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NSW Rehabilitation Model of Care

The NSW Rehabilitation Model of Care describes six care settings in which rehabilitation services are delivered: in-reach to acute care, inpatient subacute, day hospital, outpatients, home based and outreach rehabilitation. It also outlines eight guiding principles and enablers for rehabilitation services that underpin the Model.

NSW Rehabilitation Model of Care (PDF Document - 1.8 MB)

Rehabilitation Patient Stories


Implementation of the NSW Rehabilitation Model of Care will improve patient outcomes, service delivery, efficiencies and collaboration with health care providers across the health system.

The implementation of the Model of Care will include four key deliverables:

  • Establish governance
  • Gap analysis and implementation of the eight good practice principles across six care settings
  • Status of current system activity, utilisation and demand
  • Realignment of services to meet demands

Implementation Toolkit


The NSW Rehabilitation Model of Care consists of eight good practice principles.

  • Leadership
  • Equitable access
  • Multidisciplinary care teams
  • Care coordination
  • Patient centred care
  • Evidence based care
  • Appropriate care setting
  • Clinical process and outcome indicator

Care Settings

Each good practice principle is applicable across six defined care settings. The new Model of Care will define the intensity of therapy at each setting.

  • Inreach to acute
  • Sub-acute inpatient
  • Ambulatory care - Day hospital
  • Ambulatory care - Outpatients
  • Ambulatory care - Home based
  • Outreach

Patient Journey

There are five key components of the patient journey common to all care settings:

  • Referrals
  • Access and initial contact
  • Rehabilitation assessment on admission
  • Service delivery
  • Discharge and follow-up

See also: Rehabilitation Patient Stories.


Enablers describe the components of the model that are required to support implementation.

  • Workforce
  • Data and performance improvement
  • Care coordination and linkages
  • Technology
  • Appropriate infrastructure

Project Resources


Louise Sellars and Jamie Macdonald
Co-Managers Rehabilitation Network
NSW Agency for Clinical Innovation
Ph: 02 9464 4639

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