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Rehabilitation Patient Journey

Five key components of the patient journey common to all care settings have been established as part of the NSW Rehabilitation Model of Care.

Referral, access and initial contact
  • A standardised referral form and/or process for rehabilitation consultation and services
  • Early intervention practices for therapy to reduce functional decline
'Ready for rehabilitation' criteria
  • Guidelines for establishing when patients are 'ready for rehabilitation' against each care setting
Eligibility criteria
  • Eligibility refers to the extent to which services are provided only when they are needed. In the instance of rehabilitation services it requires an assessment of the value of rehabilitation in terms of the patient’s potential for rehabilitation. Organisations are responsible for determining eligibility/admission criteria and a process for appropriateness of patient admission to rehabilitation
  • Guidelines for a trial of rehabilitation
Waiting list management
  • A process for rehabilitation services access management
Transfer of care
  • A list of appropriate needs for the successful preparation for transfer of care to a rehabilitation service and within different rehabilitation care settings
Communication with patients and family
  • Standards for effective communication
  • Approach to management of patient carer expectations
Assessment on Admission
Clinical handover
  • Clinical handover standards to support continuity of care and patient safety
  • A standard process for assessment by core multidisciplinary teams
  • Assessment tools covering physical, psychological and social needs
  • Referral process for specialist therapist consultations and levels of prioritisation for these services
Transfer of care
  • Inclusion of transfer of care planning in the initial assessment
Rehabilitation planning
Case management
  • Goal setting: patient centred and communicated in a tangible way time limited and regularly reviewed
  • Protocolised care plans for patients with similar conditions e.g. post hip and knee replacement
  • Case conferencing is multidisciplinary, documented, frequent and supported by other informal communication processes
  • Case coordinators or key person allocated to each client to coordinate care across the continuum. A single point of contact for the client, family, carer, the multidisciplinary team and other service providers
Patient and carer involvement
  • Guidelines for the provision of information and education to clients, their families and carers to assist them to understand and participate in their care
Service delivery
  • Defined philosophy of therapy delivery that aligns to current good practice evidence, guidelines and standards
  • Manage intensity of therapy:
    • Type: one-on-one therapy, group therapy and self management
    • Timing, duration and frequency
    • Continuity across settings
    • Continuity over the weekend
Transfer of care, follow-up & re-entry
Transfer of care
  • Readiness for transfer criteria
  • Comprehensive discharge information for primary and community care services
Community support services and primary care
  • Integration and communication across non-government organisation, state government, federal government and private services to support continuity of care
  • Implementation of follow-up via appointment or telephone
  • Planned vs unplanned: distinguishing between these two purposes and monitoring occurrences will inform future service delivery

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