What is it
Aged health rehabilitation models describe the journey that an older person takes from an acute episode to return to a previous residence and, where possible, to independent living. All programs use a process of interdisciplinary evaluation and management to deal with the healthcare issues of sick, older persons.
How it works
The model’s integrated components include acute assessment and treatment with the establishment of a care plan, enablement goals, rehabilitation and a discharge plan.
The rehabilitation philosophy is one of enablement from early in a patient journey. Delay in rehabilitation or services that are disconnected are clinically proven to increase functional decline and increase length of stay.
This model is dependent on the availability of rehabilitation trained allied health and nursing staff and a geriatrician or rehabilitation physician. Therapy aids and assistants in nursing are highly useful resources in maintaining or encouraging patient mobility. The resourcing requirements vary based on care setting.
- Strong geriatrician/rehabilitation physician leadership
- Enablement philosophy from the acute ward onwards (e.g. ACE, OPERA)
- Quarantined allied health staff to deliver appropriate intensity of therapy
- Seven-day care models that avoid deterioration
- Goal-oriented to independent living and what that means for each individual.
Models in operation
- In-reach to acute geriatric rehabilitation inpatient unit - Concord
- Rehabilitation Day Hospital - Westmead, Concord
- Home-based rehabilitation – Hornsby, Concord
Note: Transitional Aged Care Program is a Commonwealth Department of Health funded variation on this model
- Outpatient clinics; Outreach/slow stream rehab or support at outlying facilities – Nepean
See NSW Rehabilitation Model of Care for detail.