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Rehabilitation Implementation Toolkit
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.
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) 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:
- Enhance current rehabilitation services, enabling them to better meet demand by aligning service delivery to the guiding principles outlined in the Model of Care.
- Develop and implement additional rehabilitation care settings to meet current and projected demand.
Toolkit documents:
- ACI Rehabilitation Implementation Toolkit
- ACI Evaluation and Monitoring Tool May 2013
- ACI Rehabilitation Implementation Toolkit - Checklists
+ Appendix D: Implement and Monitor
- Implement and Assess - Rehabilitation Implementation Plan
- Implement and Monitor Communications Plan template
+ Appendix E: Across the Patient Journey
- NSW Rehabilitation Model of Care Decision Tree
- Document 1 - SESLHD Rehab Referral Protocol for patients in St George Hospital
- Document 2 - St Vincent's Hospital Referral flow chart for Sacred Heart Rehab
- Document 3 - Orange Base Hospital Flowchart subacute team involvement in NF
- Document 4 - Rankin Park Centre Patient Information Handbook
Please contact the Network Manager about accessing this resource. - Document 5 - NSW Health Policy Directive: Your Health Rights and Responsibilities
- Document 6 - Rankin Park Centre - Rehabilitation Activity Coordinator PD
- Document 7 - Calvary Hospital Case Conference template
- Document 8 - POWH Weekly Case Conference form
- Document 9 - St Vincent's Hospital Family meeting record sheet
- Document 10 - St Vincent's Hospital RITH Discharge summary
- Document 11 - Rankin Park Centre Flag and Track Guideline
- Document 12 - HNELHD Inpatient follow-up phone call form
+ Appendix F: Referral and Admission
- Referral and Admission - Referral form ambulatory setting
- Referral and Admission - Referral form inpatient setting
- Document 1 - St Vincent's Hospital MRT Admission and Service Criteria Procedure
- Document 2 - Acute Rehabilitation Team (ART) guidelines - St George Hospital
- Document 3 - Orange Base Hospital - Inclusion Criteria- HUB (Draft)
- Document 4 - Referral and Admission process for Rankin Park Centre - Inpatient
- Document 5 - St Vincent's Hospital Referral to Sacred Heart Rehabilitation
- Document 6 - St Vincent's Hospital Sacred Heart Rehabilitation Trial of Rehab Policy
- Document 7 - SESLHD Rehab Referral Protocol for patients in St George Hospital
- Document 8 - Sutherland Hospital Killara Rehabilitation Admission criteria
- Document 9 - Rankin Park Day Hospital - Admission criteria
- Document 10 - Calvary Day Hospital Admission Criteria Policy
- Document 11 - St Vincent's Hospital Rehabilitation Outpatient Operational Procedures
- Document 12 - St Vincent's Hospital Rehab In The Home (RITH) referral and Criteria
- Document 13 - Orange Base Hospital - Inclusion Criteria - SPOKE (Draft)
- Document 14 - Mobile Rehab Team electronic referral printout
- Document 15 - Rankin Park Centre referral to inpatient and verbal handover forms
- Document 16 - SESLHD St George Hospital Rehabilitation Services Referral
- Document 17 - Sutherland Hospital Killara Rehabilitation unit referral form
- Document 18 - Rankin Park Day Hospital Referral form
- Document 19 - Calvary Hospital Rehabilitation referral form
- Document 20 - St Vincent's Hospital Sacred Heart Rehabilitation Outpatient Referral
- Document 21 - St Vincent's Hospital Rehab In The Home Referral Form
- Document 22 - Orange Health District - Sub-Acute Care Team Referral Form
+ Appendix G: Assessment and Service Delivery
- Assessment and service delivery - Assessment form
- Document 1 - Mobile Rehabilitation Team OT and PT Assessment
- Document 2 - Rehabilitation Plan and Admission Discharge Goal Sheet
- Document 3 - Rankin Park Day Hospital Parkinson's Assessment form
- Document 4 - Day Rehabilitation Physiotherapy Initial Assessment Form
- Document 5 - Outpatient Physiotherapy Amputee Assessment Form
- Document 6 - St Vincent's Hospital Rehabilitation In The Home Initial
+ Appendix H: Transfer of Care and Discharge
- Transfer of Care Form
- Document 1 - Rankin Park Centre Discharge checklist
- Document 2 - St Vincent's Hospital Separation of patient checklist
- Document 3 - SESIAHS Patient transfer summary
- Document 4 - GWAHS Rehabilitation Unit Discharge checklist
- Document 5 - Orange base Hospital subacute care team handover information
- Document 6 - Draft Transfer of Care from Orange Health Service