Optimizing post-discharge intensive care for neurological patients with neurorehabilitation outreach teams

Neurological conditions frequently take a long time to recover and recovery can be promoted for prolonged periods by trained staff from various medical disciplines, e.g. medical doctors, therapists from various professions, and nurses trained in neurorehabilitation, most efficiently organized as interdisciplinary teams.

People in our society with a need for home-based specialized intensive care nursing secondary to neurological conditions are, however, usually not seen and taken care of by such specialized teams.
A rather strict organizational sectorial responsibility in Germany for inpatient service on one side (neurological early rehabilitation) and for community-based health care on the other (doctors, therapists, nursing staff without specialization in neurorehabilitation working in the community) might lead to a health care situation where a potential for function recovery is not optimally supported.

In such an situation, it might well be that if the sectorial health care borders and hence barriers for specialized long-term treatment were overcome that more people might recover over an extended period to a degree that they were no longer dependent from mechanical ventilation and were no longer in need for airway protection by blocked tracheal cannulas (via tracheostomy).
If that could be achieved the number of people requiring home-based specialized intensive care nursing could be reduced.

This health care project and clinical trial “OptiNIV” (acronym for optimizing post-discharge intensive care for neurological patients) is set forth to


  1. implement in the federal state of Bavaria (Germany) regular specialized post-discharge follow-ups by neurorehabilitation teams from specialized centres for people with a need for mechanical ventilation and/or tracheal cannula and hence for home-based specialized intensive care nursing; these teams will provide individual managed care plans to health care professionals in charge at the community level, and initiate short inpatient assessments and repeat inpatient rehabilitation when a potential for weaning from mechanical ventilation and/or decannulation is observed during follow-up;
  2. and to test with a parallel-group randomised controlled trial, RCT the hypothesis that such a specialized outreach health care service increases the rates for weaning from mechanical ventilation and/or decannulation (and promotes other clinical and economic outcomes) within the first year post discharge from neurological early rehabilitation.