community rehab team kate bradfield (physiotherapist) sarah mcfarlane (occupational therapist)
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Community Rehab Team
Kate Bradfield (Physiotherapist)Sarah McFarlane (Occupational therapist)
Team Purpose
To optimise a patient’s mobility and independence with their activities of daily living by providing a specialist short-term
rehabilitation service to patients in bedded units or in their own homes
CRISIS Consists of:
•Bed based Intermediate Care
•Intermediate Care at Home – High Priority
- Medium priority
•CPAT (Community Prevention of Admission Team)
•Currently based at The Wilson, Mitcham
•Accept adults with a Merton GP
•Age > 18 years old
•Bed based units >55 years old
Community Rehab Team• Supported Discharges and POA’s
• Bed-based Rehabilitation Units (24 beds in total)
• Home-based rehabilitation (up to three calls a day 8am- 6pm).
Woodlands House (17beds)
Carter House (7 beds)
Colliers Wood Raynes Park
Referral Sources
• GP’s (via CPAT)• Hospital Therapists• Discharge co-ordinators• Community Liaison Nurses• CPAT
• Do not accept self referrals
Types of referrals
Supported discharges
•From Acute Trust
•Referrals screened by a therapist and then placed on waiting list
Prevention of Admission (POA)
•Referred by CPAT via direct referral from GP (telephone) or Rapid Response or STAR team
•Take priority over SD referrals
Conditions not accepted
• Patients presenting with symptoms primarily due to neurological diagnoses
Need to be referred to: The Community Neuro Therapy Team The unidisciplinary Neuro
Physiotherapy Team New strokes to the Early Supported
Discharge Team
• Patients with respiratory diagnoses who require only chest physiotherapy Need to be referred to:
The Community Respiratory Therapy Team
Who is appropriate?
oMust have potential to transfer with carers/ therapy staff without use of a hoist, but could be with Molift / Re-turn / Rotastand/ Sara Stedy
oDischarge destination must be known at time of referral for bed based
oMust be medically fit for rehaboMust have rehab potential
Bed-Based Therapy
Occupational Therapists, Physiotherapists & Rehabilitation Assistants
Nurses and Carers
Monday-Friday and RA weekend cover when capacity allows
Length of stay dependant on therapists’ assessment and goal achievement – usually 2-4 weeks
Weekly MDT meetings with temporary GP & nursing staff
Home Based Rehab (high board)
• Must have both Occupational Therapy (OT) and Physiotherapy (PT) goals
• Assessed by therapist on day of discharge if home by lunchtime.
• 1-3 therapy visits daily by a rehabilitation assistant• Regular reviews by Occupational Therapist and
Physiotherapist• Increase independence in personal care, meal prep,
transfers, mobility, stairs within patients own home.
Home Based Rehab (medium board)
• Require multidisciplinary input from OT &PT
• Can be supported with up to 2 - 3 calls in a week
• Contact within 3 working days of discharge from hospital to prioritize
• Increase and progress mobility, outdoor mobility, public transport and accessing the community.
Patient journey
• Mrs H is a 78 year old female living alone with no formal care services but family support.
• Background of diabetes, OA, osteoporosis, fibromyalgia, pseudo gout, cataracts
• Referred to CPAT by her GP with reduced mobility (unable to weight bear), pain in her lower limbs and not eating and drinking for 2 days
• Diagnosed with UTI.
Assessment at Home
• Assessed by CPAT at home who referred her to bed based rehab as no hospital admission needed but not safe to stay at home.
• Admitted to bedded unit the same day • Needing assistance with personal care and
meals
On admission• Assessed by therapists, required assistance of 2
people and rollator frame to transfer. Not able to mobilise
• Barthel 8/20• Developed pressure area on heel due to
prolonged period in bed, seen by tissue viability nurse
• Liaised with temporary GP to manage pt’s pain and started antibiotics for UTI
• Rehab plan agreed with pt and daily exercise sessions commenced
Treatment
• Encouraged pt to complete personal care as independently as able
• Practiced meal preparation in breakfast group• Daily exercises• Mobility practice• Stair practice• Home visit after 3 weeks input needs identified for
discharge• Wound care
On discharge• Pt able to transfer and mobilise independently
with equipment• Managing personal care and meals
independently• Managing stairs with supervision from family• Barthel 19/20• UTI resolved, pain under control and pressure
sore had healed• Referred on to HARI for further rehab and district
nursing to monitor pressure areas• Total length of stay – 4 weeks
Contact detailsCommunity Rehabilitation TeamWilson HospitalCranmer RoadMitchamCR4 4TP
Screener’s phone: 0208 687 4593Fax: 0208 646 6408
Sutton and Merton CommunityServices Administration CentreSMCS Administration TeamPO Box 70926LondonSW19 9FS
T 0845 567 2000E [email protected] 020 345 85 888
Sutton and Merton CommunityServices Administration CentreSMCS Administration TeamPO Box 70926LondonSW19 9FS
T 0845 567 2000E [email protected] 020 345 85 888
CPATTel: 02082510152
Thank you