Rehabilitation service delivery: audit tool for best practice

5. Access, equity and patient flow

This is one of eight audit templates that form the Rehabilitation service delivery: audit tool for best practice.

This tool enables rehabilitation services to plan and review their practice to identify areas that will improve service delivery and patient outcomes. It can also be useful for teams involved in planning and establishing new rehabilitation services.

The responsibilities of the organisation and the service need to be rated. Some of the core elements are solely organisational responsibilities. Others are rehabilitation service responsibilities or dual responsibilities.

The template is for the local health district, specialty health network, affiliated health organisation and/or the private health provider of rehabilitation services. The organisation or rehabilitation service should complete the areas in the template that have been left unshaded. The people or team may vary depending on the service model and setting. For the best result, involve a range of staff in the discussions.

Core element rating scale

N/A	0	1	2	3	4
Not applicable	Not achieved	Rarely achieved	Sometimes achieved	Often achieved	Always achieved

Instructions

After discussing each core element with members of the working group, agree on the rating, and note the evidence to support this rating.

Use the action plans to note areas for improvement, key actions and who is responsible.

For more information about the audit tool, visit: https://aci.health.nsw.gov.au/networks/rehabilitation/resources/audit-tool

5. Access, equity and patient flow

Organisation/health service: Date:

Team/s:

No.	Core elements	Organisational rating N/A 0 1 2 3 4	Service rating N/A 0 1 2 3 4	Supporting evidence
Access and equity
5.1	The organisation provides access and referral pathways to a continuum of care that includes all rehabilitation settings, e.g. in-reach, inpatient, day programs and community-based ambulatory rehabilitation ensuring optimal efficiency, patient outcomes and experience.
5.2	Local processes ensure patients are referred to rehabilitation as early as possible in their hospital admission.
5.3	Once a person is accepted into a rehabilitation program, minimal delays are experienced in admitting them into that program.
5.4	Admission criteria for each rehabilitation setting or program are clearly documented.
5.5	These documented admission criteria and referral processes are communicated to: acute care teams local primary health providers. Note: rate each sub-question separately.
5.6	Information on types of rehabilitation and documented admission criteria is publicly available in a variety of common languages for consumers.
5.7	A clear and transparent process is in place to review non-accepted referrals and provide alternative options for ongoing care.

Access and equity action plan

Date:

Core element #	Area for improvement	Action/s	Person responsible	Due date

No.	Core elements	Organisational rating N/A 0 1 2 3 4	Service rating N/A 0 1 2 3 4	Supporting evidence
Patient flow
5.8	The rehabilitation service has a system for determining a person’s optimal length of stay, e.g. Australian Rehabilitation Outcomes Centre (AROC) benchmarks.
5.9	The optimal length of stay is informed by input from all members of a person’s care team.
5.10	Length of stay is benchmarked with other rehabilitation programs via AROC.
5.11	Memorandums of understanding, statements of commitment, interagency agreements and employment contracts are in place for the purposes of formalising relationships with key stakeholders. This may include local National Disability Insurance Scheme (NDIS) providers, icare, private rehabilitation facilities and aged health providers.
5.12	Processes are in place for prompt liaison with icare once eligible patients are admitted into a rehabilitation program.
5.13	Processes are in place to ensure NDIS eligible patients are identified as early as possible in the patient journey and funding is applied for.
5.14	A clearly documented process for guardianship is in place, including appropriate consideration of a person’s capacity.
5.15	Data relating to discharge delays is captured and regularly reported, e.g. NDIS, aged care delays.
5.16	Data on discharge delays is reviewed and used to identify and resolve systemic barriers to timely discharge.

Patient flow action plan

Date:

Core element #	Area for improvement	Action/s	Person responsible	Due date

Published November 2023. Next review 2028. ACI/D23/3804 (ACI) SHPN (ACI) 230798-1 ISBN 978-1-76023-657-1 [ACI_4923]

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