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Flag and Track

Hunter New England Local Health District
Project Added:
8 May 2012
Last updated:
30 September 2014

Flag and Track

By Helen Baines, Kathy Bullen, Judith Dunne, Robyn Walker, Michael Pollack
Hunter New England Local Health District


The aim of the Flag and Track program is to provide the opportunity for stroke patients to be reassessed for suitability to undertake a rehabilitation program to improve their quality of life.

The program was implemented to follow up patients (approximately 8-12 weeks post stroke), to assess if any natural recovery had been made and the opportunity for an inpatient rehabilitation program was deemed appropriate.

Some patients who had suffered a severe stroke were not given an opportunity to participate in a formal rehabilitation program as deemed unsuitable on initial assessment. These patients were then transferred directly from the acute hospital setting to residential care.

There is evidence that suggests some patients may require time to naturally recover before they show signs of improvement. These patients may then be suitable candidates to participate in a rehabilitation program.

Tracking for Improvement (PDF File pdf - 410 KB)

Poster presentation from "Nursing and Midwifery 6th Annual Showcase in Clinical Innovations", HNE LHD, March 2012.


Rehabilitation Clinical Nurse Consultants (CNCs) in conjunction with Rehabilitation Consultants have designed a 'Flagging and Tracking' process that allows the rehabilitation consultant to identify suitable patients. A guideline has been developed to ensure continuous tracking and follow up of patients. Flag and Track Programme Local Guideline (PDF File pdf - 300 KB)


  1. Rehabilitation Physician identifies patient as not suitable for inpatient rehabilitation
  2. CNC Referral
  3. Identify goals and time frame
  4. CNC to send letter to General Practitioner (GP) to advise of program


  1. Enter patient into electronic record
  2. Contact made via phone to Residential Aged Care Facility
  3. Comprehensive assessment of patient
  4. Admission to Rankin Park centre / Recommendations to Aged Care Facility


Once the referral has been received the nurse will then arrange for follow up assessment. It is the CNCs responsibility to maintain contact with the patient's GP, place of residence, primary carer and the patient. This involves follow up assessments and communication of the outcome(s) to the referring consultant and GP.

All communication made is entered into the online documentation system. This allows other health professionals to view notes of the assessment recommendations and intervention.

The CNC plays a vital role in assisting the patient and their family through this journey by keeping them informed of the process. Support and education is continually given during this time when patients and the family may feel they 'have missed out' on the opportunity for rehabilitation.


The program has proved to be positive for both patients and carers by providing:

  • An opportunity for reassessment in patient's place of residence post discharge
  • Access to a rehabilitation program once goals are identified
  • An opportunity for the clinician to identify and implement practical solutions that will assist in improving quality of life and functional status
  • Social and emotional benefits of improving confidence and reassurance that a second chance of rehabilitation may be available.

During the course of the program it has become evident that if a patient is declined rehabilitation at initial assessment, then that initial clinical judgement is most likely appropriate.

Referral to the Flag and Track program provides a sense of hope for patients and their families that the opportunity for rehabilitation is still a possibility.

Due to the success of the program it has now been extended to include other neurological disorders such as Parkinson's Disease, Acquired Brain Injury, and Multiple Sclerosis.

Take home messages

  • A comprehensive nursing assessment along with good communication is imperative to ensure patients are provided with a smooth healthcare journey
  • A person centred approach is imperative when assessing patients for rehabilitation
  • Clear guidelines are important to direct and support clinicians that will allow for patients continuity of care.


Clinical Nurse Consultant Rehabilitation
Rankin Park Centre
Hunter New England Local Health District
Phone: 02 4985 5738

Clinical Nurse Consultant Rehabilitation
Rankin Park Centre
Hunter New England Local Health District
Phone: 02 4985 5738

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