Abstract
It takes time for children (adults) with severe motor and intellectual disabilities (patients with severe conditions) to return to ordinary lives that they had before hospitalization even after completion of acute-phase treatments following onset of acute diseases. The families who provide care may feel difficulty judging whether or not the patients need care, which increased during hospitalization, and living with anxiety without perspectives that the patients would be able to return to the ordinary lives after discharge. We have admitted patients to our facility in order to help them return to the ordinary lives in their communities after completing treatments at the acute care hospital. The care we provide for the patients with severe conditions have been highly individualized in each case. By reviewing the hospitalized cases, we found that there were several processes in common: 1. Assessment of disease/disorder and estimation of functional prognosis, 2. Medical management and intensive rehabilitation, 3. Reestablishment of a care plan and life simulation, and 4. Coordination of social resource use. These processes require expectation and coordination from the life-model aspect so that we can play a role as an intermediate facility specialized for accommodating children with severe conditions requiring medical care. It has been a challenge to establish a system with which we can sufficiently coordinate the patients' hospital stay as well as their daily lives from the comprehensive perspectives throughout their lives from childhood to adulthood.
