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NSW Rehabilitation Model of Care - Care Settings

The NSW Rehabilitation Model of Care encompasses six care settings as identified below.

1. Inreach to acute

  • Early intervention - potential to maintain and improve function
  • Integrated medical and rehabilitation multidisciplinary team
  • Comprehensive assessment
  • Shared care model between medical specialist groups
  • Can treat acute illness and provide rehabilitation services in parallel

Care setting 1: Inreach to acute (PDF Document - 99.5 KB)

2. Sub-acute inpatient

  • Access to a core multidisciplinary care team (medical, nursing and therapist) and access to other specialised services as required in an inpatient setting
  • Intensive multidisciplinary inpatient program for patients that require and can tolerate an intense rehabilitation program or who require the structured environment for safety reasons
  • Provision of one-on-one therapy, group therapy and client self management / family involvement in the therapy program
  • Dependant on the capacity and capability of the unit the following may be characteristics of the sub-acute care setting:
    • Streaming of care, where patients are grouped according to impairment type
    • Integrated care types for example: acute care and rehabilitation care (i.e. inreach teams and SMART beds); rehabilitation care and aged care (i.e. parallel care for orthogeriatrics).

Care setting 2: sub-acute inpatient (PDF Document - 104.1 KB)

3. Ambulatory care - day hospital

  • Intensive multi-disciplinary outpatient program for patients that requires two or more therapy appointments
  • One-on-one therapy and/or group therapy treatment session

Care setting 3: ambulatory care - day hospital (PDF Document - 97.4 KB)

4. Ambulatory care - outpatients

  • One-on-one or group therapy - discipline specific outpatient therapy
  • Access to a multidisciplinary team as required

Care setting 4: ambulatory care - outpatients (PDF Document - 85.1 KB)

5. Ambulatory care - home based

  • Provision of rehabilitation therapy within the home (usual place of residence) environment
  • Individualised and task specific therapy

Care setting 5: ambulatory care - home based (PDF Document - 97.8 KB)

6. Outreach

  • Hub and Spoke model between regional and tertiary hospitals or regional and smaller neighbouring rural hospitals
  • The outreach model may be a Consultative Model (where the hub site provides advice and support to neighbouring hospitals as required) or a Collaborative Model (where the hub site and neighbouring hospitals work together to provide a rehabilitation program for patients). Both models may run simultaneously or separately
  • Outreach coordinator and rehabilitation team collaborate with neighbouring hospital to facilitate ongoing rehabilitation and goal attainment
  • Ongoing education from the hub site to spoke hospital staff (via various mechanisms including telephone, or onsite at either hospital)
  • Collaborative rehabilitation care approach between the hub hospital and the neighbouring hospitals
  • Involvement of the general practitioner as a key coordination link for the client who is undertaking a rehabilitation program where there is limited access to Rehabilitation and Aged Care physicians. 'Hub' and 'spoke' model in which rehabilitation is provided outside a specialised rehabilitation unit.

Care setting 6: outreach (PDF Document - 104.5 KB)

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