsic capacity and responding to projected GR needs across all member countries.

Geriatric rehabilitation team structure
The structure and composition of the geriatric rehabilitation team are very different in the individual EuGMS member states. Ideally a GR-skilled physician, like a geriatrician, nursing home physician or other doctor with specialist training in care of older people, should lead the team.
The other professionals consistently included in the multidisciplinary core team are skilled nurses*, a physiotherapist, occupational therapist and social worker. In some countries this extends to include a psychologist, a pharmacist, a dietician and a speech therapist. Services should be designed to ensure that patients can access all relevant professional expertise when required.
*The word nurse also includes nurses of different levels.

Rationale and limits of standards and guidelines in GR
To ensure standardisation of treatment quality in GR across the EuGMS member states, the development and implementation of national and international standards and guidelines specific to GR are necessary. Research to provide the basis for high-level uniform treatment standards and international guidelines in GR should be prioritized and funded.

Rationale and limits of a systematic evaluation system in GR
There is currently no universally agreed approach regarding the use of indicators to drive quality assurance and improvement in GR. However, some countries have individual measures in place. We need to learn from these existing initiatives and increase health service research activities to build an agreed and feasible set of structure, process and outcome metrics for geriatric rehabilitation across Europe.

Definition of facilitators and barriers for further development of GR across Europe
GR has a long tradition in some European countries but has not yet been established in every EuGMS member state. In this respect some barriers have recently been reported. These include a lack of a policy framework for GR, a lack of available geriatric medicine resource, and determination of rehabilitation pathways based upon financial considerations rather than patients' needs.
The accumulated knowledge about barriers and facilitators to the implementation of GR requires to be collated and shared. This will enable the development and establishment of geriatric rehabilitation services across the EuGMS member states.

The rehabilitation process
GR services should be configured so that ambulatory and inpatient settings are linked. Inpatient GR can be located in hospitals, rehabilitation centres or nursing homes.
Following an acute event or functional decline due to chronic conditions, rehabilitation should start as soon as possible. It should commence in the setting closest to the patient and best able to meet his or her needs. The admission to each setting should be based upon clinical criteria. Seamless care should enable patients to move between different geriatric rehabilitation settings based upon progress and need.
A common approach to rehabilitation should be adopted by all geriatric rehabilitation settings. Comprehensive Geriatric Assessment (CGA) incorporating the perspective of the patient and informal caregivers should be used within a framework of shared decision-making to structure a tailored rehabilitation plan. This should be goal-orientated with appropriate priority given to the preferences of the patient. Goals should be measurable and time-specific.
The plan should be reviewed at regular team meetings. Discharge planning should be interdisciplinary and commence early, if possible from the point of admission.

Treatment principles
Rehabilitation should focus on minimising activity limitation and maximising societal participation, even in situations where body structure and function cannot be restored to premorbid levels. This may require the use of aids, appliances, technical and environmental adaptations. Rehabilitation programmes should encompass the psychosocial components of health and wellbeing.
Therapeutic intensity has to be tailored to the need of the individual patient and often needs to accommodate the reduced capabilities of geriatric rehabilitation patients.
Within the broad context of geriatric rehabilitation, patients present with a wide range of specific conditions. Some of these may have highly specific rehabilitation needs, for example stroke, Parkinson's disease, hip fracture, amputation, COPD and chronic heart failure.

Education in geriatric rehabilitation
To further standardise provision of GR across Europe, it is important to agree on core competencies for geriatricians and nursing home physicians and to ensure these are delivered as part of speciality training. Given that GR is interdisciplinary, the EuGMS could play a leading role to establish and support specific training in geriatric rehabilitation for relevant healthcare professions across member states.
To establish an appropriate foundation knowledge and skills for all medical practitioners we recommend inclusion of content about GR in undergraduate medical curricula.

Effective strategies to develop geriatric rehabilitation in Europe
All EuGMS member states should formally recognise the establishment and maintenance of high-quality GR as a priority. This has to be accompanied by structural, organisational and financial resources, to allow access for all people in need of GR.
Work is required to establish the cost-benefit of GR programmes across EuGMS member states. Insights should be used to further standardise the delivery of care to ensure maximum cost-benefit allowing for individual health and social care systems. This should be a research priority.
Research should consider the impact of GR when provided in ambulatory, hospital and nursing home settings. We need to understand which patient groups are best served by each approach.
There is a need to transfer GR awareness and knowledge to other medical specialties involved in the care of older people. Working relationships must be built with other specialist societies, for example those representing rehabilitation physicians, general practitioners, neurologists and surgeons, to develop shared training initiatives and guidelines.
To establish whether and how GR can play a role in preventing and treating functional decline in specific conditions such as stroke, Parkinson's, multiple sclerosis and patients with cancer, further work is needed.

Conclusion
We have, in this document, defined geriatric rehabilitation in a way that is compatible with existing service models across Europe. It is clear that, in many parts of the continent, GR is a sub-specialty which is under development, or is yet to be recognised. The definitions here can provide a starting point for those wishing to further develop geriatric rehabilitation in their jurisdiction. Additionally, this paper highlights future goals around research, education and the development of strategic alliances with other specialties, which can provide the basis of a pan-European approach to geriatric rehabilitation. The ambition now is to develop a working plan to support such work. Interested colleagues from across the continent are encouraged to join us.
Acknowledgements The authors would like to thank Finbarr Martin (Past President of the EuGMS), Stefania Maggi (President of the EuGMS) and Mirko Petrovic (Academic Director of the EuGMS) (EuGMS Executive Board) for giving the opportunity to undertake this consensus process as well as for reviewing, editing and approving the manuscript. We have to thank all member of the new founded EuGMS Special Interest Group (SIG) on GR for giving their comments to the manuscript. Furthermore the authors would like to thank Benedetta Bellotti (EuGMS secretariat) for their support throughout the whole consensus process and especially in organisation of the consensus meeting in Heidelberg.