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ACI Rehabilitation Implementation

Toolkit

May 2013

AGENCY FOR CLINICAL INNOVATION Level 4, Sage Building 67 Albert Avenue Chatswood NSW 2067 Agency for Clinical Innovation PO Box 699 Chatswood NSW 2057 T +61 2 9464 4666 | F +61 2 9464 4728 E [email protected] | www.aci.health.nsw.gov.au Produced by: Rehabilitation Network Agency for Clinical Innovation Level 4, 67 Albert Ave Chatswood

Tel: +61 2 9464 4666 | Fax: +61 2 9464 4728

First edition: June 2013 SHPN: (ACI) 130181 ISBN: 978-1-74187-909-4 Disclaimer: Content within this publication was accurate at the time of publication. This work is copyright. It may be reproduced in whole or part for study or training purposes subject to the inclusion of an acknowledgment of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above, requires written permission from the Agency for Clinical Innovation. © Agency for Clinical Innovation 2013

http://www.aci.health.nsw.gov.au/

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Table of Contents

Introduction to the toolkit ........................................................................................ 1

Using the NSW Rehabilitation Implementation Toolkit ......................................... 3

Establishing the Implementation Project ............................................................... 5

Define and assess .................................................................................................... 7

Implement and Monitor .......................................................................................... 11

Chapter 1: Across the patient journey ................................................................. 13

A process for appropriate care setting referral ........................................................... 14

Standards for effective communication with patients and families/carers ............... 23

Chapter 2: Referral and admission ....................................................................... 33

Eligibility, admission criteria, and guidelines for ‘ready for rehabilitation’ ............... 34

Referral forms for Rehabilitation services across care settings ................................ 44

Chapter 3: Assessment and service delivery ...................................................... 57

Comprehensive assessment form and tool, for utilisation by a multi-disciplinary

team ................................................................................................................................ 58

An education program for patients receiving rehabilitation services and their

families/carers ............................................................................................................... 68

Chapter 4: Transfer of care / Discharge ............................................................... 76

Transfer of Care / Discharge principles ....................................................................... 77

A process for the transfer of care, including information transfer between care

settings and/or to final discharge destination ............................................................. 83

Appendices ............................................................................................................. 92

Appendix A. Rehabilitation Network Contacts ............................................................ 93

Appendix B. List of tables and figures in the toolkit ................................................... 94

Appendix C. Glossary ................................................................................................... 95

Appendix D: Tools and Resources to implement and monitor .................................. 96

Appendix E. Tools and resources across the patient journey ................................... 97

Appendix F. Tools and resources for referral and admission .................................... 98

Appendix G. Tools and resources for assessment and service delivery ................ 100

Appendix H. Tools and resources for transfer of care / discharge .......................... 101

1

Introduction to the toolkit

The NSW Rehabilitation Model of Care

In 2011 the NSW Rehabilitation Model of Care (MoC) was endorsed by the Director-General, NSW Health, and is relevant to metropolitan, regional and rural areas in NSW. 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 MoC. An overview of the NSW Rehabilitation MoC is provided below in Figure 1.

Figure 1 NSW Rehabilitation Model of Care

The scope of services provided in each care setting, as described in the NSW Rehabilitation Model of Care, is outlined below in Table 1.

Table 1 Care Settings as defined in the NSW Rehabilitation Model of Care

Care setting Scope of services

Inreach to acute

Early rehabilitation intervention by a Multidisciplinary Team (MDT) in an acute care setting

Early intervention

Integrated medical and rehabilitation MDT

Shared care model between medical specialist groups

Can treat acute illness and provide rehabilitation services in parallel

Subacute inpatient

Subacute rehabilitation unit located within or separately to the acute hospital

Access to a core MDT and access to other specialised services as required in an inpatient setting.

Intensive multidisciplinary inpatient program.

Provision of one-on-one therapy, group and client self management / family involvement in the therapy program.

Dependent on the capacity and capability of the unit the following may be characteristics

Principles

1 Leadership2 Equitable access 3 Multidisciplinary care teams

4 Care coordination

Enablers

• Workforce• Data and performance improvement• Care coordination and linkages

• Technology

Care setting 1: Inreach to acute

Care setting 2: Sub-acute inpatient

Care setting 3: Ambulatory care – Day hospital

Care setting 4: Ambulatory care – Outpatients

Care setting 5: Ambulatory care – Home based

Care setting 6: Outreach

5 Patient centred care

6 Evidence based care7 Appropriate care setting 8 Clinical process and outcome indicators

Discharge

Care

setting

Referral

Care

setting

Referral Discharge

Care

setting

Referral Discharge

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Care setting Scope of services

of the sub-acute care setting:

o Streaming of care, where patients are grouped according to impairment type

o Integrated care types for example, acute care and rehabilitation care (i.e. in-reach teams and Specialist Management with Acute Rehabilitation Treatment beds)

Ambulatory care – Day hospital

A comprehensive rehabilitation program conducted by an MDT in an outpatient setting

Intensive multi-disciplinary outpatient program for patients that require two or more therapy appointments

One-on-one therapy and/or group therapy treatment session, may run 5hrs/day for 5 days

Ambulatory care – Outpatients

Discipline specific therapy provided in an outpatient setting

One-on-one or group therapy - discipline specific outpatient therapy

Access to a multidisciplinary team as required

Ambulatory care –Home based

Rehabilitation services provided to patient in the home

Provision of rehabilitation therapy within the home (usual place of residence) environment

Individualised and task specific therapy

Outreach ‘Hub’ and ‘Spoke’ model in which rehabilitation is provided outside a specialised rehabilitation unit

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 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)

Involvement of the GP 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.

Fundamental to the effective and efficient delivery of Rehabilitation Services is that the patient receives ‘the right care in the right place at the right time’. There are overarching key components of the patient journey common to all care settings. As a patient enters rehabilitation and transitions between care settings there is a repeating pattern of the following stages:

1. Referral/admission

2. Assessment/service delivery

3. Discharge/transfer of care

Figure 2 An integrated Rehabilitation Model of Care

Discharge

Care

setting

Referral

Care

setting

Referral Discharge

Care

setting

Referral Discharge

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Using the NSW Rehabilitation Implementation Toolkit

The NSW Rehabilitation Implementation Toolkit (the toolkit) has been developed to facilitate the implementation of the NSW Rehabilitation Model of Care.

The purpose of the toolkit is to assist the Rehabilitation Implementation Leads and other key Local Health District (LHD)

1 stakeholders to understand the value delivered in current care settings and to

identify ‘gaps’ in delivering a service that meets the needs of the local community. Specifically, the Implementation Toolkit focuses on assisting LHDs to identify opportunities to:

1. Enhance current rehabilitation services, enabling them to better meet demand by aligning service delivery to the guiding principles outlined in the Model of Care.

2. Develop and implement additional rehabilitation care settings to meet current and projected demand.

How to use the Toolkit

The toolkit has been designed to assist Rehabilitation Managers and Clinicians adopt a systematic approach to assessing the current rehabilitation service need and implementing a Model of Care that is appropriate for their local context. This document should be read in conjunction with the NSW Rehabilitation Model of Care, using it as a reference point for implementation planning and delivery of the different care settings.

This toolkit provides an approach to assessing the current care settings and developing implementation action plans. It includes the key information and tools to address the gaps identified between the ‘as is’ service delivery and an enhanced Model of Care.

The toolkit is divided into several phases for implementation with suggested activities within each. The implementation planning and activities will be at the discretion of the LHD and be based on the focus of implementation – enhancement of a current care setting vs. implementation of a new care setting. An overview of the sections of the toolkit and phases is below.

1. Implementation Project establishment: this section provides the framework for carrying out the implementation drawing on project management principles.

2. Define and assess: this section provides the steps required to review current activity to understand and confirm what you are trying to achieve based on the ‘gaps’ identified against the Rehabilitation Model of Care. Steps include:

a. Analysing current and projected activity

b. Assessing existing tools, processes and guidelines and incorporating the core elements of ‘good practice’ tools.

c. Developing new tools and resources as required for the implementation of a new rehabilitation service.

The toolkit consists of Chapters aligned to a stage of the patient journey and includes the key processes, tools and guidelines relevant to that stage (see Table 2 for details). The resources and tools are intended to assist LHDs to operationalise an integrated MoC for Rehabilitation.

Each Chapter is organised as follows

Purpose

The core elements for ‘good practice’, as agreed by the ACI Rehabilitation Network Executive.

An assessment tool for each of the eight key processes, tools and guidelines across the MoC.

1 Note: this includes the St Vincent’s Health Network

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____________________________

A set of examples of similar tools across the six care settings implemented locally at a hospital level in NSW, in addition to developed ‘ready to use’ forms for referral, assessment and transfer of care.

Suggested Key Performance Indicators – monitoring metrics that underpin both operational and outcome based performance on that process step and ‘value’ across the MoC.

An action plan to summarise the implementation activities required relevant to that tool or guideline.

Table 2 Rehabilitation Implementation Toolkit tools and guidelines

Toolkit chapters Contents

Chapter 1 – Across the

patient journey 1. A process for appropriate care setting referral

2. Standards for effective communication with patients and families/ carers

Chapter 2 –

Referral/admission 3. Eligibility/ admission criteria, providing criteria for appropriateness of patient

admission to rehabilitation

4. Referral forms for rehabilitation services across care settings

Chapter 3 – Assessment

and service delivery 5. Comprehensive assessment tool for utilisation by an MDT

6. Education programs for patients receiving rehabilitation services

Chapter 4 –

Discharge/transfer of care 7. Discharge principles

8. A process for the transfer of information between care settings

3. Implement and Monitor: in this phase of work you will bring together all the findings from the analysis to complete a detailed plan for implementation. This implementation plan will include the key activities, responsible owners, dates for delivery, risks identified, and a communication plan to complement and assist with implementation.

Key to icons used throughout the document

Throughout the document we recommend a number of reference materials, provide helpful hints and pose questions to assist analysis and implementation. To guide you in identifying these, we have added symbols according to what it is concerned with, as follows:

\

Link to policy, guidelines or other references

Provides references to Local Health District and NSW Health policies and guidelines and to good practice, evidence based documents.

1.1.1.1.1

Helpful hints

These are background information, ideas and suggestions to make implementation easier

1.1.1.1.2

Case studies

Stories from current practice which provide examples of a change or improvement.

1.1.1.1.3

Local tools and resources

A number of tools and templates have been provided in the Appendices. These are not exhaustive; you may need to refer to other relevant documents / guidelines to support implementation.

For For

Questions

A series of questions have been included to assist LHDs to assess their current service.

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Establishing the Implementation Project

Getting started

Before commencing the implementation project, you need to secure the appropriate support from the key stakeholders within the LHD. It is important to engage the LHD Executive and Rehabilitation Clinicians to facilitate the review and implementation of the Model of Care. It is assumed that when using the toolkit LHDs have agreed in principle to consider implementation of the Model of Care.

Engagement across this range of stakeholders is essential to drive decisions and implement changes, while also having access to resources to lead certain activities and deliver the required actions. Consider the following structures and roles for your implementation project. The scale and nature of your implementation project will influence your project structure and roles.

Figure 3 Example project structure and roles

Setting up your implementation project team

Effective leadership, simple governance and clear team accountabilities are crucial for the success of any project. The roles required can be determined by answering the following five questions.

a. Who will manage the day to day activities for the project?

b. Who will be the decision-making body – that is, the group to which you escalate issues, and seek approval to progress?

c. Who will tasks be allocated to for completion?

d. How will executive and clinical support be maintained for this project, and

e. How will a broader selection of stakeholders be involved in formal decision-making?

To help set up the appropriate roles within a workable governance structure, a summary of key team roles is provided below.

Point of contact for sharing implementation experiences with a network of clinical experts and champions

Groups and individuals with direct or indirect interest in the Rehabilitation Model of Care, including staff, other service providers, and patients.

Provides executive leadership and sponsorship. Must have time to dedicate to the implementation project and provide influence where required.

Decision making group, with strong clinical leadership, available to guide strategic direction of the implementation.

Dedicated resource, responsible for day to day project management and achievementimplementing the model on time and within scope

Selected individuals representing a widerange of disciplines and services, with timeavailable to deliver activities within the plan.

Executive Project Sponsor

Steering Committee

Project Manager

Project Team

Agency for Clinical

Innovation –

Rehabilitation

Network Executive

Stakeholders

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Executive Project Sponsor: A person to provide executive leadership and sponsorship should be identified for the implementation project. This person must have the time to dedicate to this project and must be able to provide influence where required.

Steering Committee: There should be a group charged with making final decisions and guiding the strategic direction of the project. Members of this group will be effective champions for the implementation project, and there will be representation across disciplines (e.g. medical, nursing, allied health) and service backgrounds (e.g. acute, subacute and ambulatory care). The Project Manager will be accountable to this group.

Project Manager: The Project Manager will understand the philosophy and principles of rehabilitation and have operational experience of rehabilitation care delivery. This person may have undertaken change projects before, or have managed a service. They will be experienced in managing multidisciplinary groups, and have dedicated time for this project throughout the period of implementation.

Project Team: A team of individuals tasked with delivering the implementation, which will be led by the Project Manager. Included may be people with specific expertise (Service planning) and those with operational experience (e.g. rehabilitation service delivery, support service staff and administrative leads). Clinical leaders may need to be on this team because they can influence peers to support the implementation process. Team members will have the capacity and expertise to undertake discrete activities within the project, and produce documents or make initial decisions on the day-to-day workings of the rehabilitation model.

Note: The Project Manager and some members of the Project Team will need to be available for the entire duration of the implementation period.

Decisions and update meetings: The implementation timeframe will be guided by the LHDs and should be focused on starting the delivery of an enhanced or new rehabilitation services as soon as practicable. The implementation process will rely on decisions being made efficiently and effectively. We recommend that regular meetings are scheduled with the different members of your team and different groups. For example, Project Team meetings can be held weekly and Steering Committee meetings fortnightly.

Clinical leadership is essential for successful implementation. Consider whether you want to include a senior clinician alongside your Project Manager to work with them on a day to day basis.

Share project plans and schedules with the multidisciplinary team.

If implementing a new care setting, consider the inclusion of staff who will be working in that care setting in your project team. It is important to involve these individuals as early as possible.

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Define and assess

The purpose of this stage is to assist you in understanding where the LHD needs to focus the implementation project. It’s important to determine the overall aims and objectives of implementing the Rehabilitation Model of Care, and why the current service delivery model is not an option for the future. You need to capture this information and develop a vision for the preferred Model of Care that can be referred to throughout the implementation process.

The analysis you will undertake here is of the current rehabilitation care settings in place in your LHD, current and future service demand, and of the current tools and resources in place. This data will inform your decision-making for the final recommended model.

Together with your Steering Committee members, consider these questions:

What evidence do we have that describes the need for a new or enhanced care setting?

What are we trying to achieve by introducing a new care setting?

Who will the care setting cater for, and what are the intended benefits?

When does it need to be implemented by?

What is our preferred model option?

How will we know if we have got this right?

There are six steps to assessing your rehabilitation service’s Model of Care: mapping stakeholders; data analysis; comparison of existing care delivery to the endorsed Rehabilitation Model of Care; analysis of the tools and guidelines contained in this toolkit; identification of KPIs to track performance

of the Model of Care across care settings; and completion of an implementation plan.

1. Map and engage stakeholders

Understanding who your key stakeholders are is essential to the success of any major change project. Mapping all key stakeholders is an important activity to that needs to be carried out early in the implementation project. This information will assist the development of the Implementation Plan and a Communication Plan that will be created for implementation. The stakeholder analysis will also allow you to consult the appropriate people as you continue with data collection and understanding how current services are delivered. Mapping and engaging key stakeholders is something that should be continually updated throughout the project.

Stakeholders can be individuals or groups who have a direct interest and accountability for the implementation of the Rehabilitation Model of Care, or who will be affected or involved in the future Model of Care and proposed changes. You can work through the following ideas to check that you have included all key stakeholders across disciplines and services.

Scope of services: Consider the scope of services that has been proposed, and list everyone who is involved in the delivery of those services from allied health, nursing and hospital transport. Involving these key people they will have a greater sense of ownership and stake in making this a success.

Types of changes: Consider the nature of some of the changes you will need to introduce (e.g. movement of staff, refurbishment of an existing clinical area) and think about the different people who will be involved in helping make this happen.

The patients: At the heart of everything are the patients and their families/carers who will be using the new care setting – include them as key stakeholders and consider how best to communicate the new service.

Types of communication: Consider the typical types of communication in any change project – progress updates, instructions or requests, reminders, meetings and information to explain or persuade.

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2. Undertake detailed data analysis and understand current service provision

Prior to defining the Rehabilitation Model of Care enhancements and/or new care setting for implementation, it is essential to understand challenges in delivering your current service to enable your LHD and project team to:

identify the need for implementing a new care setting or enhancing the current model

confirm which care settings are most appropriate and to be recommended for your local context

determine the volume and type of patients that may present

clarify the skill sets and number of staff required

provide a baseline from which to measure benefits and impacts

gauge the changes required to implement the new care setting

engage with the key stakeholders and champion the aims of the project with them.

The data analysis and extent of the current service assessment will vary depending on whether you are enhancing a current model or implementing a new care setting, and also on the availability of data.

Questions to consider when reviewing the current and proposed service:

Patients

What is the current volume of patient activity for our rehabilitation service?

What is the projected demand for our service in the future?

To what extent are rehabilitation patients able to access a service in the LHD (eg waiting times to access rehabilitation services, length of stay in an acute inpatient bed, patient and carer satisfaction)?

What are alternative and appropriate rehabilitation care settings that would enable patients to be seen by the right team in the right place, i.e. within the least resource intensive / safe care setting?

What processes and tools are in place to support access, referral, admission, assessment, care delivery and transfer of care processes?

Staff

What skills are required in an alternative care setting?

How many, and which disciplines of staff currently provide services?

What are the key relationships required for this service, e.g. with support services, acute inpatient teams, etc?

To obtain data for your LHD on current and projected service demand and supply, contact

your LHD Service Planning Unit or Casemix Unit in the first instance. Your LHD can also

review other currently collected data, such as AROC data, to enable an assessment of current

service delivery and performance.

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Logistics

What equipment and physical spaces do we need to operate the new care setting(s)?

Can we determine the costs involved with delivering this alternative model of care? Do we know what the budget is and any local funding arrangements?

3. Confirm your rehabilitation model fits within the endorsed NSW Rehabilitation MoC

It is important that while carrying out the data analysis and deciding the final Model of Care for

implementation, your LHD refers to the NSW Rehabilitation Model of Care to review all possible

options and to facilitate the selection of a model that is appropriate to the needs of the local

population and that can be delivered with available resources.

In confirming your recommended Model of Care you will need to engage with key stakeholders and

the Steering Committee to present the case for change and evidence to enable consensus and a

decision to be made. The key outcome required of your stakeholder meetings, agreed by your

Steering Committee (or equivalent) is a decision around the following:

What type (casemix and impairment type) and volume of patients will we provide services for?

What physical area and workforce will we require?

Which is our final recommended rehabilitation model and care setting(s)?

Where is our preferred delivery site?

4. Analyse current and future processes, tools and guidelines.

The following phase enables exploration of the core elements of operational good practice in

rehabilitation, specifically around the service delivery processes, tools and guidelines used to support

appropriate care delivery and patient flow.

When evaluating each of the eight processes, tools and guidelines as part of the Model of Care, there

a number of activities you will undertake. These activities outlined below are common to each of the

eight processes, tools and guidelines across the patient journey. These activities include:

a. Review the core elements of each of the eight processes, tools and guidelines:

i. A process for appropriate care setting referral

ii. Standards for effective communication with patients and families/carers.

iii. Eligibility/admission criteria for appropriateness of patient admission to rehabilitation

iv. Referral forms for rehabilitation services across care settings

v. Comprehensive assessment tool for utilisation by the MDT

vi. Education programs for patients receiving rehabilitation services

vii. Transfer of Care / Discharge principles

Depending on your recommended model (enhanced current model or new care setting) you may need to consider a full business case. Your Project Sponsor can advise on this.

The ACI will also be able to advise and direct your development of a business case for implementation.

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viii. Process and clinical checklist for the transfer of care between care settings.

These core criteria have been developed and endorsed as ‘good practice’ by the Rehabilitation Network Executive Group. They are provided as the basis on which to develop a ‘good practice’ tool or guideline.

b. Assess your service tools and resources against these core elements using the checklist provided to identify the ‘gaps’.

Checklists have been developed for each of the eight processes, tools and guidelines. The checklists are aligned to the core elements. Using the checklist will enable:

LHDs looking to enhance a current Model of Care to assess the extent to which their current processes, tools and guidelines comprise all the core elements

LHDs implementing a new care setting to review core elements of good practice for the new Model of Care and to review current tools and resources in other LHDs that have been effective in enabling the delivery of care in that setting.

The checklist has been designed to help LHDs assess tools and resources from each of the rehabilitation care settings. It allows your LHD to rate the tools according to the inclusion of core elements of ‘good practice’ to identify gaps and opportunities for improvement.

Note: While the checklist has been developed to cut across all care settings, some core elements may not be applicable to all care settings.

These checklists are provided in the following chapters in this toolkit. A stand alone copy of the eight checklists has also been provided in Appendix D for ease of use.

c. Review your tools/ resources against the recommended core elements with the view to enhance or develop your relevant tools and resources. Provided in the toolkit are examples of processes, tools and guidelines currently in use in NSW LHDs. These have been provided as a platform to developing tools and resources required for your LHD rehabilitation service. Note: they have been sourced from other rehabilitation services in NSW and may not currently include all core elements.

Where relevant, forms and checklists have been developed and are provided for use. These have been provided in an editable format to enable amendments to be made by the LHD to tailor it to the local situation. The example tools and resources provided can also be referenced and built upon to enhance and develop tools and resources for your LHD.

When enhancing or developing these new processes, tools and resources, it is important to:

Engage appropriate leadership and include all key stakeholders in the modification/design phase and throughout implementation

Assign accountable individuals in the LHD as ‘champions’

Liaise with your LHD forms committee for approval of design

Develop a communications and implementation plan to facilitate successful ‘roll-out’ and the change in practice sustained.

d. Identify KPIs for monitoring of the effectiveness of enhancing the Model of Care or implementing the new care setting. Including monitoring measures or KPIs will help you to evaluate the safety, quality and timeliness of patient care and the effectiveness of the rehabilitation model.

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It is important to collect data prior to implementation to enable comparison of the effectiveness of changes and improvements in overall patient care in the rehabilitation service in your LHD pre and post model implementation.

As part of the development of this rehabilitation implementation toolkit, a formative evaluation was completed to measure the value delivered by the models of care. Integral to the evaluation was the creation of an evaluation framework with Key Performance Indicators across the care settings. The two types of monitoring measures are included:

Operational indicators such as patient wait times to access rehabilitation and LOS in the acute inpatient bed.

Clinical indicators that relate to patient safety more specifically and measure the ‘clinical management or outcome of care’ of patients, such as functional improvement, attainment of rehabilitation goals, discharge to the usual place of residence, and patient and carer satisfaction.

You can use the evaluation framework as the basis for monitoring effectiveness of the model, selecting indicators from the framework to collect data as a baseline and into the future. A copy of the Evaluation and Monitoring Tool has been included in Appendix D.

A selection of recommended KPIs (monitoring measures) has been included throughout the toolkit. These have been sourced from the evaluation framework, however you may include additional indicators as required. A copy of the evaluation framework is located in Appendix D.

e. Complete an action plan for implementation. An action plan has been included at the end of each Chapter for completion after the self assessment. The action plan is designed to assist with the creation of a detailed implementation plan, enabling the capture of key activities, responsible owners and timeframes as you work through the toolkit.

See the next phase for information about developing an implementation plan.

Implement and Monitor

With diagnostics completed and an implementation model agreed with the Steering Committee and rehabilitation stakeholders, it is essential to now develop an implementation plan and communication plan to facilitate successful implementation. These documents are integral to keeping the project on track and stakeholders engaged and informed about the implementation progress and impact on them.

Develop the implementation plan

The Implementation Plan should document the logical sequence of events intended to move the agreement to implementation of an enhanced or new Rehabilitation Model of Care through to delivery of the service. The Project Manager will have ownership and accountability for this document.

The Implementation Plan should include:

allocated responsibility for the achievement of each activity, breaking it down into tasks where required

When choosing your KPIs:

Data should be readily available

The effort to collect the data should not outweigh the benefit

You may need to choose an indirect measure for effectiveness if there is a lack of true outcome measures.

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identification and sequencing of any tasks that depend on the completion of other tasks

assessment of any known or perceived risks and identify ways in which they might be overcome

identification of the key milestones to communicate to the relevant stakeholders.

The Implementation Plan should be used to track the progress of implementation, and allow the planning of key implementation activities on a weekly basis.

A template for creating your implementation plan has been included in Appendix D.

Develop a communications plan

A Communications Plan should be developed and as a schedule of communication activities, setting out deadlines, accountable authors and target audiences. The Communications Plan for your implementation project is likely to cover both internal project communication requirements and external communication activities associated with information-giving and the marketing of a new service. Refer to both your stakeholder map and your Implementation Plan when producing this document.

Things to consider:

How do stakeholders like to receive information – do you prefer information by email, hardcopy documentation, or through discussion?

How often does the implementation team need to meet to share information?

How will you gain input and feedback from key stakeholders?

What information do patients need about the enhanced or new Model of Care?

A template for a Communication Plan has been provided in Appendix D.

When developing your implementation plans:

Consider any factors that have pre-defined delivery timeframes and lead times, e.g. consultations for staff required to change workplace; refurbishment of facilities. Allow enough time in your plan to achieve these activities.

You may wish to merge your Implementation and Communications Plans depending on the level of detail in both. Remember, however, that your Communications Plan is a live document and will be updated regularly.

Chapter 1: Across the patient journey

Transfer of Care

Care

setting

Referral

1. A process for appropriate care

setting referral

• A tool to support consistent decision making regarding

patients being appropriately referred into a rehabilitation setting• Ensuring patients receive the ‘right care in the right place at

the right time’ across NSW Health

2. Standards for effective

communication with patients and families/ carers

• Standards that ensure health professionals effectively

communicate with patients and families/ carers• Effective communication and being informed is a right for each consumer in the health system and contributes to safe

and high quality care.

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1 A process for appropriate care setting referral

Appropriate care setting referral

Having a process for appropriate care setting referral will support consistent decision-making

regarding patients receiving the ‘right care in the right place at the right time’ across NSW

Health. A decision tree can facilitate admission and/or transfer of patients into the most

appropriate care setting and enable benchmarking. This will have benefits for both the

patient and the system.

Activities

There are five key steps to reviewing your process for appropriate care setting referral. These include:

1. Review the appropriate care setting referral principles

2. Assess your process or service tools against these core elements

3. Review the provided exemplars and resources to enhance or develop your tools for appropriate care setting referral

4. Identify KPIs for monitoring of the effectiveness of enhancing or implementing the principles

5. Complete an action plan with tasks to complete, responsible/ accountable people and timeframes for completion

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Step 1: Review the core elements for appropriate care setting referral

The core elements agreed by the ACI Rehabilitation Network Executive as ‘good practice’ in the

decision for appropriate care setting referral are outlined below.

Appropriate care setting referral principles:

Care will be delivered in the least resource intensive / safe setting, based on:

o Admission criteria

o Assessment by Rehabilitation Consultant or Rehabilitation Clinical Nurse Consultant to determine the most appropriate care setting

o Acceptance of care by the Rehabilitation consultant

o Appropriate care setting, appropriate care provider as close to home as possible.

o Availability of care settings

o Open and transparent patient and family/ carer communication throughout the decision making process in accepting referral and transfer to care

o Patients and carers are involved in decision making about the care, and are provided with the options and limitations for accessing rehabilitation services to enable informed decision making about their care options.

Transfers between care settings should be based on patient variables, delays due to provider factors (eg bed availability, awaiting home modifications) should be documented as delayed discharge.

Questions to consider:

1. Does your facility currently have a documented and consistent approach to referral of rehabilitation patients to the appropriate care setting?

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Step 2: Self assessment against the core elements/ criteria

To assess whether your rehabilitation service is in line with the core elements/ criteria for appropriate care setting referral, please complete the following checklist. This will help you determine the areas to enhance or develop your current policies, procedures, tools and resources for referring to the appropriate care setting.

Does your service have in place the following elements for referring to the appropriate care

setting?

Communications checklist Full compliance

Partial compliance

Not in place

Care will be delivered in the least resource intensive / safe setting, based on:

Admission criteria

Assessment by Rehabilitation Consultant or Rehabilitation Clinical Nurse Consultant to determine the most appropriate care setting

Acceptance of care by the Rehabilitation consultant

Appropriate care setting, appropriate care provider as close to home as possible

Availability of care settings

Open and transparent patient and family/ carer communication throughout the decision making process in accepting referral and transfer to care

Patients and carers are involved in decision making about the care, and are provided with the options and limitations for accessing rehabilitation services to enable informed decision making about their care options.

Transfers between care settings should be based on patient variables, delays due to provider factors (eg bed availability, awaiting home modifications) should be documented as delayed discharge.

Notes:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

17

Step 3 Review the provided exemplars and resources to enhance or develop your tools for appropriate care setting referral

Having considered the principles for appropriate care setting referral and identified the ‘gaps’ you can plan the development of a referral process for your LHD. Many rehabilitation services visited do not currently have a comprehensive decision tree across all care settings to enable appropriate referral. An example decision tree and referral criteria have been developed in consultation with the Rehabilitation Network Executive and are provided below. This decision tree should be followed in conjunction with reference made to the accompanying table for referral criteria.

18

Figure 4 Decision tree for appropriate referral to rehabilitation services

Patient assessed

as requiring

rehabilitation

Is the patient

currently an

inpatient?

Has the patient

completed their acute

phase of care?

Yes

Can the patient tolerate

rehabilitation in an

ambulatory care setting

No

A. Inreach to acute

Does the patient meet the

eligibility criteria for the Inreach

to acute rehab team?

No

Yes

Is the patient safe for

discharge?

Yes

B. Subacute

inpatient facility

No

* Consider:

F. Outreach - for

regional/rural

rehabilitation services

can the patient be

transferred to a

peripheral hospital to

continue rehabilitation

C. Day Hospital

D. Outpatients

E. Rehab in the home

Yes

* Consider:

Local rehabilitation

services available

Patient needs (transport,

patient goals, ability to

tolerate intensity in

different care settings)

NoYes

A decision tree and referral criteria can be found in Appendix E.

19

Table 3 Criteria for appropriate care setting referral

Less resource intensive

Outpatient Patient can function at home and is able to attend a suite of services - single or multiple rehab discipline treatment - based on their defined goals

Day Hospital Patient has substantive functional deficits and can be maintained at home (e.g. non-weight bearing)

requires multiple rehab disciplines;

has endurance to undertake multiple session

Is able to tolerate the minimum requirement for therapy per day

Therapy is goal orientated, provided by a minimum of two disciplines and is coordinated across all disciplines

Home Based Patient has substantive functional deficits and can be maintained at home

requires and is able to tolerate intensive therapy that cannot be provided in another ambulatory setting.

requires the delivery of contextualised therapy to optimise rehabilitation outcomes - this cannot be replicated in a hospital-based care setting

Inreach to acute

care2 Patient is an admitted patient in an acute hospital setting and

requires multidisciplinary treatment to improve their functional status

is able to tolerate the minimum requirement for therapy per day

Outreach As per the Subacute Inpatient

Rehabilitation is able to be provided in a peripheral facility closer to the patient’s home and support network.

More resource intensive

Subacute Inpatient

Patient requires an intensive period of rehabilitation to achieve identified rehabilitation goals to facilitate discharge/resettlement to an identified form of accommodation

anticipated to benefit from rehabilitation

can tolerate intensive inpatient rehab

Is able to tolerate at a minimum of 2 – 3 hours of therapy per day.

2 The decision tree for inreach to acute is based on the assumption that the model works as intended, therefore the patient is

under the care of the acute inpatient team, and referral decisions are not based on bed availability and hospital access block

20

____________________________

A range of referral tools are used across NSW and were identified through site visits and stakeholder consultations. These referral tools are care setting specific and assist appropriate referral into that care setting or for that patient cohort. Examples are outlined below:

Table 4 Appropriate care setting referral tools used in selected NSW rehabilitation services

Rehabilitation Site/ policy

Communication tool Document type/ reference

1 St George

Hospital

Rehabilitation

Services

St George Hospital has a common referral method for all rehabilitation

settings. A flow chart outlines the different pathways a patient can travel

depending on the assessment of need by the rehabilitation registrar or

consultant. (eg ART, subacute inpatient at St George Hospital or Calvary

Rehabilitation Unit)3.

Appendix E

Document 1

2 St Vincent’s

Hospital

A referral flow chart for the Sacred Heart Consultation service is located

within the referral policy4. This outlines the options for an acute inpatient

being referred for rehabilitation consult within the Sacred Heart

Rehabilitation Service and the various care setting options. Appendix E

Document 2

3 Orange Base

Hospital

Orange Base Hospital has a high-level flowchart for subacute team

involvement and the transfer of care into the peripheral sites for outreach

services.

Appendix E

Document 3

4 Australian

Stroke

Coalition

The Australian Stroke Coalition. Assessment for Rehabilitation

Pathway and Decision-Making Tool (Manual, 2012) outlines a

pathway and decision making tool for assessment of acute

stroke for rehabilitation. See below for more detail.

See The Australian Stroke Coalition website for the assessment for

Rehabilitation Pathway and Decision-Making Tool.

Refer to link

3 Rehabilitation (inpatient) admission criteria: St George Hospital. Clinical Business Rule SGSHHS CLIN203 (2012) – Appendix

1: SESLHD Rehabilitation Referral Protocol for Patients in St George Hospital (page 5). 4 St Vincent’s Hospital Sydney Referral to Sacred Heart Rehabilitation Consultation Service Policy (Policy 1.32). Figure 1

Referral flow chart for the Sacred Heart Consultation Service (page 4).

http://australianstrokecoalition.com.au/projects/assessment-for-rehabilitation-pathway-and-decision-making-toolnual-and-decision-making-tool

21

____________________________

Step 4: Identify KPIs for monitoring of the effectiveness of enhancing or implementing the standards

Now that you have developed standards, tools and resources for appropriate care setting referral principles you need to define how you will measure the change in practice. Key performance indicators will assist to demonstrate changes and improvements in overall patient care.

Relevant key metrics from the evaluation framework have been provided in Table 5 below. When combined with other metrics collected and analysed for all tools and resources, and within the wider context of the evaluation framework, a comprehensive approach to assessment of performance of each care setting can be achieved.

Table 5 Monitoring measures from the evaluation framework and other suggested measures

Indicator Data source Frequency

Delayed Discharges Site internal documentation/ patient flow portal

Six monthly

% of patients discharged to a form of accommodation. AROC/ Site internal documentation

Six monthly

Australian Stroke Coalition. Assessment for Rehabilitation Pathway and Decision-Making Tool (Manual, 2012)

1.

The Assessment for rehabilitation pathway is a comprehensive process to enable fair and

accountable decision making when assessing patients for stroke rehabilitation. It is based on

evidence from a literature review and pilot work at stroke units across Australia. A summary of

the process is provided below:

1. Based on literature it was agreed that all stroke survivors be considered for rehabilitation

unless they meet agreed exceptions (eg. returned to pre-morbid function, palliation, coma

and/or unresponsive, declined rehabilitation).

2. The rehabilitation setting should be determined by:

Client preference and need, i.e. ability to function in their own versus an alternate environment.

Expert opinion.

Best available evidence.

3. In addition, using the Assessment for Rehabilitation: Decision-Making Tool will assist in

determining where rehabilitation occurs. This requires analysis of where the identified needs

are best met for the various domains, that is, whether the stroke survivor can be managed at

home, in the community/outpatients or in an inpatient (IP) setting. The Decision-Making Tool

can be used to formulate the Rehabilitation plan and should form the basis for all subsequent

reviews.

For further information and access to the pathway and decision making tool for use please refer to the Australian Stroke Coalition website: Assessment for Rehabilitation Pathway and Decision-Making Tool.

http://australianstrokecoalition.com.au/projects/assessment-for-rehabilitation-pathway-and-decision-making-toolnual-and-decision-making-tool/http:/australianstrokecoalition.com.au/projects/assessment-for-rehabilitation-pathway-and-decision-making-toolnual

http://australianstrokecoalition.com.au/projects/assessment-for-rehabilitation-pathway-and-decision-making-toolnual-and-decision-making-tool/http:/australianstrokecoalition.com.au/projects/assessment-for-rehabilitation-pathway-and-decision-making-toolnual

22

Step 5: Action Plan

An action plan has been included as the final step to facilitate recording the key activities required for

implementation. The action plan is designed to assist with the creation of a detailed implementation

plan, enabling the capture of key activities, responsible owners and timeframes as you work through

the toolkit.

Complete the action plan below with the activities, timeframes and activity owners for the tasks

needed to develop a decision tree for appropriate care setting referral.

Table 6 Action plan for decision tree for appropriate care setting referral

Activity Timeframe Activity owner

1.

2.

3.

4.

5.

6.

DDeecciissiioonn ttrreeee ccoommpplleettiioonn cchheecckklliisstt

Reviewed the core elements principles for appropriate care setting referral

Identified and reviewed the relevant exemplar tools and resources

Enhanced or developed relevant tools and resources to ensure the rehabilitation service is

in-line with the recommended principles for appropriate care setting referral

Implemented KPIs for monitoring the effectiveness of enhancing or implementing the referral

principles

2

Standards for effective communication with patients and families/carers

Purpose of standards for effective communication with patient and families/ carers:

Standards for effective communication with patient and families/ carers aim to remove barriers to successful patient-clinician communication. All health professionals have a fundamental responsibility to effectively communicative with patients and families/ carers.

Effective communication and being appropriately informed is a right for each consumer in the health system and contributes to safe and high quality care. Communication is enhanced when health professionals ensure that the information is understood and the patients’ or consumers ‘language and communication needs are met.

Good communication between health professionals and patients, families/ carers builds trust, involves the patient more fully in health decision making, helps the patients make better health decisions and enhances patient satisfaction.

Activities

There are five key steps to reviewing your rehabilitation facilities standards for effective communication with patient and families/ carers. These include:

1. Review the core elements of standards for effective communication with patients and families/carers

2. Assess your service against these core elements using the self-assessment checklist provided and identify the ‘gaps’ against the standards

3. Review the provided exemplars and resources to enhance or develop your tools for effective communication with patients and families/ carers

4. Identify KPIs for monitoring the effectiveness of enhancing or implementing the standards

5. Complete the action plan provided, including the activities to complete, responsible owners and timeframes for completion

Patient communication standards focus on all patients having their communication needs met. In particular, standards support communication for the most vulnerable patients: those who have high communication needs; hearing, vision, or cognitive impairment; speak a language other than English; have limited literacy or knowledge about health care; or have sexual identity, cultural, or religious differences.

24

Step 1: Review the core elements of standards for effective communication with

patients and families/carers.

The core elements have been agreed by the ACI Rehabilitation Network Executive as ‘good practice’ in effective communication with patients and families/ carers.

Core criteria/ elements for effective communication with patient and families/ carers:

On admission: Inform patients of their rights, Identify the patient’s preferred language for discussing health care and ensure an interpreter is available as required, communicate information about unique patients needs to the care team

During assessment and treatment: identify and address patient communication needs during assessment, involve patients and families in the care process, accommodate patient cultural, religious or spiritual beliefs and practice.

Engage patients and families/ carers:

o Patients and their families/ carers are engaged during the admission, assessment, treatment and discharge/ transfer of care planning.

o Patients and families / carers are given clear verbal and written information about their diagnosis/ rehabilitation journey, expectations of their role in rehabilitation and discharge instructions that meets the patient needs.

o Information is given in a timely way.

o Confirm that the patient and their families/ carer understand the information. (The information communicated must be acknowledged and verified by the receiver in order for the exchange of information to be effective).

o Appropriate information on all treatment options is provided to ensure the patients /carers/and families are able to make informed decisions and partner with treatment providers in goal setting and the rehabilitation journey.

o Carer needs are met by giving those opportunities to ask questions, give feedback and discuss concerns. Carers are also given support linking them into local services and support groups


1. What communication materials and handouts do you currently use to enhance communication with patient and their families/carers?

2. How do staff currently engage with the patient and their family/ carer?

25


To assess whether your rehabilitation service is in line with the core elements/ criteria for effective communication with patients and families/ carers, please complete the following checklist. This will help you determine the areas to enhance or develop your current policies, procedures, tools and resources for communicating with patients and families/ carers across the patient journey.

Does your service have in place the following elements for communicating with patients,

families and carers?


Partial compliance

Not in place

Admission

Process to inform patients of their rights (eg handout given to patients)

Process to identify the patient’s preferred language for discussing health care (and ensure an interpreter is available as required)

Process to communicate information about unique patient needs to the care team

On assessment and treatment

Identify and address patient communication needs during assessment

A method to involve patients and families in the care process

A process to accommodate patient cultural, religious or spiritual beliefs and practice

Engagement throughout

Patients and families/ carers are given clear verbal and written information about:

their diagnosis/ rehabilitation journey

expectations of their role in rehabilitation

discharge instructions that meets the patient needs

Confirmation that the patient and their families/ carer understand the information.

Appropriate information on all treatment options is provided to enable informed decision-making by patients /carers/and families and partnering with treatment providers in goal setting and the rehabilitation journey.

Carers are given the opportunity to ask questions, give feedback and discuss concerns and are linked

26


Partial compliance

Not in place

into local services and support groups.

Patients, their families/ carers are engaged during admission, assessment, treatment and discharge/transfer of care planning.

Notes:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

27

Step 3: Review the provided exemplars and resources to enhance or develop your tools for effective communication with patients and

families/ carers

Now that you have assessed your communication with patients and families/ carers across the patient journey and identified the ‘gaps’ you can start to plan the resources required to enhance or develop your rehabilitation service.

Table 7 Communication tools used in selected NSW rehabilitation services



Referral/ admission

1 Rankin Park Patient information packs handed out on admission. Rankin Park reported to have a local guideline

Client/patient/resident information package: GNC (GNC: 12_017) which outlines the distribution of

the information package, including privacy and rights and responsibilities brochures for patient on

admission into a service within the Greater Newcastle Cluster. An example list of what is included in

the pack is listed below:

Patient information handbook:

o General information and information regarding the rehabilitation service offered

o Rehabilitation staff and their roles

o During your stay and discharge

o What will I have to pay for?

o Important information and policies

o Communication

o My rights as a client

o Facilities and services close by

o Support services for carers

Leaflets (LHD documents)

Appendix E

Document 4

A range of tools are used across NSW that enable effective communication with patients and families/ carers. Some good examples of communication tools used throughout the patient journey were identified through site visits and stakeholder consultations and are listed below.

28

____________________________

____________________________



o Your rights & responsibilities as a client, patient or visitor

o NSW Information privacy leaflet for patients

o Compliments and complaints – information for patients and their families

o Hand hygiene Australia – information for patients and visitors

o Carer support services

o Information booklet on Delirium

o Information booklet on safe footwear

2 HNELHD Policies and procedures

Greater Newcastle Cluster local guideline: Guidelines for assessment of clients from culturally and linguistically diverse communities and non-English speaking backgrounds (NESB) - GNC 08_004

HNELHD: Health clients requiring interpreter services related to language & deafness - Document Number: GNC11_008

HNELHD: Blind / vision impaired clients - Document Number: GNC 12_065

Contact site

3 NSW Health Policy Directive

The NSW Health, Your Health Rights and Responsibilities policy directive5 outlines the

rights and responsibilities of NSW Health services and staff, and patients and carers. Basic rights are detailed in the policy, including; Access, Safety, Respect, Communication, Participation, Privacy, and the right to Comment. In regards to communication with patients, families and carers the following is outlined and discussed:

Communication: The right to be informed about services, treatment and options in a clear and open way. Interpreter services, support people and information provision are also outlined in the patient handout that is a component of the directive.

Participation: The right to be included in decisions and choices about health care

Appendix E

Document 5

Assessment and service delivery

4 Rankin Park Rehabilitation Coordinator/ case manager role: The Rehabilitation Activities Coordinator (RAC) role at Rankin Park centre. This role acts as a case manager and a central point of contact for

the patient and their families/ carers to address issues around their care, discharge or the coordination of the rehabilitation process.

Appendix E

Document 6

5 NSW Health, Your Health Rights and Responsibilities policy directive (Document Number PD2011_022). Accessed at: http://www0.health.nsw.gov.au/policies/pd/2011/pdf/PD2011_022.pdf

29

____________________________



5 NSW Ministry of Health

Communication scripting tools: The AIDET framework (Acknowledge, Introduce, Duration,

Explanation, Thank You) for staff to communicate with patients and/or families. This can also be used to communicate between staff members. (Note: this has been shown to lead to better patient satisfaction, staff satisfaction, and clinical outcomes). Another tool used is the ‘GDAY’ framework

(Greet and Introduction, Discuss what is expected, Approximately how long, You’re important to us)

For further information refer to the AIDET framework: Refer to the Studer Group : https://www.studergroup.com/home/index.dot

http://www.archi.net.au/resources/patientexperience

Refer to Patient and Carer Experience resources on the ARCHI website

6 Calvary Day Hospital

POWH

Weekly Multi-Disciplinary Team (MDT) meetings or MDT case conferences. It was reported that

it is not standard practice for the patient to be present at these weekly MDT meetings however, the aim is for information to be reported back to the patient and family/ carer post meeting.

Appendix E

Documents 7- 8

7 St Vincent’s Hospital/ Sacred Heart Rehabilitation – currently being trialled

Family meetings. It was reported that family meetings were not common practice at sites, with

complex patients offered case conferences as needed. However, every patient was offered a family conference at Rankin Park where time is allocated every week for rehabilitation consultations/ geriatricians and the MDT to conduct family meetings on each of the two subacute inpatient wards. In some facilities triggers have been developed locally to alert staff to the need for a family case conference. Some of these local triggers may be a long length of stay or patients receiving more than two disciplines in their therapy program

Appendix E

Document 9

8 The National Safety and Quality Health Service (NSQHS) Standards

6

Standard 2: Partnering with consumers: aims to improve processes of consumer and

carer participation from the basic provision of information and basic consumer consultation to the engagement of consumers and carers in partnerships with the organisation. The guide outlines a range of tools and resources from Australian and international sources which can be adapted and applied to different Australian healthcare

organisations.

Refer to The Australian Commission on Safety and Quality in Health Care (ACSQHC) website: http://www.safetyandquality.gov.au/

Refer to website

Discharge/transfer of care

6 Australian Commission on Safety and Quality in Health Care. Safety and Quality Improvement Guide Standard 2: Partnering with Consumers (October 2012). Sydney. ACSQHC, 2012.

https://www.studergroup.com/home/index.dot

http://www.safetyandquality.gov.au/

30



9 St Vincent’s RITH

Discharge summaries to patients GP/ relevant medical physicians and other organisations involved

in the care of the patient to enable smooth transfer of care

Appendix E

Document 10

10 Rankin park Flag and Track program at Rankin Park facilitates a review three to six months post discharge for

residential aged care patients with the potential for improvement post hospital discharge. Following review, these patients are offered further rehabilitation if it is considered beneficial to their outcomes. The Rankin Park Centre Flag and Track program local guideline (Document Number: GNC RPC 12_106) is provided for reference.

Appendix E

Document 11

11 Rankin Park Inpatient follow up phone call, made to all patients discharged from the subacute inpatient unit at

Rankin Park. All members of the MDT conduct phone calls to patients to check they had a safe transition home. The communication script and two page inpatient follow up phone call form is provided.

Appendix E

Document 12

** Refer to the Define and assess section at the front of the toolkit for tips on enhancing/ developing tools in your service

Refer to Appendix A for the contact details of site contacts to discuss or gain further documentation of communication strategies.

31

Step 4: Identify KPIs for monitoring of the effectiveness of enhancing or implementing the standards

Now that you have developed standards, tools and resources for effective communication with patients and families/carers you need to define how you will measure the change in practice. Key performance indicators will assist to demonstrate changes and improvements in overall patient care.

Relevant key metrics from the evaluation framework have been provided in Table 8 Monitoring measures from the evaluation framework and other suggested measures below. When combined with other metrics collected and analysed for all tools and resources, and within the wider context of the evaluation framework, a comprehensive assessment of performance of each care setting can be achieved.



% patient/carer satisfaction with service delivery Site internal documentation/ PETs

Six monthly

Additional key metrics specific to communication standards adopted in your LHD can be collected and analysed to monitor the effectiveness of the changes implemented.

Step 5: Action Plan




the toolkit.

Complete the action plan below with the activities, timeframes and activity owners for the tasks needed to develop your communication tools and standards.

Table 9 Action plan for communication standards


1.

2.

3.

4.

5.

6.

32

CCoommmmuunniiccaattiioonn wwiitthh ppaattiieennttss aanndd

ffaammiilliieess//ccaarreerrss ccoommpplleettiioonn CChheecckklliisstt

Reviewed the core elements of standards for effective communication with patients and

families/carers.

Completed the assessment using the checklist and identified the ‘gaps’

Identified and reviewed the relevant exemplar tools and resources

Enhanced or developed relevant tools and resources to align the rehabilitation service to the

recommended standards for effective communication with patients and families/ carers

Implemented KPIs for monitoring of the effectiveness of enhancing or implementing the

communication standards

33

Chapter 2: Referral and admission

Transfer of care

Care

setting

Referral

3. Eligibility, admission criteria, and

guidelines for ‘ready for rehabilitation’

• Eligibility/ admission criteria are a documented agreed

set of standards to promote appropriate admissions into care settings, promote optimal use of allocated beds and support services to manage patient flow between

services and/ or settings.

4. . Referral forms for Rehabilitation

services across care settings

• A referral from provides a standardised mechanism for

referral into rehabilitation care settings. It provides background information for review of patients.

2 Eligibility, admission criteria, and guidelines for ‘ready for rehabilitation’

Purpose of eligibility/ admission and guidelines for ‘ready for rehabilitation’:

Eligibility/ Admission criteria are a documented agreed set of standards to:

Promote appropriate admissions to each care setting

Promote optimal use of allocated beds

Support services to manage patient flow between services and/ or settings

Provide a guideline for non-rehabilitation clinicians when assessing patients for

transfer to a rehabilitation setting

Assist in bed management issues and waiting list management.

Activities

There are five key steps to be undertaken in reviewing your rehabilitation facilities

eligibility, admission criteria, and guidelines for ‘ready for rehabilitation’. These include:

1. Review the core elements of eligibility/admission and ‘ready for rehabilitation’ criteria.

2. Assess your service against these core elements using the checklist provided and identify the ‘gaps’ against the elements.

3. Review the provided exemplars and resources to enhance or develop your tools for eligibility/admission and ‘ready for rehabilitation’ criteria.

4. Identify KPIs for monitoring the effectiveness of enhancing or implementing the core elements into your eligibility/admission and ‘ready for rehabilitation’ criteria.

5. Complete an action plan with tasks to complete, responsible/ accountable people and timeframes for completion.

35

Step 1: Review the core elements of standards for eligibility/admission and ‘ready

for rehabilitation’

The following core elements have been agreed by the ACI Rehabilitation Network Executive as

‘good practice’ in effective eligibility/admission and ‘ready for rehabilitation’ criteria.

Eligibility/Admission and ‘Ready for Rehabilitation’ criteria:

Patient is medically able to participate in the rehabilitation program in that care setting. The patient has been assessed by an appropriate professional (eg rehabilitation physician, rehabilitation coordinator or other) as requiring rehabilitation in that care setting/ environment (based on their physical/ medical/ functional, cognitive, psychosocial, social needs).

There are clear, achievable rehabilitation goals documented and agreed.

Discharge destination has been discussed with patient/carer and agreed or the team is working towards a discharge destination.

The patient and/or carer consents and is able to participate in the rehabilitation process, including the intensity of therapy provided, in that care setting (i.e. motivation/ active patient participation). Patient and/or carer rehabilitation needs are aligned to service delivery available in care setting.

Special needs are able to be met in that care setting (eg non weight bearing patients).

Clear and accurate documentation of ongoing management plan and necessary follow-up.

The patient falls within the care setting case mix classifications agreed/ able to be accommodated in that care setting.

There is consideration of a trial of rehabilitation to determine a patient’s ability to participate and potential to benefit from the program.


1. Do your eligibility/ admission criteria facilitate appropriate referral and

admission of patients into your rehabilitation service?

2. Is the patient/carer involved in the decision and consents to participate in

rehabilitation in that setting?

3. Is there consideration of patient needs when the referral decision is made?

36


To ensure that your rehabilitation service is in line with the core elements/ criteria for effective eligibility / admission / ready for rehabilitation criteria, please complete the following checklist.

Do your documented eligibility/admission and ‘ready for rehabilitation’ criteria contain the

following elements?

Admission criteria checklist Full compliance

Partial compliance

Not in place

Patient is medically able to participate in the rehabilitation program in that care setting

The patient has been assessed by an appropriate professional (eg rehabilitation physician, rehabilitation coordinator or other) as requiring rehabilitation in that care setting/environment (based on their physical/ medical/ functional, cognitive, psychosocial, social needs)

There are clear, achievable rehabilitation goals that have been documented and agreed.

Discharge destination has been discussed and agreed or the team is working towards a discharge destination

The patient and/or carer consents and is able to participate in the rehabilitation process, including the intensity of therapy provided, in that care setting (i.e. motivation/ active patient participation)

Patient and/or carer rehabilitation needs aligned to service delivery available in care setting

Special needs are able to be met in that care setting (eg non-weight bearing patients)

There is clear and accurate documentation of an ongoing management plan and necessary follow-up.

The patient falls within the care setting case mix classifications agreed/ able to be accommodated in that care setting

There is consideration of a trial of rehabilitation to determine a patient’s ability to participate and potential to benefit from the program.

37

Notes:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Step 3: Review the provided exemplars and resources to enhance or develop your tools for eligibility/admission and ‘ready for rehabilitation’

criteria.

Now that you have assessed your eligibility/admission criteria, and guidelines for ‘ready for rehabilitation’ and identified ‘gaps’ you can start to plan the resources required to enhance or develop your rehabilitation service.

Table 10 Eligibility / admission criteria used in selected NSW Rehabilitation services

Rehabilitation Site Context

Inreach to acute

1 St Vincent’s Hospital Mobile Rehabilitation Team (MRT)

St Vincent’s Hospital is a large 350 bed in the inner city of Sydney. The Hospital is a centre for heart and lung transplantation.

The primary objective of the MRT is to enhance the treatment of patients in the acute setting by providing simultaneous rehabilitation services.

Operates on a ‘pull’ system, whereby patients are identified and assessed before being selected to program

Selected patients will on average be seen by the MRT for ten days

Main impairment types of patients is reconditioning/restorative

Appendix F

Documents 1 - 3

2 St George Hospital Acute Rehabilitation Team (ART)

St George Hospital is major trauma centre for southern Sydney with over 500 beds.

Primary objective of the ART is to enhance the treatment of patients in the acute setting through the provision of rehabilitation

Patients selected for the program are usually moderately to severely impaired and are awaiting subacute inpatient rehabilitation,

The majority of rehabilitation facilities across NSW had documented eligibility/admission criteria contained within policies, procedures or business rules providing criteria for the appropriateness of patient admission to the rehabilitation service.

There are a range of formats used across NSW that were identified through site visits. Some good examples of eligibility/admission criteria across care settings are outlined below.

A two week trial of rehabilitation is accepted in most rehabilitation sites visited, however, formally documented criteria for a trial of rehab are not always in place.

The Sacred Heart Rehabilitation Service has a documented policy for a trial of rehabilitation. This is referred to in the policy Referral to the Sacred Heart Rehabilitation Consultation Service and contained in the Sacred Heart Trial of Rehabilitation Policy (see Table 4).

39


with a focus on preventing functional decline of patients during acute hospitalisation

4 Orange Orthogeriatric Inreach

The outreach model involves a subacute multidisciplinary team which provides both inreach and outreach rehabilitation services across the care continuum

Focus is on enhancing the care, assessment and management of Orthogeriatric patients providing early intervention for patients over 65 years who have a fracture.

Subacute Inpatient

5 Rankin Park The subacute inpatient setting consists of 2 patient wards (20 beds each) which is co-located to the acute hospital

Patients are streamed based on casemix

Patients generally have complex conditions. Majority are older and have multiple co-morbidities.

Appendix F

Documents 4 - 8

6 St Vincent’s Hospital/ Sacred Heart Rehabilitation

Sacred Heart Rehabilitation unit is co-located to St Vincent’s Hospital.

The unit provides seven-day rehabilitation for a wide range of conditions.

The unit has established an Intensity of Therapy Program (ITP) to accelerate patient functional recovery in a subacute inpatient rehab setting through enhanced intensity of therapy, reducing rehabilitation length of stay.

The Sacred Heart Rehabilitation Service has a separate documented policy for a trial of rehabilitation. This is referred to in the policy Referral to the Sacred Heart Rehabilitation Consultation Service and contained in the Sacred Heart Trial of Rehabilitation Policy.

7 St George Hospital St George Hospital Rehabilitation unit is a co-located unit within the St George Hospital.

The Rehabilitation unit provides treatment for patients who have had neurological injury, multi-trauma and lower limb amputations.

The unit has established an Intensity of Therapy Program (ITP) is to accelerate patient functional recovery in a subacute inpatient rehab setting through enhanced intensity of therapy, reducing rehabilitation length of stay.

8 Sutherland Hospital The Sutherland Hospital is a major metropolitan hospital and an associated teaching hospital of the University of NSW.

The Rehabilitation unit has established an Intensity of Therapy Program is to accelerate patient functional recovery in the subacute inpatient setting through enhanced intensity of therapy, reducing rehabilitation length of stay.

The average patient age is 86, with the main impairment types reconditioning (31%), orthopaedic fractures (20%) and orthopaedic replacements (20%)

The maximum capacity for the ITP at one time is 15 patients

Before the resourcing model was enhanced, patients received an average of 21 minutes of therapy a day, increasing to an average of 125 minutes a day for patients selected to the program

Patients receive therapy either from a multidisciplinary team, or a single discipline depending on their casemix

40


Day Hospital

9 Rankin Park Multidisciplinary focus

Referrals come from medical specialists in acute and subacute settings and also the community

Main impairment types of patients are stroke, neurological conditions and reconditioning

Appendix F

Document 9 -10

10 Calvary Hospital Calvary Day Hospital was established in 2006 and includes a combination of private and public beds. It is located close to the St George Hospital in Kogarah.

Provides a physiotherapy focus for patients

Referrals to Calvary’s day hospital are made from the inpatient unit and the community

The current patient mix is predominantly made up of orthopaedic patients (64%) and deconditioned / falls patients (18%), with an average age of 70 years.

Outpatients

11 St Vincent’s/ Sacred Heart Health Service

The primary objective of this Model of Care is to provide patients with rehabilitation services, avoiding a new or extended hospital admission. This service provides physiotherapy, occupational therapy, speech pathology, social work, dietetics and clinical and neuro-psychology services to patients in the local community.

Referrals are made from the hospital (high priority patients) and the community (lower priority patients)

The largest proportion of referrals to the outpatient program comprises of patients with neurological impairments.

Appendix F

Document 11

Home Based

12 St Vincent’s Rehabilitation In The Home (RITH)

The primary objective of this Model of Care is to provide patients with rehabilitation services in the home without requiring a new or extended hospital admission

The RITH program runs across Prince of Wales and St Vincent’s Hospitals with referrals made from both medical staff and allied health staff in the inpatient setting

Maximum capacity of 20 patients across both hospitals.

Main impairment types are orthopaedic and stroke.

Appendix F

Document 12

Outreach

13 Orange Base Hospital


Focus is on enhancing the care, assessment and management of Orthogeriatric patients through a consultative outreach service in

41


peripheral hospitals

Maintenance therapy is provided in neighbouring facilities, adopting a ‘Hub and Spoke’ Model of Care.

Appendix F

Document 13


Refer to Appendix A for the contact details of site contacts to further discuss or gain further documentation of communication strategies.

Step 4: Identify KPIs for monitoring the effectiveness your eligibility/admission and

‘ready for rehabilitation’ criteria

Now that you have enhanced or developed documented eligibility/admission criteria and ‘ready for rehabilitation criteria you need to define how you will measure the change in practice. Key performance indicators will assist to demonstrate changes and improvements in overall patient care.

Relevant key metrics from the evaluation framework have been provided in the Table 11 Monitoring measures from the evaluation framework11. When combined with other metrics collected and

analysed for all the tools and resources, a comprehensive approach to assessment of the performance of each care setting can be achieved.

Table 11 Monitoring measures from the evaluation framework


Average waiting time between assessment of a patient being ‘ready for rehab’ and when they start treatment

Site internal documentation Quarterly

% patients with multidisciplinary care plan within 7 days of admission

AROC


Number of episodes of care AROC


Number of occasions of service AROC


% of discharged patients with unplanned re-admissions (usually within 28 days of discharge)


Step 5: Action Plan




the toolkit.

Complete the action plan below with the activities, timeframes and activity owners for the tasks needed to develop your eligibility/admission and ‘ready for rehabilitation’ criteria.

Table 12 Action plan for decision tree for eligibility/admission and ‘ready for rehabilitation’ criteria


1.

2.

3.

4.

5.

43

6.

AAddmmiissssiioonn ccrriitteerriiaa ccoommpplleettiioonn

cchheecckklliisstt

Reviewed the core elements of eligibility / admission / ready for rehabilitation criteria


Reviewed the relevant exemplar tools and resources

Enhanced or developed relevant tools and resources to facilitate a rehabilitation service in-

line with the recommended standards for eligibility/admission and ‘ready for rehabilitation’

criteria


eligibility/admission and ‘ready for rehabilitation’ criteria

4 Referral forms for Rehabilitation services across care settings

Purpose of referral forms for Rehabilitation services across care settings:

A referral form provides a standardised mechanism for referral into rehabilitation care

settings. It provides background information for review of patients, initial information to

determine appropriateness of admission into the care setting, and to enable triage of

patients for assessment and review.

Activities

There are five key steps to be undertaken in reviewing your rehabilitation facilities referral

forms. These include:

1. Review the core elements of referral forms for rehabilitation services across care settings

2. Assess your service against these core elements using the checklist provided and identify the ‘gaps’ against the elements

6. Review the provided exemplars and resources to enhance or develop your tools for referral forms across care settings

3. Identify KPIs for monitoring the effectiveness of enhancing or implementing referral forms

4. Complete an action plan with tasks to complete, responsible/ accountable people and timeframes for completion

Referral forms across rehabilitation care settings in NSW:

The need for a comprehensive referral form varies by care settings. The following trends were reported at site visits and have been recommended in the toolkit:

Subacute inpatient co-located with the acute hospital: a screening tool for clinicians was considered adequate when referring to the co-located rehabilitation service as acute and subacute clinicians have established communication and interactions within the hospital. An example ‘lanyard style’ screening tool has been developed and can be found in Appendix D of the toolkit

Subacute inpatient located offsite (stand alone facility): a comprehensive referral form is considered necessary in this care setting as the receiving facility requires information for assessment and triage. An example comprehensive referral form has been developed and can be found in Appendix D of the toolkit

Ambulatory care settings: a comprehensive referral form is considered important in this care setting as receiving clinicians require background information for assessment and triage. An example comprehensive referral form for ambulatory care settings has been developed and can be found in Appendix D of the toolkit

45

Step 1: Review the core elements of referral forms for rehabilitation services across

care settings

The core elements of a ‘good practice’ referral form, as agreed by the ACI Rehabilitation Network Executive, for are outlined below.

* It should be noted that as stated above, referral forms across care settings will vary based on local processes. Referral forms should contain the majority of the core elements listed below, however with difference in care settings and patient cohorts these will need to be tailored at the local level.

Referral form core criteria/ elements:

Patient contact details

Referring facility/ professional (team contacts)

Principal diagnosis (clinical history/diagnosis)

Reason for referral (identified issues, aim, goals, program type, program length, type of rehab/ treatment)

Present functional level

Pre-morbid functional level and social history (eg lived alone in own home; residential aged care)

Risk assessment (eg falls risk, behaviour, mental health)

Familial/Carer and social support are available to participate and assist

Discharge:

o Discharge destination (planned) (eg home, Residential Aged Care Facility (RACF), son’s home)

o Potential barriers to discharge (eg requires home modifications)

Previous rehabilitation admissions (location) / length

Other relevant information (care setting specific)

o Precautions / contraindications


1. Do your referral forms enable clear and effective communication for assessment

and admission into your rehabilitation service?

2. Do your referral forms outline the patient condition, rehabilitation aims, and

planned discharge destination?

46


To assess whether your rehabilitation service is in line with the core elements/ criteria for your referral forms, please complete the following checklist.

Does your service have in place the following elements on your referral form?

Referral form checklist Full compliance

Partial compliance

Not in place

Patient contact details

Referring facility/ professional (team contacts)

Principal diagnosis (clinical history/diagnosis)

Reason for referral (identified issues, aim, goals, program type, program length, type of rehab/treatment)

Present functional level

Pre-morbid functional level and social history (eg lived alone in own home; residential aged care)

Risk assessment (eg falls risk, behaviour, mental health)

Familial/Carer and social support are available to participate and assist

Discharge:

Discharge destination (planned) (eg home, Residential Aged Care Facility (RACF ), child’s home)

Potential barriers to discharge (eg requires home modifications)

Previous rehabilitation admissions (location) /length

Other relevant information (care setting specific)

Precautions / contraindications

47

Notes:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

________________________________________________________________________________

Step 3: Review the provided exemplars and resources to enhance or develop your tools for referral forms across care settings

Now that you have assessed your referral form and identified the ‘gaps’ you can start to plan the resources required to enhance or develop these further.

Table 13 Referral forms used in selected NSW Rehabilitation services

Doc no.

Rehabilitation Site

Context Document type/ reference

Inreach to acute


St Vincent’s Hospital is a large 350 bed in the inner city of Sydney. The Hospital is a centre for heart and lung transplantation.

The primary objective of the MRT is to enhance the treatment of patients in the acute setting by providing simultaneous rehabilitation services.

Operates on a ‘pull’ system, whereby patients are identified and assessed before being selected to program. Selected patients will on average be seen by the MRT for ten days

Main impairment types of patients is reconditioning/restorative

Appendix F

Document 14

Subacute Inpatient

2 Rankin Park The subacute inpatient setting consists of 2 patient wards (20 beds each) which is co-located to the acute hospital


Referral forms currently being used across NSW hospitals are in a variety of forms; paper-based or electronic depending on the software used and maturity of IT systems and infrastructure in place at sites.

The process for referral to services varies from a detailed documented form to other informal methods (eg phone call or letters). This flexibility in referral processes was able to occur as a formal review/assessment by a rehabilitation CNC/Consultant was standard practice after a referral and prior to accepting patient for admission. Sites consulted agreed that a detailed referral form assists staff to identify appropriate rehabilitation patients and prevent inappropriate assessments.

A range of referral forms and processes were identified through site visits. Examples of referral forms across care settings by hospital are listed below in Table 13 Referral forms used in selected NSW Rehabilitation services and can be found in Appendix D.

49

Doc no.

Rehabilitation Site


Patients generally have complex conditions. Majority are older and have multiple co-morbidities. Appendix F

Document 15-17 3 St George Hospital St George Hospital Rehabilitation unit is a co-located unit within the St George Hospital.



4 Sutherland Hospital

The Sutherland Hospital is a major metropolitan hospital and an associated teaching hospital of the University of NSW.

The rehabilitation unit has established an Intensity of Therapy Program is to accelerate patient functional recovery in the subacute inpatient setting through enhanced intensity of therapy, reducing rehabilitation length of stay.

The average patient age is 86, with the main impairment types reconditioning (31%), orthopaedic fractures (20%) and orthopaedic replacements (20%)

The maximum capacity for the ITP at one time is 15 patients

Before the resourcing model was enhanced, patients received an average of 21 minutes of therapy a day, increasing to an average of 125 minutes a day for patients selected to the program

Patients receive therapy either from a multidisciplinary team, or a single discipline depending on their casemix

Day Hospital

5 Rankin Park Multidisciplinary focus

Referrals come from medical specialists in acute and subacute settings and also the community

Main impairment types of patients are stroke, neurological conditions and reconditioning

Appendix F

Document 18-19 6 Calvary Calvary Day Hospital was established in 2006 and includes a combination of private and public beds. It is located close to the St

George Hospital in Kogarah.

Provides a physiotherapy focus for patients

Referrals to Calvary’s day hospital are made from the inpatient unit and the community

The current patient mix is predominantly orthopaedic patients (64%) and deconditioned / falls patients (18%), approx age 70 yrs.

50

Doc no.

Rehabilitation Site


Outpatients


The primary objective of this Model of Care is to provide patients with rehabilitation services, avoiding a new or extended hospital admission. This service provides physiotherapy, occupational therapy, speech pathology and clinical and neuro-psychology services to patients in the local community.

Referrals are made from the hospital (high priority patients) and the community (lower priority patients)

The largest proportion of referrals to the outpatient program is made up of neurologically impaired persons.

Appendix F

Document 20

Home Based


The primary objective of this Model of Care is to provide patients with rehabilitation services in the home without requiring a new or extended hospital admission

The RITH program runs across Prince of Wales and St Vincent’s Hospitals with referrals made from both medical staff and allied health staff in the inpatient setting

Maximum capacity of 20 patients across both hospitals.

Main impairment types are orthopaedic and stroke.

Appendix F

Document 21

Outreach



Focus is on enhancing the care, assessment and management of Orthogeriatric patients through a consultative outreach service in peripheral hospitals


Appendix F

Document 22


Refer to Appendix A for the contact details of site/ LHD Rehabilitation Implementation leads to further discuss or gain further

documentation of communication strategies.

Example referral forms and checklists

Three example referral tools and forms have been provided below and can be tailored to care settings.

1. A screening tool developed to assist Acute Care treating teams in better identifying patients requiring referral to a rehabilitation service. This tool can be attached to ID badges, as a reference card or placed in other key areas within the wards for easy reference.

2. Standard referral forms for patients being referred to an admitted subacute care setting

(referring from out of service)

3. Standard referral forms for patients being referred to an ambulatory care setting (day

hospital, outpatients and hospital in the home)

The example referral tools have been provided in an editable format to enable amendments to be made to tailor it to the local LHD care setting.

Example Screening Tool

Referral screening criteria to the subacute admitted care setting (co-located care setting) which can be to be attached to identification cards/name badges.

Screening criteria for referral of admitted patients in a co-located care setting

1. LoS > 5 days in the acute setting

2. Requires two disciplines of therapy

3. Discharge has been delayed

4. The patient is medically able to participate

5. The patient/carer is willing to participate in the rehab program

6. Patient is likely to benefit from period of rehabilitation to improve functional capacity, in turn facilitating more timely discharge OR functional status precludes discharge to previous form of accommodation or independent living.

For referrals call: xxxxx

52

Example referral form – admitted subacute care setting (referring from out of service)

54

Example ambulatory care setting referral form

55

Step 4: Identify KPIs for monitoring the effectiveness of enhancing or implementing

referral forms

Now that you have developed referral forms you need to define how you will measure the change in practice. Key performance indicators will assist to demonstrate changes and improvements in overall patient care.

Relevant key metrics from the evaluation framework have been provided in the Table 14 Monitoring measures from the evaluation framework and other suggested measures14 below. When combined with other metrics collected and analysed for all tools and resources, and within the wider context of the evaluation framework, a comprehensive assessment of performance of each care setting can be achieved.



Number of rehabilitation referrals/ number of patients admitted and accepted into the rehabilitation service

Site internal documentation/ Audit

Six monthly

Step 5: Action Plan




the toolkit.


needed to develop and implement referral forms.

Table 15 Action plan for implementing referral forms

Action Responsible person Timeframe

1.

2.

3.

4.

5.

6.

56

RReeffeerrrraall ffoorrmm ccoommpplleettiioonn cchheecckklliisstt

Reviewed the core elements of referral forms



Enhanced or developed relevant tools and resources as required to bring the rehabilitation

service in-line with the elements of referral forms

Implemented the KPIs for monitoring the effectiveness of referral forms

57

Chapter 3: Assessment and service delivery

Referral Transfer of Care

Care

setting

5. Comprehensive assessment tool

for utilisation by an MDT

• A comprehensive assessment tool enables the MDT to

assess patients using a validated, consistent and standardised process.• The tool allows a baseline measure on which to assess

a patient’/s progress and monitor the effectiveness of treatment.

6. Education programs for patient

receiving rehabilitation

• Education programs aim to actively engage patients

and their families/ carers in their rehabilitation. It can assist them in understanding and managing their impairment, progression or disease or recovery, planned

therapy and the rehabilitation program.

5

Comprehensive assessment form and tool, for utilisation by a multi-disciplinary team

Purpose of a comprehensive assessment form and tool, for utilisation by a MDT:

A comprehensive multidisciplinary assessment tool enables the MDT to assess patients

using a validated, consistent and standardised process. The tool allows a baseline measure

on which to assess a patient’s progress and monitor the effectiveness of treatment. The tool

enables improved data collection and reporting across facilities, as well of benchmarking of

patient outcomes.

A comprehensive MDT assessment form can enhance the patient-centred care approach,

minimising duplicative assessments and enabling the documentation of key information in a

single location. The form is complementary to the assessment tool and as a communication

tool between the team, allows the assessment (e.g. FIM) score to be documented and

shared.

Activities

There are five key steps to be undertaken in reviewing your rehabilitation facilities’ assessment form and tools. These include:

1. Review the core elements of standards for assessment forms and tools


3. Review the provided exemplars and resources to enhance or develop your assessment form

4. Identify KPIs for monitoring of the effectiveness of enhancing or implementing the assessment form/tool

5. Complete an action plan with activity to complete, responsible owners and timeframes for completion

Philosophy of the assessment tool:

The assessment process enables comprehensive assessment of patient’s participating in a rehabilitation program. When choosing a standardised assessment tool, there are some important elements to consider:

The standardised MDT assessment tool should assess the essential domains of a rehabilitation program (independence, activity and participation)

The standardised assessment tool needs to be able to measure effectiveness and efficiency of the program and achievement of patient’s goals

Individual discipline specific tools should be available and used as appropriate

59

Step 1: Review the core elements of a comprehensive assessment form and tool, for

utilisation by a multi-disciplinary team

The core elements of ‘good practice’, as agreed by the ACI Rehabilitation Network Executive, are outlined below.

Assessment form and tool core criteria/ elements:

An assessment is conducted by the core multidisciplinary team on admission into the care setting.

A comprehensive assessment form is used and includes diagnosis, medical history, physical, psychological and social needs, outcome measures and transfer of care planning.

The assessment form outlines goals and timeframes to achieve the goals.

A standardised, evidence-based multi disciplinary assessment tool is used on admission and discharge at a minimum to assess function and outcomes of the program. Appropriate tools by care setting include:

o Admitted care setting: FIM

o Non-admitted care setting: Australian Modified Lawton’s IADL Scale7

Individual discipline specific assessment tools are used as appropriate throughout the admission to monitor individual disciplines treatment effectiveness.

Assessment and monitoring will occur throughout the patient stay to monitor treatment effectiveness.


1. How does the multi disciplinary team document and share assessment

information?

7 The AROC Ambulatory clinical data sets chief outcome measure is the Australian Modified Lawton’s IADL Scale. Information

can be accessed at http://ahsri.uow.edu.au/aroc/ambulatorydataset/index.html

Standardised assessment tools used by AROC

AROC (Australasian Rehabilitation Outcomes Centre) was established with a main goal of improving clinical rehabilitation outcomes by benchmarking rehabilitation providers nationally. AROC produces information on the efficacy of interventions through the systematic collection of outcomes information in the rehabilitation sector, both the inpatient and ambulatory settings. To do this effectively data is collected reliably and consistently.

The key tools used to track change and severity of disability within the AROC data dictionaries for both the Inpatient and Ambulatory settings are the FIM and Australian Modified Lawton’s IADL Scale respectively. These tools have been chosen as they have been shown to be sensitive, valid and reliable in their respective care setting. They are now being used to collect

and benchmark data across similar service models and patient groups

It should be noted that these tools measure rehabilitation outcomes in a broad context across the spectrum of care and service delivery models. As such, they are not designed, or intended, to replace existing patient, discipline, or service specific tools, but to be an additional tool used to enable benchmarking across all participating services.

http://ahsri.uow.edu.au/content/groups/public/@web/@chsd/@aroc/documents/doc/uow094509.pdf

http://ahsri.uow.edu.au/aroc/ambulatorydataset/index.html

60


To assess your rehabilitation service is in line with the core elements/criteria for assessment forms and tools, please complete the following checklist.

Does your service have the following elements on you documented multi disciplinary

assessment form and assessment tool?

Comprehensive assessment checklist Full compliance

Partial compliance

Not in place

A comprehensive assessment is documented by the core multidisciplinary team on admission into the care setting

Our assessment form includes:

Diagnosis

Medical history

Physical, psychological and social needs

Outcome measures

Transfer of care planning

Outline goals and timeframes to achieve the goals

A standardised, evidence-based multi disciplinary assessment tool is used on admission and discharge at a minimum to assess outcomes of the program

This is recorded on the assessment form or other relevant location

Individual discipline specific assessment tools are used as appropriate throughout the admission to monitor individual disciplines treatment effectiveness

The patient assessment will be repeated throughout the patient stay (at a minimum on admission and discharge for comprehensive assessments) to monitor treatment effectiveness.

Frequency of assessment will be based on the assessment type and individual patient needs.

61

Notes:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Step 3: Review the provided exemplars and resources to enhance or develop your

assessment form

Now that you have assessed your assessment form and tool and identified the ‘gaps’ you can start to plan the resources required to enhance or develop your service.

A range of assessment tools are currently being used across care settings in NSW. The most commonly reported assessment tools are outlined in the table below.

Table 16 Assessment tools used in NSW Rehabilitation services

Care setting Assessment tool

Admitted care setting Functional Independence Measure (FIM)

Goal Attainment Scale (GAS)

Individual discipline specific tools

Non-admitted care setting Lawton’s IADL assessment

Goal Attainment Scale (GAS) light

Functional Independence Measure (FIM)

Individual discipline specific tools

A range of comprehensive MDT assessment forms used in NSW were identified throughout the site visits. Examples of assessment forms across care settings by hospital are outlined in the table below and can be found in Appendix G.

Table 17 Assessment forms used in selected NSW Rehabilitation services

Doc no.

Rehabilitation Site

Context Document reference no.

Inreach to acute

1 St Vincent’s Hospital MRT

MRT Occupational Therapy and Physiotherapy Assessment

Appendix G Document 1

Subacute Inpatient

62

Doc no.

Rehabilitation Site

Context Document reference no.

2 POWH Rehabilitation plan and admission/ discharge goal sheet


Day Hospital

3 Rankin Park Parkinson’s program assessment form and assessment tools


4 Calvary Day Rehabilitation Initial assessment form


Outpatients

5 Rankin Park Physiotherapy amputee assessment


Home Based

6 St Vincent’s (RITH)

Initial assessment form


** Refer to the Define and assess section at the front of the toolkit for tips on enhancing/ developing

tools in your service

An example assessment form has is provided on the following pages to enable amendments to be made to tailor it to the local LHD care setting. An editable version of this tool can be found in Appendix G.

Refer to Appendix A for the contact details of site/ LHD Rehabilitation Implementation leads to further

discuss or gain further documentation of communication strategies.

63

Example assessment form for rehabilitation services

Page 1 of 3

64

Page 2 of 3

65

Page 3 of 3

66


assessment forms and tools

Now that you have enhanced or developed multidisciplinary assessment forms and tools you need to define how you will measure the change in practice. Key performance indicators will assist to demonstrate changes and improvements in overall patient care.

Relevant key metrics from the evaluation framework have been provided in the table below. When combined with other metrics collected and analysed for all tools and resources, and within the wider context of the evaluation framework, a comprehensive assessment of performance of each care setting can be achieved.



Improved Functional Status (measured by change in

FIM/Modified Lawton’s/ Goal Attainment Scale /Other)

AROC/site internal documentation

Quarterly

Step 5: Action Plan

To enable implementation of your new tools and resources, an action plan has been included as the

final step. The action plan is designed to assist with the creation of a detailed implementation plan,

enabling the capture of key activities, responsible owners and timeframes as you work through the

toolkit.


needed to implement multidisciplinary assessment forms and tools.

Table 19 Action plan for decision tree for implementing multidisciplinary forms and tools


1.

2.

3.

4.

5.

6.

67

CCoommpprreehheennssiivvee MMDDTT aasssseessssmmeenntt

ccoommpplleettiioonn cchheecckklliisstt

Reviewed the core elements of multidisciplinary forms and tools




recommended elements for multidisciplinary assessment forms and/or tools

Implemented KPIs for monitoring of the effectiveness of enhancing or implementing a

multidisciplinary assessment form and/or tool

6

An education program for patients receiving rehabilitation services and their families/carers

Purpose of education programs for patients and their families/carers:

Education programs for patients receiving rehabilitation services aim to actively engage

patients and their families/carers in their rehabilitation. An education program can assist

patients and families in understanding and managing their impairment, progression of

disease or recovery, planned therapy and the rehabilitation program. It is important for

enabling patient’s to meet their rehabilitation goals and can facilitate patient empowerment

and self management.

Education programs can be delivered in a variety of formats depending on the care setting,

the cohort of participants and the most effective mode of delivery. Education may be

delivered:

in group sessions

one-on-one sessions with individual disciplines

using handouts and written education material to patient involvement in self-

management

using internet resources from support networks, groups and peak bodies

using different technology to support delivery.

Activities

There are five key steps to be undertaken in reviewing your rehabilitation facilities’ education programs for patients and their families/carers. These include:

1. Review the core elements of standards for development of rehabilitation education programs for patients and carers


3. Review the provided exemplars and resources to enhance or develop your rehabilitation education program

4. Identify KPIs for monitoring the effectiveness of enhancing or implementing rehabilitation education programs

5. Complete an action plan with activities to complete, responsible owners and timeframes for completion

69

Step 1: Review the core elements of a education program for patient’s receiving

rehabilitation services and their families/carers

The core elements, as agreed by the ACI Rehabilitation Network Executive, for ‘good practice’ are outlined below.

Core criteria/ elements/ principles for the development of rehabilitation education programs

The following principles should be considered for education programs:

Rehabilitation services should have education programs in place for patients receiving rehabilitation.

Education programs should target the individual patient and/or family/carer with the opportunity for patient and family/ carer to be included, provide input and feedback into the programs.

Where possible, the education programs should be available in a group format.

Education tools can be disease specific and/or discipline specific.

Education programs should be holistic covering the physical, social and psychosocial aspects of recovery.

Education programs should include information brochures for patients and their families/ carer.

Education programs should be goal focussed, individualised and flexible for use at various points in the patient’s rehabilitation journey.

Individualised education program materials should be updated as the patient progresses in the rehabilitation program.

Checklists/ timetables should be in place to facilitate the patient receiving education.

Materials should be available in a language that accommodates literacy, impairment and reading age, in addition to language spoken.


1. Does your service include education programs that allow the inclusion of the patient’s family/carer?

2. Are your education programs currently provided in a variety of formats and supported by written material?

70

Step 2: Self assessment against the core elements/criteria

To ensure that your rehabilitation service is in line with the core elements/ criteria for your education programs for patient and their families/carers, please complete the following checklist.

Does your rehabilitation education program for patients and their families/carers contain the

following elements?

Patient / carer education checklist Full compliance

Partial compliance

Not in place

Rehabilitation service has education programs in place for patients receiving rehabilitation

The education program targets the individual patient and/or family/carer with the opportunity for patient and family/ carer to be included, provide input and feedback into the programs

Where possible, education programs are provided in a group format

Education tools provided to patients and their families/carers are disease specific and/ or discipline specific

The education program is holistic covering both the physical, social and psychosocial aspects of recovery.

The education program includes information brochures for patients and their families/ carer

The education programs are goal focussed, individualised and flexible for use at various points in the patient’s rehabilitation journey.

The individualised education program materials are updated as the patient progresses in the rehabilitation program.

The unit has checklists and/or a timetable to facilitate the patient receiving education.

Education materials are available in a language that accommodates literacy, impairment and reading age, in addition to language spoken.

71

Notes:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

________________________________________________________________________________


rehabilitation education program

Now that you have assessed your rehabilitation education program for patients and families/carers and identified the ‘gaps’ you can start to plan the resources required to enhance or develop these programs further.

Education programs for Rehabilitation services in NSW

Rehabilitation services in NSW vary in the extent, breadth and size of the education programs delivered to patients receiving rehabilitation. Some exemplar education programs for patients and their families/carers are discussed below:

Rankin Park day hospital delivers a structured comprehensive education program as part of their six to eight week Parkinson’s disease program and Falls prevention program. This structured program consists of education sessions delivered around the relevant topics to each group by members of the multi-disciplinary team. For example, the Parkinson’s disease program has a variety of topics around: exercise which is delivered by Physiotherapy; Speech, swallowing and voice problems, delivered by a Speech Pathologist; Activities of Daily Living delivered by the Occupational Therapist; and medical issues delivered by the rehabilitation consultant. An example program from Rankin Park is shown below in Table 20.

St Vincent’s Sacred Heart Rehabilitation department currently conducts a number of inpatient and outpatient programs including those with an education focus. These include:

− Clinical Psychology led Mindfulness and Relaxation group: this group is run by a clinical psychologist once a week in the inpatient unit (soon to be extended to outpatients). The purpose of the group is to provide education to help minimise suffering associated with pain, increased anxiety or decreased mood in the context of hospital admission and recovery. It is also designed to educate patients with coping mechanisms to enhance calmness.

− Carer Support Group: this group, run once a month by social work, started in 2013. Group was developed in accord with The Carer's Act 2010 and the Carers Charter of NSW. The Carers group provides opportunities to: receive education pertaining to the carer role; gain emotional support through sharing experiences and feelings with others in a similar role; discover ways of alleviating stress and learning relaxation techniques; learn about community services; and understand more about the condition and needs of the person for whom they care.

72

A range of education programs for patients and families/carers are being delivered across NSW and were identified through site visits. An example of a comprehensive group rehabilitation education program run at the Rankin Park Centre in Newcastle is shown in the table below.

This structure is an example of a group education program that could be delivered by members of the multidisciplinary team in a rehabilitation care setting as an adjunct to therapy and individual one-on-one specific education to meet the needs of the patient and family/carers. The topics and speakers can be flexed depending on the care setting and patient types in the rehabilitation service

Table 20 Exemplar Rehabilitation Patient and family/ carer weekly group education program

Session Topic Presenter

Week 1 Medical issues Medical officer

Week 2 Activities of Daily Living Occupational Therapy

Week 3 Mobility and exercise Physiotherapy

Week 4 Speech, swallowing and communication Speech Pathology

Week 5 Patient social issues and carer support Social worker

Week 6 Self care, medication management Registered nurse

Week 7 Nutrition in recovery and dietary management Dietician

Week 8 Impact of injury and social connectedness with the community

Mindfulness and relaxation

Clinical Psychologist

Week 9 Tai Chi Allied Health Assistant

In addition to group exercise programs individual disciplines educate patients and their families/carers on a one-on-one basis using pre-populated information, resources and exercise sheets. Rehabilitation services commonly utilise fact sheets and information guides produced for specific conditions (eg the National Stroke Foundation information booklets, locally developed amputee care guides).

Examples of resources available for rehabilitation services are provided in the table below.

Table 21 Rehabilitation education material for patients and their families/carers

Impairment type Education resource Links

1 Stroke National Stroke Foundation

-What is a stroke

-After stroke information

-Prevention

StrokeEngine – education materials for individuals with

stroke and their families

Stroke Recovery Association NSW

The Heart Foundation

The Stroke Society of Australasia

National Stroke

Foundation

StrokeEngine

Stroke Recovery

Association NSW

The Heart Foundation

The Stroke Society of

Australasia

2 Brain Injury Brain Injury Australia Brain Injury Australia

http://strokefoundation.com.au/

http://strokefoundation.com.au/

http://strokengine.ca/family/index.php

http://www.strokensw.org.au/

http://www.strokensw.org.au/

http://www.heartfoundation.org.au/Pages/default.aspx

http://www.strokesociety.com.au/

http://www.strokesociety.com.au/

http://www.braininjuryaustralia.org.au/

73


Brain Injury Association of NSW

The Brain Injury Centre

Synapse Reconnecting Lives (Formally QLD Brain Injury

Association)

Centre for Neuro Skills (USA)

Brain Injury Association of

NSW

The Brain Injury Centre

Synapse Reconnecting

Lives (Formerly QLD Brain

Injury Association)

Centre for Neuro Skills

(USA)

3 Neurological

conditions MS Australia

Parkinson’s Australia

Motor Neurone Disease Australia

Australian Huntington’s Disease Association

National Institute of Neurological Disorders and Stroke

MS Australia

Parkinson’s Australia

Motor Neurone Disease

Australia

Australian Huntington’s

Disease Association

National Institute of

Neurological Disorders and

Stroke

4 Spinal cord injury Spinal Cord Injuries Australia (resource and knowledge

centre library)

The Spinal Cord Injury Network

Lifetime Care and Support Authority

Spinal Cord Injuries

Australia

The Spinal Cord Injury

Network

Lifetime Care and Support

Authority

5 Amputation of limb Amputee Association of NSW Amputee Association of

NSW

6 Arthritis Arthritis Australia

Agency for Clinical Innovation Osteoarthritis Chronic

Care Program Model of Care

Arthritis Australia

Agency for Clinical

Innovation Osteoarthritis

Chronic Care Program

Model of Care

7 Pain syndromes Pain Australia

Australian Pain Management Association

Pain Australia

Australian Pain

Management Association

8 Orthopaedic

conditions

Australian Orthopaedic Association Australian Orthopaedic

Association

9 Cardiac The Heart Foundation The Heart Foundation

10 Pulmonary Lung Foundation Australia resources (eg Pulmonary

Rehabilitation Toolkit)

The Thoracic Society of Australia and New Zealand

Lung Foundation Australia

The Thoracic Society of

Australia and New Zealand

11 Burns The Australian and New Zealand Burns Association The Australian and New

Zealand Burns Association

http://www.biansw.org.au/

http://www.biansw.org.au/

http://www.braininjurycentre.com.au/aus/index.php?option=com_content&view=frontpage&Itemid=1

http://synapse.org.au/



http://www.neuroskills.com/

http://www.neuroskills.com/

http://www.resus.org.au/policy/guidelines/section_9/head_injury.htm

http://www.parkinsons.org.au/

http://www.mndaust.asn.au/

http://www.mndaust.asn.au/

http://www.ahdansw.asn.au/

http://www.ahdansw.asn.au/

http://www.ninds.nih.gov/



http://scia.org.au/

http://scia.org.au/

https://spinalnetwork.org.au/

https://spinalnetwork.org.au/

http://www.lifetimecare.nsw.gov.au/

http://www.lifetimecare.nsw.gov.au/

http://www.amputeesnsw.org.au/

http://www.amputeesnsw.org.au/

http://www.arthritisaustralia.com.au/index.php/arthritis-information/information-sheets.html

http://www.aci.health.nsw.gov.au/models-of-care/musculoskeletal/osteoarthritis-chronic-care-program




http://www.painaustralia.org.au/

http://www.painmanagement.org.au/home

http://www.painmanagement.org.au/home

http://www.aoa.org.au/

http://www.aoa.org.au/

http://www.heartfoundation.org.au/Pages/default.aspx

http://www.lungfoundation.com.au/

http://www.thoracic.org.au/

http://www.thoracic.org.au/

http://www.anzba.org.au/

http://www.anzba.org.au/

74


12 Re-conditioning/

restorative

Stepping on – A falls prevention program

NSW Health - Staying active and on your feet

Active & Healthy Guide

Stepping on – A falls

prevention program

Staying active and on your

feet

Active & Healthy Guide

Step 4: Identify KPIs for monitoring the effectiveness of education programs for

patients and families/carers

Now that you have enhanced or developed your education programs for patient and their families/carers you need to define how you will measure the change in practice. Key performance indicators will assist to demonstrate changes and improvements in overall patient care.

Relevant key metrics from the evaluation framework have been provided in Table 22 Monitoring measures from the evaluation framework21 below. When combined with other metrics collected and analysed for all tools and resources, and within the wider context of the evaluation framework, a comprehensive assessment of performance of each care setting can be achieved.



% patient/carer with a patient/carer education program Site internal documentation/ PETs

Six monthly

The Health Coaching Australia Model of Health Change

Calvary Hospital has trained a number of rehabilitation clinicians in health coaching and behaviour change

through workshops with Health Coaching Australia (HCA).

The HCA Model of behaviour change is a clinical practice decision framework that enables clinicians to

integrate client-centred communication and health behaviour change support into clinical consultation and

programs. Although the HCA training was established through the NSW Health Chronic Disease

Management Program connecting care in the community program people with chronic condition(s) the

health change approach can be applied to any individual or group setting where clients or patients are

required to take some action to achieve better health or quality of life outcomes. The techniques are

applicable across the spectrum of health goals and clinical contexts including the rehabilitation setting.

Other conditions it is applicable to include chronic condition management, disability, disease prevention

and health wellness. For further information see the HCA website.

http://www.steppingon.com/

http://www.steppingon.com/

http://www.cec.health.nsw.gov.au/__documents/programs/falls-prevention/stay-active.pdf

http://www.cec.health.nsw.gov.au/__documents/programs/falls-prevention/stay-active.pdf

http://www.activeandhealthy.nsw.gov.au/

http://www.healthchangeaustralia.com/

75

Step 5: Action Plan

To enable implementation of your new education resources and tools, an action plan has been

included as the final step. The action plan is designed to assist with the creation of a detailed

implementation plan, enabling the capture of key activities, responsible owners and timeframes as

you work through the toolkit.

Fill out the action plan below with the activities, timeframes and activity owners for the tasks needed

to complete the development of education programs for patient and their families/ carers.

Table 23 Action plan for the development of education programs


1.

2.

3.

4.

5.

6.

PPaattiieenntt//ccaarreerr eedduuccaattiioonn ccoommpplleettiioonn

cchheecckklliisstt

Reviewed the core elements of the development of education programs for patients and

their families/carers



Enhanced or developed education programs for patients and their families/carers to facilitate

the alignment of the rehabilitation service with the core elements

Implemented KPIs for monitoring the effectiveness of enhancing or implementing education

programs for patient and their families/carers

76

Chapter 4: Transfer of care / Discharge

Referral Transfer of care/

Discharge

Care

setting

7. Discharge principles • A set of documented elements that promote a

consistent planning process from the point of admission for discharge/ transfer of care.

8. Process for the transfer of

information between care settings/ Clinical checklists to prepare for transfer of care

• A documented process for the transfer of care,

including information between care settings, aims to improve care coordination, patient care and patient flow through care settings.

7 Transfer of Care / Discharge principles

Purpose of transfer of care / discharge principles:

Transfer of Care / Discharge principles are a set of documented standards that promote a

consistent planning process from the point of admission to transfer of care / discharge of a

patient. Implementation of these elements will enhance patient outcomes, safety and

experience and assist sites to ensure patients are being reviewed on a regular basis and

being discharged in a timely manner to the most appropriate care setting/ home.

Activities

There are five key steps to be undertaken in reviewing your rehabilitation facilities discharge practices. These include:

1. Review the core elements of standards for discharge principles


3. Review the provided exemplars and resources to enhance or develop your transfer of care/ standards for discharge

4. Identify KPIs for monitoring the effectiveness of enhancing or implementing the documented principles


78

Step 1: Review the core elements of a transfer of care / discharge principles

The ‘good practice’ transfer of care / discharge principles, as agreed by the ACI Rehabilitation Network Executive, are outlined below.

Transfer of Care / Discharge principles

Discharge planning commences at the point of admission.

Discharge planning is a transparent process that is collaborative and includes the patient/carer in the planning process.

Patients all have clear documented rehabilitation goals established on admission.

A documented Estimated Date of Discharge (EDD) or treatment timeframe is set for each patient (in line with rehabilitation goals) to establish projected date to coordinate patients requirements and transfer of care.

The assessment of readiness for discharge is based on attainment of rehabilitation goals.

Reassessment against patient goals takes place throughout the patient admission to ensure patient is tracking towards projected admission timeframes.

The rehabilitation goals have been met for that setting or the patient is unable to progress further with treatment.

The patient does not require ongoing care in that setting, but is safe to complete rehabilitation in a less resource intensive care setting or has completed rehabilitation for that episode of care.

The discharge environment is suitable for the patient’s needs (eg subacute setting, home, supported accommodation).

The patient / carer as well as all medical, nursing and allied health staff involved in the patient’s care participate in decision making for transfer of care / discharge.


1. Is there a process in place to enable the planning of discharge from the point of

admission?

2. Does your rehabilitation facilities discharge process facilitate the inclusion of

patients and families/carers in planning and decision-making?

79

Step 2: Self assessment against the principles

To assess whether your rehabilitation service is in line with the core principles for discharge, please complete the following checklist.

Does your rehabilitation service incorporate the core principles for discharge?

Transfer of care / discharge principles checklist Full compliance

Partial compliance

Not in place

Discharge planning commences at the point of admission

Discharge planning is a transparent process that is collaborative and includes the patient/carer in the planning process

Clear documented rehabilitation goals on admission

A documented Estimated Date of Discharge (EDD) or treatment timeframe is set for each patient (in line with rehabilitation goals) to establish projected date to coordinate patients requirements and transfer of care

The assessment of readiness for discharge is based on attainment of rehabilitation goals.

Reassessment against patient goals takes place throughout the patient admission to ensure patient is tracking towards projected admission timeframes

The rehabilitation goals have been met for that setting or the patient is unable to progress further with treatment

The patient does not require ongoing care in that setting, but is safe to complete rehabilitation in a less resource intensive care setting or has completed rehabilitation for that episode of care.

The discharge environment is suitable for the client needs (eg subacute setting, home, supported accommodation).

The patient / carer as well as all medical, nursing and allied health staff involved in the patients care participate in decision making to transfer care / discharge.

80

Notes:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

________________________________________________________________________________


transfer of care/ standards for discharge

Now that you have assessed your discharge process and identified the ‘gaps’ you can start to plan the resources required to enhance or develop this process further.

NSW Health has developed a Policy Directive and set of resources around discharge/ the process for

‘transfer of care’ entitled Care Coordination: Planning from Admission to Transfer of Care in NSW

Public Hospitals. The policy directive outlines the five steps in coordinating patient care to improve the

patient experience and improve patient flow within the hospital. Each Health Service is required to

meet the standards outlined in the policy.

The policy and associated documents to assist implementation, and the links to access these are

provided in the table below. While these apply predominantly to the inpatient care setting, the

elements are applicable in the ambulatory care setting as well.

Table 24 NSW Health Policy Directive and associated documents around discharge

Document Type Hyperlink to website and resource Summary

Policy Directive From Admission to Transfer of Care in NSW Public Hospitals Policy Directive (PD2011_015)

Reference Manual Care Coordination: From Admission to Transfer of Care in NSW Public Hospital - Reference Manual

These documents provide

additional information and

guidance to assist staff with

the implementation of the

mandatory requirements of

the Care Coordination; From

Admission to Transfer of Care

in NSW Public Hospitals

Policy Directive

(PD2011_015).

Staff education book Care Coordination: Planning from Admission to Transfer of Care in NSW Public Hospital - Staff Booklet

Patient brochure Care Coordination Patient Brochure

http://www.health.nsw.gov.au/policies/pd/2011/PD2011_015.html



http://www.health.nsw.gov.au/pubs/2011/care_coordination_referen.html



http://www.health.nsw.gov.au/pubs/2011/care_coordination_staff_b.html



http://www.health.nsw.gov.au/pubs/2011/care_coordination_patient.html

81


transfer of care / discharge principles

Now that you have enhanced or developed a process to implement the transfer of care / discharge principles you need to define how you will measure the change in practice. Key performance indicators will assist to demonstrate changes and improvements in overall patient care.




Number of delayed discharges AROC v4

Site internal documentation

Quarterly

Proportion of patients with discharge plan AROC


Quarterly

% patients discharged to a form of accommodation AROC


Quarterly

Step 5: Action Plan

To enable implementation of the discharge principles, an action plan has been included as the final

step. The action plan is designed to assist with the creation of a detailed implementation plan,


toolkit.

Fill out the action plan below with the activities, timeframes and activity owners for the tasks needed

to complete an approach to implementing the discharge principles.

Table 26 Action plan for discharge principles


1.

2.

3.

4.

5.

6.

82

TTrraannssffeerr ooff ccaarree // ddiisscchhaarrggee pprriinncciipplleess

ccoommpplleettiioonn cchheecckklliisstt

Reviewed the core principles of discharge


Reviewed the relevant resources

Enhanced or developed relevant tools and resources to align the rehabilitation service with

the recommended standards for discharge


discharge principles

8

A process for the transfer of care, including information transfer between care settings and/or to final discharge destination

Purpose of a process for the transfer of care:

A documented process for the transfer of care, including relevant patient information

between care settings aims to improve care coordination, patient care and patient flow

through care settings.

Transfer of care clinical checklists aim to improve patient safety, communication, and patient

flow within the hospital, and improve the patient experience. Clinical checklists aim to

provide a documented set of tasks which need to be met before a patient can be discharged

or transferred to another facility. A health professional is responsible for ensuring the details

are checked, completed and agreed to by the patient before leaving the care setting.

Activities

There are five key steps to be undertaken in reviewing your rehabilitation facilities process for the transfer of care. These include:

1. Review the core elements of standards for processes for the transfer of care


3. Review the provided exemplars and resources to enhance or develop your process for the for transfer of care

4. Identify KPIs for monitoring the effectiveness of enhancing or implementing the documented criteria


84

Step 1: Review the core elements of the process for the transfer of care

The core elements for ‘good practice’, as agreed by the ACI Rehabilitation Network Executive, for the transfer of information between care settings are outlined below.

Transfer of care core criteria/ elements

Clinician to clinician communication to agree on the transfer and confirm that the patient is ‘medically stable’ or other important admission criteria are met.

A Transfer of Care summary with a clear management plan is sent to appropriate stakeholders or given to the patient

A clinical checklist or equivalent is completed to prepare for transfer of care for all appropriate admitted patients before they return to the community. The transfer of care checklist must cover the following information

8:

o Estimated date of transfer

o Destination of transfer (including equipment/ home medications provided/ completed)

o Notification transport booked

o Personal items returned

o Referral services booked

o Patient/care education completed

o Care plan

o Transfer of care summary provided to patient that includes medication information, community and GP referral information and follow up appointments.

All other documentation (eg diagnostic results) and referrals are packaged and provided for the patient at time of transfer of care

Transfer of care to an inpatient setting should occur within agreed timeframes


1. Does your rehabilitation facility have a documented process for the transfer of

care?

2. Are there established communication processes between rehabilitation services

and care settings to enable good practice transfer of care?

8 NSW Health Policy Directive. Care Coordination: Planning from Admission to Transfer of Care in NSW Public Hospitals.

PD2011_015.

85


To assess whether your rehabilitation service processes are in line with the core elements/ criteria for the process for the transfer of care, please complete the following checklist.

Does your service have in place the following elements for the transfer of care?

Transfer of Care process checklist Full compliance

Partial compliance

Not in place

Clinician to clinician communication to agree on the transfer and confirm that the patient is ‘medically stable’ or other important admission criteria are met.

A Transfer of Care summary with a clear management plan is sent to appropriate stakeholders or given to the patient

A clinical checklist or equivalent is completed to prepare for transfer of care for all appropriate admitted patients before they return to the community. The transfer of care checklist must cover the following information:

Estimated date of transfer

Destination of transfer (including equipment/ home medications provided/ completed)

Notification transport booked

Personal items returned

Referral services booked

Patient/care education completed

Care plan

Transfer of care summary provided to patient that includes medication information, community and GP referral information and follow up appointments.

All other documentation (eg diagnostic results) and referrals are packaged and provided for the patient at time of transfer of care

Transfer of care to an inpatient setting should occur within agreed timeframes

86

____________________________

Notes:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

________________________________________________________________________________

An example transfer of care checklist and can be tailored to the local LHD care setting. The checklist

can be found on the following page and an editable tool can be found in Appendix H.

The National Safety and Quality Health Service (NSQHS) Standards1

The NSQHS Standards are designed to assist health services to deliver safe and high quality

care and provide a nationally consistent and uniform set of measures of safety and quality for

application across a wide variety of health care services. The Standards are integral to the

accreditation process as they determine how and against what an organisation’s performance

will be assessed.

Standard 6: Clinical Handover is one of the 10 standards. This standard aims to ensure there is

timely, relevant and structured clinical handover that supports safe patient care. Standard 6:

Clinical Handover requires health service organisations to implement documented systems for

effective and structured clinical handover.

87

Example clinical checklist for transfer of care

88


process for the transfer of care

Now that you have assessed your transfer of care process and identified the ‘gaps’ you can start to plan the resources required to enhance or develop these further.

Table 27 Transfer of care tools used in selected NSW Rehabilitation services

Doc No.

Rehabilitation Site

Context Documents reference no.

Subacute Inpatient

1 Rankin Park/ HNELHD

The subacute inpatient setting consists of 2 patient wards (20 beds each) which is co-located to the acute hospital


Patients generally have complex conditions. Majority are older and have multiple co-morbidities.

The Rankin Park Centre uses a documented ‘Trial discharge/discharge checklist’ in which activities and items to be completed prior to discharge are outlined and responsibilities allocated to clinicians (eg rehabilitation activities coordinator and the allocated nurse). This checklist was designed after a review of the units discharge planning process.

Appendix H Document 1

2

St Vincent’s Hospital/ Sacred Heart Rehabilitation

Sacred Heart Rehabilitation unit is co-located to St Vincent’s Hospital.

The unit provides seven-day rehabilitation to a range a wide range of conditions.


The Sacred Heart Rehabilitation Service at St Vincent’s Hospital has a clinical checklist on the back of the inpatient care plan in which the nursing staff responsible for the patient on the day of discharge would check the patient is ready and safe for discharge.


3 St George Hospital/ SESLHD

St George Hospital Rehabilitation unit is a co-located unit within the St George Hospital.



SESLHD has created a transfer of care checklist for people being admitted and discharged from facilities. The discharge checklist contains a series of Yes/No questions for those being transferred to another facility, to residential aged care facilities and discharged to home.


4 Greater Western AHS

The Far West Local Health District has a small number of rehabilitation beds at Broken Hill Hospital. Rehabilitation services are provided to a limited extent

Transfer of information between care settings

In the inpatient setting clinician to clinician communication takes place to agree the transfer of care and provide details on medical status or therapy goals to individual allied health disciplines.

The ISBAR (Introduction, Situation, Background, Assessment, and Recommendation) handover tool is commonly used when conducting handover between care settings. In addition, a transfer of care summary and/or MDT discharge summary with a clear plan for ongoing management and referral to specialities is seen as ‘good practice’ to accompany the patient on transfer. This occurs between the inpatient settings and non-admitted care settings in NSW rehabilitation facilities.

89

Doc No.

Rehabilitation Site

Context Documents reference no.


Outreach



Focus is on enhancing the care, assessment and management of Orthogeriatric patients through a consultative outreach service in peripheral hospitals


Appendix H Document 5 - 6

** Refer to the Define and assess section at the front of the toolkit for tips on enhancing/ developing

tools in your service

Transfer of care checklists

Transfer of care checklists are commonly completed in the 24 – 48 hours prior to discharge by staff to prepare for a patients discharge. They outline the key elements to be considered and checked prior to the patient being transferred to another care setting or discharged home.

Common elements in a transfer of care checklist are outlined in the NSW Health Policy directive ‘Care Coordination: Planning from admission to transfer of care in NSW Public Hospitals’ (PD2011_015). These are listed below:

Confirm discharge arrangements with the patient, their family and the service providers.

Confirm transport arrangements 24 hours before discharge.

Ensure GP letter is written and order patients medication to take home.

Ensure the patient has received and been educated in the use of any aids / equipment.

Ensure Medical (sick) Certificate is written if required.

The policy states that this is not an exhaustive list and each health service/ unit should build on these fundamentals to address specific local circumstances.

Refer to Appendix A for the contact details of site contacts to discuss or gain further documentation

of communication strategies.

____________________________

90

Step 4: Identify KPIs for monitoring of the effectiveness of enhancing or implementing

a process for the transfer of care

Now that you have enhanced or developed a process for the transfer of care you need to define how you will measure the change in practice. Key performance indicators will assist to demonstrate changes and improvements in overall patient care, for example you may need to develop a selection of process measures to assess the effectiveness of the transfer of care document in your LHD.




Number of delayed discharges AROC v4


Quarterly

Proportion of patients with discharge plan AROC


Quarterly

Step 5: Action Plan

To enable implementation of your new resources and tools an action plan has been included as the

final step. The action plan is designed to assist with the creation of a detailed implementation plan,


toolkit.


needed to complete the process for the transfer of care and checklist.

Table 29 Action plan process for the transfer of care


1.

2.

3.

4.

5.

6.

91

TTrraannssffeerr ooff ccaarree pprroocceessss ccoommpplleettiioonn

cchheecckklliisstt

Reviewed the core elements of transfer of care




recommended elements for transfer of care

Implemented KPIs for monitoring the effectiveness of enhancing or implementing the

elements

92

Appendices

Acknowledgements:

The development of this toolkit has been achieved with contribution from the Agency for Clinical

Innovation Rehabilitation Network Executive who has provided direction and assistance.

A special thank you to the NSW Rehabilitation Services who have been involved in the consultation

process and who have kindly contributed their tools and references for inclusion in this toolkit.

Sites included are:

Rankin Park Centre, Hunter New England Local Health District

St Vincent’s Hospital, St Vincent’s Health Network

The Prince of Wales Hospital, Calvary Hospital, The Sutherland Hospital and St George Hospital, South Eastern Sydney Local Health District.

Orange Base Hospital, Western NSW Local Health District.

Please Note: The forms sourced from St Vincent’s Hospital include the old St Vincent’s Hospital logo.

Appendices D to H outlines the tools and references collected from Rehabilitation facilities throughout

NSW.

93

Appendix A. Rehabilitation Network Contacts

Key contact - ACI

Selected Site Rehabilitation – site contacts (as at May 2013)

LHD Site Name Position Contact details

HNELHD Rankin Park Kathy

Bullen

Service Manager

Rankin Park Centre [email protected]

SVHN St Vincent’s

Hospital

A/Prof

Steven

Faux

Director

Rehabilitation

Services

[email protected]

SESLHD St George

Hospital

John Estell Director

Rehabilitation

Medicine

[email protected]

SESLHD Sutherland

Hospital

Philip

Conroy

Director

Rehabilitation

Medicine

[email protected]

SESLHD POWH Greg

Bowring

Director

Rehabilitation

Medicine

[email protected]

WNSWLHD Orange

Base

Hospital

Kate

Polain

Clinical Nurse

Consultant -

Rehabilitation

[email protected]

WNSWLHD Orange

Base

Hospital

Tracey

Drabsch

Physiotherapist

Sub-acute Care

Team

[email protected]

Claire O'Connor

Rehabilitation Network Manager

Agency for Clinical Innovation

Tel: (02) 9464 4639

Email: [email protected]

mailto:[email protected]






mailto:Claire.O'[email protected]

94

Appendix B. List of tables and figures in the toolkit

Figures:

Figure 1 NSW Rehabilitation Model of Care ............................................................................................ 1

Figure 2 An integrated Rehabilitation Model of Care ............................................................................... 2

Figure 3 Example project structure and roles .......................................................................................... 5

Figure 4 Decision tree for appropriate referral to rehabilitation services ............................................... 18

Tables:

Table 1 Care Settings as defined in the NSW Rehabilitation Model of Care ........................................... 1

Table 2 Rehabilitation Implementation Toolkit tools and guidelines ........................................................ 4

Table 3 Criteria for appropriate care setting referral .............................................................................. 19

Table 4 Appropriate care setting referral tools used in selected NSW rehabilitation services .............. 20

Table 5 Monitoring measures from the evaluation framework and other suggested measures ............ 21

Table 6 Action plan for decision tree for appropriate care setting referral ............................................. 22

Table 7 Communication tools used in selected NSW rehabilitation services ........................................ 27

Table 8 Monitoring measures from the evaluation framework and other suggested measures ............ 31

Table 9 Action plan for communication standards ................................................................................. 31

Table 10 Eligibility / admission criteria used in selected NSW Rehabilitation services ......................... 38

Table 11 Monitoring measures from the evaluation framework ............................................................. 42

Table 12 Action plan for decision tree for eligibility/admission and ‘ready for rehabilitation’ criteria ..... 42

Table 13 Referral forms used in selected NSW Rehabilitation services ............................................... 48

Table 14 Monitoring measures from the evaluation framework and other suggested measures .......... 55

Table 15 Action plan for implementing referral forms ............................................................................ 55

Table 16 Assessment tools used in NSW Rehabilitation services......................................................... 61

Table 17 Assessment forms used in selected NSW Rehabilitation services ......................................... 61


Table 19 Action plan for decision tree for implementing multidisciplinary forms and tools ................... 66

Table 20 Exemplar Rehabilitation Patient and family/ carer weekly group education program ............ 72

Table 21 Rehabilitation education material for patients and their families/carers ................................. 72


Table 23 Action plan for the development of education programs ........................................................ 75

Table 24 NSW Health Policy Directive and associated documents around discharge ......................... 80


Table 26 Action plan for discharge principles ........................................................................................ 81

Table 27 Transfer of care tools used in selected NSW Rehabilitation services .................................... 88


Table 29 Action plan process for the transfer of care ............................................................................ 90

95

Appendix C. Glossary

Acronym Description

ACI Agency for Clinical Innovation

AROC Australasian Rehabilitation Outcomes Centre

ART Acute Rehabilitation Team

FIM Functional Independence Measure

GP General Practitioner

ITP Intensity Therapy Program

KPI Key Performance Indictor

LHD Local Health District

MDT Multidisciplinary Team

MoC Model of Care

MRT Mobile Rehabilitation Team

NSW New South Wales

RITH Rehabilitation In The Home

PET Patient Experience Tracker

96

Appendix D: Tools and Resources to implement and monitor

1. Checklists for each of the eight processes, tools, guidelines

2. Evaluation and Monitoring Tool

3. Implementation Plan Template

4. Communication Plan Template

97

Appendix E. Tools and resources across the patient journey

Appropriate care setting referral process

Doc

No

Rehabilitation

Site/ policy

Sample documents

Referral/ admission

1 St George

Hospital

Rehabilitation (inpatient) Admission criteria: St George Hospital. Clinical Business

Rule SGSHHS CLIN203 (2012) – Appendix 1: SESLHD Rehabilitation Referral

Protocol for Patients in St George Hospital (page 5).

2 St Vincent’s

Hospital

St Vincent’s Hospital Sydney Referral to Sacred Heart Rehabilitation Consultation

Service Policy (Policy 1.32). Figure 1 Referral flow chart for the Sacred Heart

Consultation Service (page 4).

3 Orange Base

Hospital

Sub-acute care team Orthogeriatrics for neighbouring facilities.

Standards for effective communication with patient and families/ carers

Doc

No

Rehabilitation

Site/ policy

Communication tool

Referral/ admission

4 Rankin Park Rankin Park Centre Patient Information Pack

5 NSW Health Policy

Directive

The NSW Health, Your Health Rights and Responsibilities policy directive9

Assessment and service delivery

6 Rankin Park Rehabilitation Coordinator/ case manager role: The Rehabilitation Activities Coordinator (RAC) job description

7/ 8 Calvary Day Hospital/ POWH

Weekly Multi-Disciplinary Team (MDT) meetings or MDT case conferences.

9 St Vincent’s Hospital/ Sacred Heart Rehab

Family meetings template – currently being trialled.

Discharge/transfer of care

10 St Vincent’s Rehabilitation In The Home

Discharge summaries

11 Rankin park Flag and Track program

12 Rankin Park Inpatient follow up phone call

9 NSW Health, Your Health Rights and Responsibilities policy directive (Document Number PD2011_022). Accessed at:

http://www0.health.nsw.gov.au/policies/pd/2011/pdf/PD2011_022.pdf

98

Appendix F. Tools and resources for referral and admission

Eligibility, admission and guidelines for ‘ready for rehabilitation’

Doc No

Rehabilitation Site Sample document

Inreach to acute


St Vincent’s Hospital Mobile Rehabilitation Program Admission and Service Criteria Procedure (2012)

2 St George Hospital Acute Rehabilitation Team (ART)

SESLHD. Acute Rehabilitation Team (ART) guidelines - St George Hospital (Clinical Business Rule SGSHHS CLIN164)

3 Orange Orthogeriatric Inreach

Orange Health Service – Operational Procedure Subacute care team Inclusion criteria (Hub site)

Subacute Inpatient

4 Rankin Park Referral and admission process for Rankin Park Centre (Inpatient) - Document Number: GNC RPC 12_064.

5

6

St Vincent’s Hospital/ Sacred Heart Rehabilitation

St Vincent’s Hospital Sydney Referral to Sacred Heart Rehabilitation Consultation Service Policy

Sacred Heart Rehabilitation Service – Trial of Rehabilitation program

7 St George Hospital SESLHD. Rehabilitation (inpatient) admission criteria: St George Hospital (Clinical Business Rule SGSHHS CLIN203)

8 Sutherland Hospital SESLHD. Sutherland Hospital. Admission to Killara Rehabilitation beds criteria.

Day Hospital

9 Rankin Park HNELHD. Rankin Park Day Hospital admission criteria (Document Number: GNC RPC 12_060)

10 Calvary Hospital Calvary Health Care. Admission criteria policy – Day Hospital

Outpatients


Sacred Heart Health Service Operational Procedure Rehabilitation Outpatient Operational Procedures

Home Based


SVH Rehabilitation in The Home Referral and Service Criteria Procedure

Outreach


Orange Health Service – Operational Procedure Subacute care team Inclusion criteria (Spoke site)

99

Referral forms

Doc No

Rehabilitation Site Sample documents

Inreach to acute


St Vincent’s Hospital electronic Web deLacy referral from

Subacute Inpatient

15 Rankin Park Rankin Park Centre Inpatient Referral form

16 St George Hospital Rehabilitation Services Referral (contained within admission policy)

17 Sutherland Hospital Killara Rehabilitation unit referral form

Day Hospital

18 Rankin Park Rankin Park Day Hospital Referral form – Rehabilitation/ Falls

19 Calvary Hospital Calvary Hospital rehabilitation referral form

Outpatients


St Vincent’s Hospital Sacred Heart Rehabilitation Outpatient Referral

Home Based


St Vincent’s Hospital Rehabilitation In The Home referral form

Outreach


Orange Health Service - Subacute care team referral form.

100

Appendix G. Tools and resources for assessment and service delivery

Assessment form

Doc No


Inreach to acute


MRT Occupational Therapy and Physiotherapy Assessment

Subacute Inpatient

2 POWH Rehabilitation plan and admission/ discharge goal sheet

Day Hospital

3 Rankin Park Parkinson’s program assessment form and assessment tools

4 Calvary Hospital Day Rehabilitation Initial assessment form

Outpatients

5 Rankin Park Physiotherapy amputee assessment

Home Based


Initial assessment form

101

Appendix H. Tools and resources for transfer of care / discharge

Transfer of care checklist

Doc No


Subacute Inpatient

1 Rankin Park/ HNELHD

Rankin Park Centre discharge checklist (trial)

HNELHD Inpatient transfer check list envelope/ Discharge information package

2 St Vincent’s Hospital/ Sacred Heart Rehabilitation

Separation of patient checklist (located on the back page of the St Vincent’s Hospital Multidisciplinary Care Plan).

3 St George Hospital/ SESLHD

SESIAHS Patient transfer summary

4 Greater Western AHS

Rehabilitation Unit Discharge Checklist

Outreach


Orange Base Hospital – Subacute care team handover information sheet


Orange Base Hospital - Subacute care team handover summary

Street address: Level 4, Sage Building 67 Albert Avenue Chatswood NSW 2067

Postal address: Agency for Clinical Innovation PO Box 699 Chatswood NSW 2057

T +61 2 9464 4666 F +61 2 9464 4728

[email protected] www.aci.health.nsw.gov.au