Rehabilitation service delivery: audit tool for best practice

4. Rehabilitation care, treatment, and outcome

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.

This template requires the service to be rated. Because it addresses the activities and inputs of the rehabilitation service, the person, people, or team may vary depending on the service model and setting. For example, the service may be provided in a day rehabilitation program, in-reach rehabilitation, or rehabilitation in the home. If there are multiple settings, apply the rating scale to each setting, if appropriate. (The decision to score settings individually is at the discretion of the working group.) 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

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

2.	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

4. Rehabilitation care, treatment, and outcomes

Organisation/health service: Date:

Team/s:

No.	Core elements	Service rating N/A 0 1 2 3 4	Supporting evidence
Communication
4.1	All client documentation and medical records are readily available to all members of the care team.
4.2	The client and their carers are informed of the optimal and predicted length of stay within 24-48 hours of admission to the rehabilitation care setting. Any change to this length of stay is immediately communicated to the patient and carers.
4.3	There is a documented process to facilitate easy access to the clinical team for carers. This may include the use of a key person role. (See below under Care coordination).

Communication action plan

Date:

Core element #	Area for improvement	Action/s	Person responsible	Date due

No.	Core elements	Service rating N/A 0 1 2 3 4	Supporting evidence
Goal-directed care plans
4.4	Each client has a documented goal-directed care plan that includes medical, nursing and allied healthcare.
4.5	The care plan includes client-centred goals, realistic time frames and strategies for goal attainment.
4.6	Care plans are regularly reviewed and updated with input by all members of the care team (including medical, allied health and nursing).
4.7	Care plans are reviewed and updated in collaboration with the client and their carers.
4.8	In the inpatient setting, each client contributes to the development of their daily timetable of therapy and activities and is provided with a copy.

Goal-directed care plans action plan

Date:

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

No.	Core elements	Service rating N/A 0 1 2 3 4	Supporting evidence
Self-management
4.9	Self-management is facilitated by the clinical team, e.g. patient education, peer support programs, coaching, etc.
4.10	Individualised approaches are used with each patient based on an assessment of the client’s: readiness to participate current self-management knowledge, skills and priorities health literacy, ability to learn and engage in self-management. Note: Rate each sub-question separately.
4.11	Self-directed activities are routinely included as part of the rehabilitation care plan.
4.12	The client is provided with daily opportunities for semi-supervised or independent practice as part of their rehabilitation care.
4.13	Where appropriate, day, evening, overnight or weekend leave is used to facilitate the development of self-management skills.
4.14	Clients are encouraged to take an active role in identifying and selecting external providers for use on discharge, e.g. community programs (where applicable).
4.15	Clients are encouraged to review their rehabilitation program against their goals and make decisions in relation to future needs.

Self-management action plan

Date:

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

No.	Core elements	Service rating N/A 0 1 2 3 4	Supporting evidence
Person-centred care, treatment and shared decision making
4.16	The rehabilitation service delivers care in an inclusive, non-judgmental manner that ensures all people feel safe and supported in their rehabilitation program.
4.17	The client is encouraged to articulate their valued activities, people, places, cultural background and beliefs as part of assessment, treatment and ongoing education.
4.18	The client and their carers develop person-centred rehabilitation goals with the clinical team upon admission using a shared decision-making framework.
4.19	Evidence-based treatment approaches to meet identified goals are discussed and the program agreed with the client and their carers.
4.20	Clients are provided therapy by the most appropriate members of the allied health team required to meet their identified goals. This includes physiotherapy, dietetics, occupational therapy, speech pathology, clinical psychology and neuropsychology, social work, prosthetics and orthoptics.
4.21	Regular review of a client’s rehabilitation program is undertaken to ensure that rehabilitation is being provided in the most appropriate setting and intensity for their needs and circumstances.
4.22	Rehabilitation goals are regularly reviewed and updated throughout a client’s rehabilitation program.
4.23	Rehabilitation is conducted at an intensity and level of complexity suitable to the client and their goals.
4.24	Vocational rehabilitation and support to return to work is provided in accordance with the person’s goals, as required.
4.25	In the in-reach and inpatient settings, experienced rehabilitation nurses are available on all shifts.
4.26	Rehabilitation nurses work with clients to increase the intensity of rehabilitation activity by using and reinforcing on-the-spot goals negotiated with the client.
4.27	Within the inpatient setting, staff facilitate an environment where peer interaction, support and mentoring are encouraged, and clients provide support to each other, e.g. the use of shared living arrangements and small group programs.
4.28	Potential barriers to client communication are identified and alternative methods of communication used, as required.
4.29	The clinical team provides support to those who have communication challenges, as required. This may include speech pathology, the use of interpreters and alternative technology.

Person-centred care, treatment and shared decision-making action plan

Date:

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

No.	Core elements	Service rating N/A 0 1 2 3 4	Supporting evidence
Client education
4.30	An orientation package is provided to all clients when they are accepted into a rehabilitation program.
4.31	Clients are educated about the need to be proactively engaged in the rehabilitation process prior to admission. This is reinforced over the course of admission.
4.32	Clients and carers are educated about the benefits and risks (where applicable) of different interventions.
4.33	Clients and carers are provided with education on the different settings of care and empowered to make their own decisions on the most appropriate setting of care (where clinically appropriate).
4.34	Staff have a shared understanding of the need for all clients to have time to process information, cognitively reframe and build resilience as a part of their rehabilitation program.
4.35	Education is tailored to the client to ensure different cultural and learning styles are considered. This may include the use of different mediums and different time intervals for delivering information.
4.36	Clients and carer are asked for feedback on education provided and level of information that is understood.

Client education action plan

Date:

Core element #	Area for improvement	Action/s	Person responsible

No.	Core elements	Service rating N/A 0 1 2 3 4	Supporting evidence
Care coordination
4.37	The clinical team includes a dedicated case management, care coordination or key person role to ensure coordinated continuity of care across the service settings and communication with the client and their carers.
4.38	Where required, case management is flexible, reinforcing and fostering the development of a client’s self-management skills.

Care coordination action plan

Date:

Core element #	Area for improvement	Action/s	Person responsible	Date due

Outcome measurements
For the purposes of this section, the following definitions are used: Standardised functional measures: clinician obtained measures that quantify a client’s performance of particular tasks and activities, e.g. the Berg balance scale, timed up and go test Patient reported outcome measures (PROMs): measures that capture the patient’s perspective about how illness or care impacts on their health and wellbeing Patient reported experience measures (PREMs): measures that capture the patient’s perception of their experience with the healthcare provided by services. Continue to use the rating scale N/A 0 1 2 3 4.

No.	Core elements	Service rating N/A 0 1 2 3 4	Supporting evidence
4.39	The rehabilitation service uses a range of standardised functional measures in alignment with all components of the World Health Organization International Classification on Functioning, Disability and Health.
4.40	Standardised functional measures are used to monitor the client’s progress. At a minimum, measures are recorded at admission and discharge, with documented procedures for intermittent measures set by the service.
4.41	Services have a documented process detailing which outcome and experience measures are to be used for specific patient cohorts, conditions and treatments.
4.42	Services have a documented process detailing how outcome and experience measures are to be documented and followed up.
4.43	Results of functional measures are communicated to the client after each measurement.
4.44	Patient reported outcome measures (PROMs) and patient reported experience measures (PREMs) are routinely captured and used by the clinical team for the purposes of care planning.
4.45	Individual and collective results of patient/service outcomes, PREMs/PROMs are reviewed by the treating team and opportunities for improvement identified (e.g. participation in Australasian Rehabilitation Outcomes Centre benchmarking.

Outcome measures core elements action plan

Date:

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

No.	Core elements	Service rating N/A 0 1 2 3 4	Supporting evidence
Culturally appropriate care
4.46	Rehabilitation care is designed and delivered in a culturally appropriate manner for those clients who identify as Aboriginal and Torres Strait Islander. Refer to My rehab, my journey.
4.47	Aboriginal liaison officers are involved in the care of people who identify as Aboriginal and/or Torres Strait Islander.
4.48	Rehabilitation care is designed and delivered in a culturally appropriate manner for those clients from culturally and linguistically diverse backgrounds, including the use of multicultural health services and interpreters where required.

Culturally appropriate care action plan

Date:

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

No.	Core elements	Service rating N/A 0 1 2 3 4	Supporting evidence
Behaviour support
4.49	A process is in place to identify clients in need of a structured behaviour support framework to enable positive change for those clients who exhibit behaviours of concern.
4.50	Rehabilitation services have access to a clinician trained in positive behaviour support to complete functional assessments, develop behaviour support plans and train and support staff.
4.51	Where a behaviour support plan is required, this plan includes least restrictive practices, the use of positive reinforcement and fosters the development of self-regulation skills.

Behaviour support 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 978-1-76023-652-6 [ACI_4923]

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