In Germany a number of patients who are suffering from acquired brain injury and chronic neurological disability are either undersupplied or exposed to inappropriate care in their social environment. The number of these patients is increasing due to the changes in the procedures of care and due to demographic factors. While acute medical care and early rehabilitative treatment is accessible throughout the German health care system the necessary multimodal and competent care is rare or absent in the social participative sites such as life and occupational environments of the patients. The complex impairment of the brain, the central organ for sensorial, executive and other cognitive functions of human beings, renders the affected patient an exception in the system of medical and social care - this has only inadequately been considered in the past. The authors explain the necessity to disclose the status of a "human-with acquired-brain damage (Mensch-mit-erworbener-Hirnschädigung, MeH)" explicitly as severely disabled. The paper recommends a number of structural and procedural elements that have proven to overcome the insufficient or inappropriate support in integrating the patients suffering from acquired brain injury and chronic neurological disability in their social environment as well as for a demand-focused support with sustainable rehabilitative and ambulant follow-up procedures. Comparisons with other developed health care systems and international guidelines show that with organizing of early-supported-discharge, community-ambulation, shared-care and community-based-rehabilitation these problems have long since been identified elsewhere. Community-based and resident-oriented concepts have already been systematically implemented. In order to achieve the necessary support for the individual patient, a nation-wide development is necessary in Germany to perform the principles of the German social code and the principles of the Convention on the Rights of Persons with Disabilities of the United Nations: Goals of rehabilitation have to be more than functional treatment. Activation of the patient and supporting their coping and adaptive processes are necessary to achieve social participation and (re)integration into the community and in occupational life as implied by the standards of our society. Important elements of these are (1) identification of the individual patient and his/her burden during acute phase treatment or early rehabilitation (defined red-flag), (2) an individual clinical reasoning and planning of interventions and help, (3) general acceptance of the defined demands by all "players" in medical and social networks, (4) coordination and supervision of the medical and social interventions and of the assistive processes necessary in the individual environment. What seems to be needed is (5) systematic orientation to the goal of individual social participation at all levels of support, (6) cross linking, cooperation and development of the existing medical and social structures on site, (7) expansion ...

SINGER-data could be collected of 429 patients. In sum, results recommend to use the SINGER in outpatient neurorehabilitation, though with some restrictions. In comparison to BI and FIM, the SINGER results show in any case considerably less ceiling effects. The further exclusive use of FIM and, above all, BI cannot be recommended. But for very weak affected patients SINGER is poor sensitive for change and because SINGER is not covering all relevant aspects of rehabilitation a combined clinical use of SINGER and other assessment instruments seems to be a constructive solution.

In the meantime outpatient centres of neurorehabilitation are well-established as care providers and commonly accepted by service providers. However a comprehensive availability does not exist. The results show comparable structures of the centres, what is mostly determined by the service provider audited regulatory framework. Different concepts result in different processes. There are a lot of hints with respect to different concepts in form and content to implement the legally obligated mandate. In general their work with context -factors is still a frequently unused potential. It can be countered by the therapeutic inclusion of the social and environmental living conditions of the patients.

No abstract

Der Fallbericht beschreibt die Situation einer jungen Studentin nach schwerem Schädel-Hirn-Trauma und die lebensentscheidende Bedeutung, die dem neuropsychologischen Bericht zukommt. Während eines Rehabilitationsaufenthaltes wurden neuropsychologische Befunde dokumentiert, die im Entlassungsbericht zu einem Abraten von der Fortsetzung ihres Pharmaziestudiums und der Darstellung einer schwer beeinträchtigen Person führten. Auf Initiative der Familie wurde eine Zweitmeinung eingeholt, die sich von der vorhergehenden Einschätzung deutlich unterschied. Nicht mit erhobenem Zeigefinger, sondern unter Ausbildungs- sowie ethischen Gesichtspunkten soll die Notwendigkeit zu hoher Sorgfaltsleistung, Nützlichkeit und Professionalität bei der neuropsychologischen Diagnostik und Therapie dargestellt werden.