NSW Rehabilitation Model of Care Enablers
Enablers describe the components of the NSW Rehabilitation Model of Care that are required to support implementation. The enablers in the Model are: Workforce, Data and performance improvement, Role of Research, Care coordination and linkages, Technology and Appropriate infrastructure.
Rehabilitation requires a multidisciplinary workforce to enable improvement in patient functioning and successful achievement of goals. For all staffing categories (medical, allied health and nursing), the demand for services and the patient mix should determine the requirement for staff with particular qualifications and skills. Sufficient staffing to meet the demand and capability requirements of patients impacts directly on delivery of high quality patient care and intensity of therapy.
Rehabilitation services are moving towards interdisciplinary teamwork where staff focus across multiple therapy disciplines and share a common patient population, common patient care goals and have responsibility for complementary tasks. The team is actively interdependent.
Interdisciplinary care crosses traditional boundaries and blends the practices and expertise of each discipline involved. Interdisciplinary care can further enhance a patient centred care approach and reduce duplicative assessments.
Furthermore some health teams are transitioning to transdisciplinary care. This involves a team of professionals who work together to share knowledge and skills across disciplines.
Transdisciplinary teamwork improves communication and cooperation, and provides integrated care to the clinic’s patients. The aspect of transdisciplinary care that distinguishes it from all other team models is its emphasis on cross-training. Rehabilitation services must consider how to use the skills and talents of the current workforce to their best advantage.
Data and Performance Improvement
Information and data management are used to assist services to understand and meet their operational and strategic objectives. Furthermore information and data are used to effectively support and improve performance as related to rehabilitation care and service delivery.
Robust performance monitoring and evaluation processes are informed by data collection, analysis, and tracking over time. Data collection contributes to the development of an evidence-based understanding of the quality of a rehabilitation service by measuring it against common standards of care. The use of ‘uniform outcomes measurement, group benchmarking and data-driven hospital-specific strategies for change’ can facilitate continuous improvement.
To determine the effectiveness and efficiency of a rehabilitation service there are a number of levels at which performance should be measured:
- Individual clinician level – to measure and improve the care provided by a clinician. Individual clinicians can review their performance through several processes including clinical audit, peer review and patient outcome data that has been attributed to individual clinicians.
- Clinical team or unit level – teams should discuss the data collected on each indicator and identify areas of practice variation that require investigation. Clinical teams should review local performance and as far as possible compare this performance to other peer services and past performance. A review of data reported to AROC and the ACHS (via the rehabilitation clinical indicators) is one mechanism in which services can review performance and identify local outliers or issues and areas for improvement.
- Hospital / organisation level – data can flag issues that will need organisational investigation using a scientific method and protocol alteration. Services should report data to their local hospital or organisation as agreed. These data may include activity data (including: length of stay, occasions of service, impairment type, number of transfers), and performance data (including: adverse events, waiting for rehabilitation times, patient satisfaction).
- State / territory and national levels – for the purposes of identifying the need for improved government policy and strategies. NSW Health data collection for rehabilitation services is via Synaptix and HIE. Data is currently collected at a national level in relation to rehabilitation through AROC (via SNAP) for subacute rehabilitation units only. AROC have commenced collecting data for ambulatory care services and services should be encouraged to participate in this data collection and provide feedback to AROC in relation to their needs.
Role of Research
Research occurring within clinical units has been demonstrated to improve the quality of clinical outcomes for patients treated in that unit. Teams undertaking research generally feel more pride in their work, and feel that they are part of a specialist or expert team. Knowledge of individual clinicians is improved, and networking opportunities are expanded.
Having data collection infrastructure in a unit expands research opportunities for teams working in that unit. Rehabilitation clinicians and units should have a philosophy of considering/undertaking research activities, especially if they are undertaking interventions/processes which they believe are unique or innovative.
Care coordination and linkages
The primary goal of rehabilitation services is to support the restoration of function and self-sufficiency to the level prior to that illness or injury within the constraints of the medical prognosis for improvement. Linkages with support services that exist within the community are essential in safely transitioning a person back to their previous residence with functional independence.
Clear linkages and formal processes for coordination should cover the following categories:
Clinical support services
- Access to support services including pathology, radiology and pharmacy are required to provide a clinical service.
External and community support services
- Building strong linkages across the acute and community services sector is a critical success factor to improving access to the envisioned NSW Rehabilitation Model of Care into the future.
- A primary goal for sub-acute services is to improve a patient’s function with the aim of the patient returning home with as much functional independence as possible. Integration with community support services is essential in ensuring a patient’s successful transition from hospital to home.
- Community support services include services such as the Transition Aged Care Program, Home and Community Care, ComPacks, Ageing Disability and Home Care, Aged Care Assessment Teams and primary health services.
- Arrangements should be made with other service providers prior to transfer and relevant patient information made available to those service providers.
- A statewide view of availability of transport will support ease of transfer between city and country and tertiary and general rehabilitation services and enable care to be provide in the most appropriate setting
- Further timely access to home modification services and specific equipment is crucial to ensuring a patients transition to home on the expected date. As far as possible where these services are required the process for modification or acquisition should be initiated on admission to prevent delay.
Individual clinicians and team/units, work most effectively when links and networks are efficient and effective. Further to the linkages mentioned above, there are a range of other linkages which are invaluable in improving the quality of service, and the quality of patient experience. Examples include: consumer advocacy groups, universities/research institutions/teaching institutions, professional organisations (eg, Rehabilitation Nurses Association, Stroke Services NSW).
Specialised services provide support for patients with particular impairments or needs. In the case of patients with spinal or brain injury who are not treated in specialised units, access to spinal or brain injury outreach services and specialist medical expertise in these areas is required. Local services should build links with state-wide services in these areas are applicable.
Specialised services such as driving assessments and sexuality clinics are presently only available in limited places. These specialised services assist patients with specific individual needs or goals. Access to these services can be costly and clear eligibility/admission criteria are essential. Access should not be determined by individual financial status. Referral to these services may be coordinated through the local service or at the local Health District level where the patient is receiving treatment.
Technology has a role in enhancing the effectiveness of rehabilitation service delivery in the future. Specifically this relates to:
- Use of video conferencing and teleconferencing to facilitate communication between health care professionals particularly in outreach models or where additional clinical expertise is required
- Information and communication systems to support information sharing across care settings between service providers and across geographical boundaries. Information systems must support the collection of a minimum dataset for tracking patients and activity, and for collecting appropriate data to monitor the effectiveness and outcomes of rehabilitation services. The system should have links to the LHD systems and provide a way of tracking individual patients across different care settings and the broader health system.
We have received feedback that another enabler to implementation is infrastructure. Infrastructure includes the provision of buildings with suitable disabled access and gym space along with suitable equipment. The infrastructure and equipment required to provide effective rehabilitation will vary according to the patient mix and types of services provided. As the complexity of a service increases the range and level of equipment, infrastructure and therapy areas would be expected to increase. The setting in which the rehabilitation service is provided also impacts on the infrastructure and equipment required.