Inclusion of a rehabilitation intervention in the catalogue of follow-up rehabilitation using the example of cochlear implant follow-up treatment

Abstract

As part of a medical treatment or surgical procedure, a rehabilitation programme can be provided. This rehabilitation can also be carried out as so-called follow-up treatment (in German: “Anschlussheilbehandlung”, AHB). The German Pension Insurance (Deutsche Rentenverischerung, DRV) has defined several medical interventions that can be conducted by AHB in a catalogue of medical indications. This catalogue is regularly revised and expanded if necessary. This paper describes the process of including cochlear implant (CI) follow-up therapy in the AHB indication catalogue. This process can be considered exemplary for other rehabilitative procedures.

The first task was to organize the process of CI treatment in such a way that the formal requirements for AHB were met. The main requirement was that the rehabilitation programme be started within 14 days of discharge from hospital. To ensure this, the initial fitting of the CI processor (as part of the basic therapy) must have taken place beforehand. The concept of early fitting of the CI processor (within 2 to 3 days after surgery) was successfully confirmed in a feasibility study. In a subsequent pilot project, the feasibility and safety of early rehabilitation after CI fitting was also demonstrated. This provided proof in principle of the feasibility of this measure as AHB. After the results of the pilot study were reviewed by the German Medical Service, rehabilitation after CI surgery was included in the DRVʼs AHB indication catalogue in September 2024.

Keywords

cochlear implant - rehabilitation - AHB - follow-up treatment - follow-up rehabilitation

Introduction

Rehabilitation following a surgical procedure is an essential part of treatment in many medical fields in order to optimize the success of treatment. For example, rehabilitation as part of treatment with a cochlear implant (CI) is planned to improve speech intelligibility and quality of life in everyday situations [1] [2] [3].

There are a variety of different rehabilitation procedures that can be initiated individually by the treating clinic. For some medical treatments, it is possible to start rehabilitation as follow-up treatment (German: “Anschlussheilbehandlung”, AHB) within 14 days of the end of the inpatient stay. The German Pension Insurance (Deutsche Rentenversicherung, DRV) has accomplished a catalogue of indications for AHB [4]. This catalogue regulates for which medical interventions AHB can be carried out and which requirements must be met. AHB is not provided for all medical interventions. The AHB indication catalogue is regularly revised and supplemented as necessary.

In the following, the steps to include a rehabilitation measure that was previously only possible as a curative treatment in the AHB indication catalogue will be explained using the example of hearing rehabilitation after cochlear implantation (CI rehabilitation).

The care of patients with profound hearing loss or deafness with a CI is a standardized process in Germany. The German “Leitlinie Cochlea-Implantat” [Cochlear Implant Care Guideline] (017–071; AWMF) [1], which was updated in 2020, served as basis for the creation of the German “Weißbuch Cochlea-Implantat Versorgung Deutschland” [White Paper on Cochlear Implant Care in Germany] by the German Society for Otorhinolaryngology, Head and Neck Surgery (DGHNO-KHC) [3]. Both documents provide the framework for the introduction of the German “Cochlear Implant Register” (DCIR) [5] [6] and the certification programme for the German “CI-versorgende Einrichtungen” [Cochlear Implant Care Institutions] (CIVE) [7].

The development of quality-assured diagnostic and therapeutic standards also includes the continuous incorporation of new developments and advances. In particular, this also includes procedural changes resulting from improvements in treatment processes. One example of this is the further development of surgical approaches in the context of CI surgery. The progressive minimisation of surgical access and the resulting acceleration of the post-operative healing time result in potential changes in the subsequent treatment steps. Taking the CI as an example, the significantly reduced postoperative swelling results in the possibility of an accelerated fitting of the CI processor and thus an earlier start of basic and follow-up therapy as well as CI rehabilitation. Until now, it has been common clinical practice to start basic therapy around four to six weeks after CI surgery. By optimizing the implantation technique, it is now possible to start basic therapy just a few days after the surgical procedure. In previous studies, the authors were able to derive the concept of “early fitting” from this and have presented long-term data on this concept [8] [9] [10].

With regard to the processes set out in the AWMF guideline and the CI white paper, there are currently no precise time specifications for the start of basic and follow-up therapy. A change in the timing of these measures is therefore formally compliant with the guideline and white paper.

The early fitting of the CI processor, i. e. the start of basic therapy just a few days after implantation, makes it possible to start rehabilitation at an earlier stage and thus make AHB possible in the first place. Previously, inpatient rehabilitation was only possible as a curative treatment, and this was subject to cost approval by the responsible cost bearer with a complex authorisation procedure. Applying for inpatient rehabilitation therefore often involved a great deal of administrative time for both the applicant and the funding organisation, as well as uncertainty regarding the outcome of the approval process. The introduction of early fitting (start of basic therapy in the first few days after the operation) opened up the possibility for follow-up therapy to conceptualise the subsequent hearing rehabilitation not as a classic inpatient treatment procedure, but as AHB. AHB is defined as a rehabilitation measure that is directly or at least very closely related in time and therefore causally to inpatient hospital treatment. A maximum period of 14 days after discharge from hospital until the start of the rehabilitation programme is mandatory. In principle, AHB can be carried out on an inpatient or full-day outpatient basis in a rehabilitation centre approved for this purpose by the German Pension Insurance (DRV) [4]. Requirements for an AHB rehabilitation facility can be found in the requirements profile for inpatient medical rehabilitation facilities with authorisation for the AHB procedure of the DRV [11].

In 2019, a pilot study was initiated in collaboration with the MEDIAN Kaiserberg-Klinik Bad Nauheim, DRV Bund and DRV Hessen, Knappschaft Bahn/See and Deutsche Angestellten-Krankenkasse (DAK) in order to test the feasibility of early follow-up therapy. Patients who received a CI at the Department of Otorhinolaryngology at Frankfurt University Hospital and early fitting were referred for further treatment as part of inpatient CI rehabilitation to the Kaiserberg-Klinik in Bad Nauheim within 14 days of being discharged from inpatient therapy. This procedure was intended to simulate the process of AHB. A total of 75 patients were included in the study. 54 patients were admitted to inpatient rehabilitation within 14 days, analogous to AHB; the remaining patients were admitted to inpatient rehabilitation as a control group after going through the usual application process with a significant delay. The recorded data has since been published [12].

Due to the preparatory work described above, CI rehabilitation was included in the German AHB catalogue in 09/2024. This inclusion means that ENT clinics are now able to initiate inpatient rehabilitation within two weeks of implantation via the social services of the clinical facility. Inclusion in the AHB catalogue will lead to a considerable improvement in procedures in the future by reducing bureaucracy in the application process. In addition, legal certainty will be achieved for the patients concerned, as after inclusion in the AHB catalogue, both those with statutory and private insurance – provided that the medical requirements are met – only the social insurance requirements need to be checked and an individual application for cost coverage no longer needs to be submitted. The inclusion of CI rehabilitation in the AHB catalogue thus represents a real milestone in follow-up therapy to improve processes for all patients supported with a CI in Germany in the future. In this paper, the necessary preparatory work and the formal process will be presented, as these can also be transferred to other areas of ENT medicine as models.

Definition of follow-up treatment

AHB is a rehabilitation programme that is initiated immediately or in close medical and temporal connection with inpatient hospital treatment. A maximum period of 14 days from hospital discharge to the start of the rehabilitation programme must be observed. AHB can be carried out on an inpatient or full-day outpatient basis at a suitable rehabilitation centre [4]. The AHB indication catalogue of the German Pension Insurance (DRV) defines which medical treatments can be followed by rehabilitation as AHB and which requirements must be met.

Before AHB can be initiated, the treating physician at the clinic must assess the patientʼs eligibility for AHB. If the requirements are met, the application is submitted via the clinicʼs social services (AHB application, form G0250) [4]. It is also important to have early contact with the rehabilitation clinic, preferably before the operation, so that a bed can be reserved in good time.

Establishment of AHB using the example of CI treatment

The steps and preparatory work that led to the inclusion of CI rehabilitation in the AHB indication catalogue are described below.

CI fitting process

The CI is an established treatment method for profoundly hearing impaired or deaf patients [13]. In order to ensure a standardized procedure for CI care, the care process was described in the form of a medical guideline [1] [3]. The aim is to achieve a uniformly high level of quality for all CI recipients throughout Germany.

The CI rehabilitation process according to the medical guideline “Leitlinie CI-Versorgung” [1] [3] has already been described in detail elsewhere [14]. Once the indication has been established, CI surgery is performed, followed by basic therapy. This includes the initial activation of the CI processor as well as the introduction of audiological, hearing and speech therapy measures and medical checks. The aim of the follow-up treatment is to use the device to its full intend for the patient. It also includes audiological, hearing and speech therapy measures as well as medical checks. Once the follow-up therapy has been completed, lifelong aftercare is provided to ensure the best possible use of the CI system in the long term. Technical aftercare can be delegated by the CI hospital to cooperating facilities. According to the CI guideline updated in 2020, a rehabilitation programme is recommended, which can be part of the basic or follow-up therapy [3].

Rehabilitation in the context of CI treatment

According to the “Leitlinie CI-Versorgung” [3], CI rehabilitation is part of the standard procedure. The hearing and speech therapy part of the follow-up therapy can take place under the supervision of an ENT specialist at the institution providing the CI (ENT clinic) or at a co-operating rehabilitation facility. The aim of a rehabilitation programme for adults is not only the full use of the CI, but also the professional and social integration on the basis of an improved spoken language communication with the CI [3].

In a previous study by Zeh & Baumann (2015) [15], the effect of inpatient rehabilitation was analyzed quantitatively. For this purpose, audiometric data from standardized hearing tests of 1,355 CI users were evaluated retrospectively. The data was compared on admission and discharge after 3–5 weeks of inpatient hearing therapy. The results showed that patients achieved an average improvement in their speech perception of 20 percentage points as a result of the rehabilitation programme. This effect was independent of the patientʼs age. The study results showed that all patients benefited from inpatient rehabilitation, regardless of the duration of deafness or time of CI use. (Inpatient) CI rehabilitation is therefore a scientifically validated part of CI care that contributes significantly to the optimal utilization of the CI system. However, there is currently no standardized concept for the structure of rehabilitation after CI treatment, so that rehabilitation takes place in inpatient, outpatient, day-care or block weeks. Scientific data with larger patient cohorts are currently only available in Germany for inpatient rehabilitation programmes following CI treatment. There is no comparable data on the efficiency of other rehabilitation concepts, e. g. the rehabilitation programmes carried out in many places as part of several short blocks.

Previously, inpatient rehabilitation had to be carried out as a curative procedure, for which an individual application (form G100) had to be submitted to the funding organization. Depending on the federal state and the expertise of the person in charge, the rejection rate varied considerably, especially for adult patients. Objections, expert opinions or even court proceedings were often necessary to obtain authorisation. This led to long waiting times and high efforts for patients [16].

Requirements for the establishment of CI-AHB

In order for CI rehabilitation to be included in the AHB catalogue, the necessary conditions for carrying out early rehabilitation first had to be created. To this end, care processes and structures were fitted or newly established.

Early fitting of the CI processor as a prerequisite for carrying out CI rehabilitation as AHB

Until now, basic therapy, which includes the initial activation of the CI system, has been carried out approximately four to six weeks after CI surgery to ensure that the healing process of the implant and wound healing are complete [17] [18]. This means that it has not been possible to start rehabilitation within two weeks after discharge. However, this is an essential prerequisite for the implementation of a rehabilitation programme as AHB.

Improvements in surgical techniques (e. g. small incision technique [19]) have made it possible to reduce the size of surgical access points, which in turn has led to a reduction in post-operative swelling. It was possible to activate the CI processor considerably earlier, only a few days after the CI operation, due to significantly smaller and therefore faster healing wounds.

The fundamental feasibility of early activation of the CI processor and its safety has already been demonstrated in previous studies [8] [9] [10]. It could be shown that the waiting time between CI surgery and initial activation of the CI processor could be significantly shortened by early fitting within 3 days (median) after surgery compared to activation after the standard healing time (28 days, median). No wound healing disorders or serious complications were observed. It could be shown that early fitting does not offer any medical or hearing therapy disadvantages for patients, but on the contrary enables an earlier start to CI rehabilitation.

However, it is necessary for the initial activation of the CI system to be carried out as part of the basic therapy in the institution providing the CI (ENT clinic). Not every patient is automatically suitable for early activation of the CI processor. A medical assessment (including sufficient wound healing) and an audiological feasibility check (including sufficient coupling between CI processor and implant) are therefore essential before initial activation.

The early activation of the CI system a few days after the operation enables the transition from basic therapy (initial adaptation phase) to follow-up therapy within 2 weeks after discharge after surgery. This also means that CI rehabilitation can begin within 2 weeks of discharge from hospitalisation. The early activation of the CI system thus lays the foundation for the implementation of CI rehabilitation as follow-up rehabilitation (AHB).

Investigating the feasibility of CI rehabilitation as AHB

The next step was to investigate the feasibility and safety of early CI rehabilitation as AHB in a pilot project [12]. This was made possible by a co-operation between the ENT University Clinic Frankfurt, the MEDIAN Kaiserberg-Klinik Bad Nauheim and various cost bearers (German Pension Insurance [DRV] Bund, DRV Hessen, Knappschaft Bahn/See, Deutsche Angestellten-Krankenkasse [DAK]). By considerably simplifying the application process for CI rehabilitation, the waiting time for admission to the rehabilitation centre has been significantly reduced.

The study showed that the waiting time for the start of rehabilitation could be reduced to an average of 14 days (min. 8/max. 23 days) thanks to the very early initiation of the rehabilitation programme, while patients had to wait an average of 106 days (min. 35/max. 520 days) for the start of rehabilitation under the previous application procedure. The basic CI therapy and the rehabilitation process for both study groups is shown schematically in [Fig. 1].

Fig. 1 Schematic representation of basic CI therapy and the rehabilitation process; top: inpatient early rehabilitation following the initial adaptation phase (intervention group); bottom: inpatient rehabilitation following the standard application procedure (control group).

92.6 % of patients were able to start very early CI rehabilitation within 14 days. On average, these patients completed the rehabilitation programme 7 weeks after the CI operation. The rehabilitation effort was comparable to the previous rehabilitation procedure. Furthermore, a comparable development of speech comprehension was shown after very early rehabilitation and after standard procedures.

The pilot study on the concept of inpatient early CI rehabilitation showed that this is feasible and safe as follow-up rehabilitation (AHB). The decisive advantage of this rehabilitation concept is that it enables a significant reduction in the waiting time for the start of rehabilitation. This leads to a prompt improvement in speech comprehension and earlier reintegration into work and everyday life for the patient.

Introduction of CI rehabilitation as AHB

In September 2024, CI rehabilitation was included in the AHB indication catalogue after the results of the pilot study were reviewed by the Medical Service [4]. This means that the approval process can now be significantly simplified and accelerated.

The prerequisite for the implementation of AHB is an assessment of the CI patientʼs suitability for such a rehabilitation procedure by the attending physician. The main basis for this is the ENT specialistʼs assessment of the surgical wound, the implant site with regard to the postoperative swelling of the scalp, the presence of complications such as neuro-otological impairments (dizziness, tinnitus or loss of residual hearing), cranial nerve dysfunction (facial nerve palsy) or other cranio-cervical dysfunctions. The cognitive and psychosocial rehabilitation ability must also be checked. This “approval” for rehabilitation is given by the CI-specialised ENT specialist at CIVE as part of the basic CI therapy. This non-delegable task of the CIVE, which is relevant for ensuring the quality of care, has been part of the current CI guideline of the AWMF since 2020 [1]. Furthermore, the initial fitting of the CI processor must be carried out as part of the basic therapy in the CIVE before the AHB programme begins [4].

CI early rehabilitation as AHB can be applied for as a fast-track or direct initiation procedure via the social services of the implanting clinic. This takes place during the inpatient stay after CI surgery. The AHB application (form G0250) and the medical part of the report of findings (form G0260) are sent.

The social services department also selects the rehabilitation clinic where the AHB is to be carried out. To ensure that a bed can be reserved there in good time within the 14 days, it should be discussed with the patients before the implantation, preferably when the date of the operation is set, whether they wish to undergo AHB. If so, the rehabilitation clinic should be informed so that a bed can be made available in good time.

A decisive advantage of carrying out CI rehabilitation as AHB immediately after basic therapy is the significant reduction in the waiting time between CI surgery and rehabilitation measures. This enables patients to improve their hearing and speech comprehension much earlier. In addition to these obvious advantages for patients, the positive health economic effect must also be taken into account. The earlier improvement in hearing with immediate AHB also allows earlier reintegration into vocational activity. In addition, the application process and the initiation of CI rehabilitation as an AHB through the direct initiation procedure is much easier administratively than the previous application process. This saves time and costs for all parties involved.

The inclusion of CI rehabilitation in the AHB catalogue is not intended to replace the existing rehabilitation concepts, but to supplement them. In principle, this concept enables early CI rehabilitation for every patient, depending on individual requirements, but it should be noted that not every patient is suitable for AHB. For example, pronounced post-operative swelling resulting from the CI operation can severely compromise the technical fitting of the CI processor or even endanger the integrity of the implant and the health of the patient (skin necrosis and risk of implant loss). In some cases, it may take several weeks for the swelling to subside sufficiently before the CI processor can be activated and fitted. The individual suitability of a patient for CI-AHB must therefore be assessed by the ENT specialist at CIVE as part of the basic therapy (initial fitting). The initial activation of the CI system and the assessment for the initiation of suitable rehabilitation measures is a central part of the basic therapy and therefore a non-delegable task of the CIVE.

Outlook

The realisation of CI rehabilitation as AHB requires a number of structural prerequisites. Firstly, the rehabilitation centre must meet the requirements profile of the DRV and be able to offer CI rehabilitation as an inpatient or all-day outpatient concept. Secondly, the DRV must be authorised to carry out rehabilitation as AHB in accordance with the requirements profile [11]. Furthermore, adjustments in the process of initiating the rehabilitation measure on the part of the CIVE are necessary (e. g. contacting the rehabilitation clinic and booking an admission appointment before the operation, involving the clinicʼs social services during the inpatient stay to fill out the necessary AHB forms), as well as in the rehabilitation facilities. For example, the rehabilitation centre must be able to provide rehabilitation places for suitable patients at very short notice.

To date, the costs of AHB have only been covered for insured persons for whom the DRV is the cost bearer for the rehabilitation programme. As a rule, however, the statutory health insurance funds (German: “Gesetzliche Krankenversicherung”, GKV) and accident insurers as well as the “Beihilfestellen” agree to the AHB catalogue of the DRV; in individual cases (e. g. if it is unclear who is the cost bearer), it may be advisable to consult the cost bearer.

AHB is a particular advantage for those with private health insurance: inpatient rehabilitation measures that are not listed in the AHB catalogue of the DRV are often assessed by private health insurers (German: “Private Krankenversicherung”, PKV) as “sanatorium treatment” and the costs are refused. If the rehabilitation measure is listed in the AHB catalogue, the rehabilitation measure is regarded as “hospital treatment” and the PKV usually covers the costs, unless the PKV policyholders have contractually agreed otherwise.

At the time of writing this article, CI rehabilitation as AHB is therefore guaranteed for all patients for whom the DRV is the payer. For other cost bearers, the assumption of costs for AHB is not yet formally secured, but a rejection is generally not to be expected, as it is considered a consensus that the AHB indication catalogue is accepted by all rehab bearers.

The structural change is currently in a transitional phase until the necessary organisational and structural processes have been fully fitted by all those involved in the process, i. e. in particular the cost bearers. This will be the indispensable prerequisite for ensuring that all patients, regardless of the individual cost bearer, actually benefit from the advantages of the AHB procedure.

In the future, the inclusion of CI rehabilitation in the AHB catalogue, and thus the concept of early CI rehabilitation, should also be included in the future revision of the CI guideline and the CI White Paper. In addition, a scientific evaluation of the psychosocial and economic effects, for example on quality of life or employability, should be carried out in further studies.

In the future, the concept of AHB could also be applied to other areas of ENT, such as rehabilitation measures after sudden hearing loss or dizziness. As shown in this article, extensive scientific preparatory work is required for this.

The inclusion of CI rehabilitation in the AHB catalogue offers considerable advantages for newly implanted CI patients or for patients following revision surgery. If there is a medical and audiological indication, the combination with an early fitting will considerably speed up the treatment process. This simplifies the necessary administrative procedures. Overall, the inclusion of CI rehabilitation in the AHB catalogue therefore represents a considerable improvement in the processes associated with CI treatment for the payers, the CI-providing facilities, the rehabilitation facilities and especially for the patients.

Summary

• CI rehabilitation as AHB is possible after CI provision since 09/2024

• Prerequisite:

  • CI rehabilitation can be started within 14 days after discharge

  • (Early) fitting of the CI processor has been completed

  • Suitability of the patient for AHB confirmed by an ENT-specialist (CIVE)

• AHB is initiated via the CIVE social services

• The rehabilitation facility must have organisational structures that enable CI rehabilitation as AHB:

  • Inpatient or all-day outpatient concept

Conflict of Interest

The authors declare that they have no conflict of interest.

Acknowledgement

We would like to thank the DRV Bund and DRV Hessen, as well as the Knappschaft Bahn/See and Deutsche Angestellten Kasse (DAK) for their support of the pilot project on the “Frankfurt Concept for Inpatient Early Cochlear Implant Rehabilitation”. We would also like to thank all patients for their participation in the study.

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Publication History

Article published online:
05 May 2025