Why are there regional differences in participation in Kela rehabilitation? – Solutions require joint action from Kela and the wellbeing services counties

On the face of it, referral to Kela rehabilitation can be described as a straightforward process. However, a more in-depth examination reveals several different factors that cause regional variation in whether people actually receive rehabilitation from Kela, and whether it matches their needs and is provided in a timely manner.

Participation in Kela rehabilitation varies between regions. The variation is service-specific, i.e. the regional variation in participation in vocational rehabilitation provided by Kela appears to differ from participation in intensive medical rehabilitation.

Many different factors can affect how referrals to Kela rehabilitation services are made in different areas and whether rehabilitation is implemented. It is important for Finns’ wellbeing, functional capacity and work ability that unnecessary regional differences in access to wellbeing services can be eliminated.

In a recent research report, we present the results of a research project in which we focused on the factors behind regional differences in the phases of referral to Kela rehabilitation. In the study, we examined the comprehensive situation from the perspective of the rehabilitation system.

In this blog text, we highlight some of the key findings from the study, along with suggestions as to how regional differences could be addressed.

Applying for rehabilitation is straightforward, but referral overall is more complicated

Applying for rehabilitation organised by Kela is a process that, in principle, is implemented in the same way regardless of region. The process is defined, among other things, by the fact that applying for rehabilitation usually requires a doctor’s statement on the need for rehabilitation caused by an illness or injury, and that participation in rehabilitation requires a positive rehabilitation decision from Kela. The decision is based on Kela’s uniform criteria.

Applying for rehabilitation is part of the broader process of referral to rehabilitation. Referral can be viewed as five phases:

1. Identifying the need for rehabilitation
2. Assessment of the need for rehabilitation and preparation of a rehabilitation plan
3. Applying for rehabilitation
4. Making a rehabilitation decision
5. Use of the rehabilitation service

The process seems clear. However, from the perspective of the rehabilitation system, many factors affect whether a person is referred to rehabilitation and how well the rehabilitation is carried out.

The location and distance to and from services matter when organising services. The location of primary health care services may affect how easy it is to get a doctor’s appointment where the need for rehabilitation can be identified or assessed. The location of rehabilitation services, on the other hand, may affect how easy it is for a person to participate in the rehabilitation granted to them.

The resources available in the service system and the various cooperation models for assessing the need for rehabilitation, for example, may also affect a referral to rehabilitation.

Referral is also indirectly influenced by the fact that the rehabilitation system is so complex. The system is funded, managed and implemented by many different parties side by side – including public health care and Kela. For example, it may be difficult for professionals writing referrals to rehabilitation if there is not a smooth division of duties and cooperation between the professionals and organisations in such an entity.

A closer look at the phases of referral to rehabilitation reveals more problematic points.

At least four features that vary from region to region affect referral

In the study, we identified four features that vary regionally and which affect referral to Kela rehabilitation in several of the rehabilitation services. These include:

• Professionals’ knowledge of the rehabilitation services, the criteria for making referral decisions, and the rehabilitation system in its entirety
• Operating models and operating cultures in referral to rehabilitation
• Organisation of services in different regions
• Available resources (such as the number of Kela service providers or health care resources in the area for identifying and assessing the need for rehabilitation)

Some areas feel that there is sufficient information about the service. Other areas feel that there is far too little information. There are areas with strong operating models for cooperation in referral to rehabilitation, for example, while other areas lack similar models completely.

Services may also have been organised in different ways in different areas, which affects customer referrals. For example, in some areas, health care services provide the necessary service themselves. In other areas, the client is referred to Kela rehabilitation for the service. There is also variation in the resources used.

However, it should be noted that the regional number or share of the population participating in rehabilitation does not indicate whether clients are receiving sufficient support. The region may also have its own effective means of addressing people’s needs without them needing to become Kela rehabilitation clients.

The reasons for regional differences vary by service

Regional differences may also stem from service-specific factors. In the study, we examined four rehabilitation services provided by Kela: speech therapy, rehabilitative psychotherapy, vocational rehabilitation aimed at supporting integration into work, and rehabilitation courses for persons who have had a cerebrovascular accident.

In speech therapy, for example, the extent to which health care services provide access to a needs assessment for rehabilitation varies by region. Health care services in different regions also refer clients to speech therapy organised by primary health care to varying degrees.

Even in rehabilitative psychotherapy, there is variation in how clients can access a needs assessment through health care. On the other hand, there is also variation in whether there is a party responsible for the client’s process, and how much support is available to the client during a referral from health care services to rehabilitation and rehabilitative psychotherapy.

With regard to vocational rehabilitation that aims at supporting integration into work, there is variation in how well the need for rehabilitation is recognised in the first place. There are also differences in the assessment of work ability and management of the client’s overall situation.

There is regional variation in rehabilitation courses for people who have had a cerebrovascular accident at least in terms of how well responsibility is assumed for the client’s process and monitoring of the situation.

Proposed solutions for the wellbeing services counties and Kela

Based on the results of the study, we compiled seven solution proposals for Kela and the wellbeing services counties that will enable them to jointly support equal access to Kela rehabilitation regardless of region:

1. Kela and the wellbeing services counties clarify the understanding of the situations in which a client is referred to Kela rehabilitation and which actor is responsible for the process of referring a client to rehabilitation.
2. Kela and the wellbeing services counties jointly build and maintain operating models for referral to Kela rehabilitation.
3. Kela and the wellbeing services counties ensure a common understanding of Kela rehabilitation and the processes of referral to rehabilitation.
4. The wellbeing services counties will make rehabilitation a visible part of their region’s strategy and services as a whole.
5. Regardless of the situation, health care services react to clients’ established or potential needs for rehabilitation.
6. Kela ensures that clients receive appropriate rehabilitation by developing criteria for making positive rehabilitation decisions along with new types of services.
7. Kela ensures that there is data available on Kela rehabilitation and referral to rehabilitation.

How the study was carried out

The study was carried out at Kela between 2020 and 2022.

The aim of the multi-method study was to increase knowledge of regional differences and their causes in the availability of rehabilitation organised by Kela from the perspective of the rehabilitation system.

The research questions were as follows:

• What types of differences are there between regions when referring clients to Kela rehabilitation?
• What types of reasons are there for the differences between regions in referring clients to Kela rehabilitation?

We sought answers to the research questions in registers as well as from the experiences and views of professionals and experts. We collected information from professionals involved in rehabilitation and referral to rehabilitation, as well as from experts in the regional organisation and implementation of rehabilitation (including Kela’s experts).

We used Kela’s registers, open statistical sources (such as THL’s Sotkanet and Statistics Finland), a national survey and regional focus group interviews. We analysed the data using quantitative and qualitative methods.

At the end of the study, we organised a workshop for Kela’s rehabilitation referral experts, where the results of the study and their significance were discussed in relation to the new wellbeing services counties.

Author

Sari Miettinen
Senior Researcher, Kela
sari.miettinen@kela.fi
Twitter: @SariMiettinen

More information

Miettinen S, Pulkki J, Ukkola I, Paavonen AM, Rinne H, Heino P, Poikkeus L (2023) Alueellisen yhdenvertaisuuden tukeminen Kelan kuntoutukseen ohjautumisessa – tutkimuksesta ratkaisuehdotuksia. Kela.