Rehabilitation, Aged & Community Care (RACC)
University of Canberra Public Hospital (UCPH)
Model of Care
Version Control
No.
Date
Remarks
1.0
28- Jul-14
Extracts of report issued for Round 1 User Group consultation (sections 2, 3 & 4)
1.1
8- Aug-14
Updated following Round 1 User Group meetings
1.2
12-Aug-14
Extract of report for Round 2 User Group meetings
1.3
30- Sept14
Updated extract for Round 2 User Group meetings incorporating feedback from Linda
Kohlhagen – for reference at meetings only (not for circulation)
1.4
8-Oct- 14
Updated draft following Round 2 User Group meetings
1.5
28- Nov14
Updated draft incorporating feedback following Round 2 User Group meetings and
targeted work re ambulatory services.
1.6
5-Dec-14
Updated draft incorporating feedback and outcomes of targeted work re inpatient
services.
1.7
19-Dec-14
Updated draft following Round 3 User Group meetings
1.8
9-Jan-15
Updated draft for Round 4 User Group meetings
1.9
23-Jan-15
Updated draft for Reference Group meeting 28/1/15. Incorporates feedback received
from Round 4/5 User Group meetings including document restructure.
2.0
13-Feb-15
Final incorporating outcomes of Reference Group meeting and other feedback provided.
3.0
9-Mar-15
Final incorporating feedback provided
4.0
1-Oct-15
Final incorporating definitional clarification around models of care and models of service
delivery and structural changes
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Table of Contents
1
2
Introduction .......................................................................................................................... 5
1.1
Consultation Process undertaken to inform this document................................... 6
1.2
Acronyms and Glossary ....................................................................................... 8
1.2.1
Acronyms ........................................................................................................ 8
1.2.2
Glossary.......................................................................................................... 9
Profile of Current RACC Activities ................................................................................... 12
2.1
2.1.1
Inpatient Care Settings .................................................................................. 13
2.1.2
Inpatient Service Pathways ........................................................................... 14
2.2
Ambulatory Care Settings ............................................................................. 18
2.2.2
Ambulatory Service Pathways ....................................................................... 21
RACC Benefits/Strengths of Current Services and Areas for Improvement ....... 22
2.3.1
Strengths/Benefits of Current Services.......................................................... 22
2.3.2
Areas for Improvement .................................................................................. 23
2.4
Known Innovations to be incorporated for future RACC Services ...................... 25
Overarching Future Model of Care for RACC Services across the ACT ........................ 27
3.1
4
Ambulatory Services .......................................................................................... 18
2.2.1
2.3
3
Inpatient Services .............................................................................................. 13
Description of Service ........................................................................................ 28
3.1.1
Overarching Principles .................................................................................. 28
3.1.2
Care Settings ................................................................................................ 34
RACC Services to be provided at UCPH .......................................................................... 35
4.1
Inpatient Services .............................................................................................. 36
4.1.1
Service Elements .......................................................................................... 36
4.1.2
Inpatient Care Continuum/Patient Pathway ................................................... 39
4.1.3
Inpatient Care - Service Delivery Team ......................................................... 47
4.2
Ambulatory Services – Day Programs and Sessional Therapy/Services ............ 49
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4.2.1
Service Elements .......................................................................................... 49
4.2.2
Ambulatory Services Care Continuum/Patient Pathway ................................ 54
4.2.3
Ambulatory Services - Service Delivery Team ............................................... 57
4.3
Therapeutic and Recreational Spaces at UCPH ................................................ 59
4.4
RACC Clinical Services Based Off-Site from UCPH .......................................... 60
4.5
Hydrotherapy ..................................................................................................... 62
5
RACC Community Based Services ................................................................................... 64
6
Appendices ........................................................................................................................ 67
6.1
Reference Documents ....................................................................................... 67
6.2
Outline of UCPH Service Streams and RACC Services ..................................... 68
Table of Tables
Table 1: Outline of Current Community Based Services (based at Community Health Centres) ... 20
Table 2: Outline of Future RACC Community Based Services ...................................................... 64
Table of Figures
Figure 1: Outline of Existing RACC Services................................................................................. 12
Figure 2: RACC Inpatient Services Pathway – Rehabilitation ........................................................ 15
Figure 3: RACC Inpatient Services Pathway – Geriatric Services ................................................. 16
Figure 4: RACC Referrals ............................................................................................................. 21
Figure 5: RACC Continuum of Care .............................................................................................. 27
Figure 6: Outline of RACC Services to be provided at UCPH ........................................................ 35
Figure 7: RACC Referral/Intake Process for a New Patient ........................................................... 40
Figure 8: RACC Referral/Intake Process for an Existing RACC Patient ........................................ 41
Figure 9: Generalised RACC Patient Pathway .............................................................................. 41
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1
Introduction
The ACT Health Infrastructure Program (HIP) plans for the future health infrastructure
requirements of the ACT and regional catchment areas. It focuses on service planning and delivery
of major capital works. HIP has delivered a number of capital projects in recent years including
developments at the Canberra Hospital and community health centres. The University of Canberra
Public Hospital (UCPH) is one of the key major infrastructure projects currently being planned.
UCPH will be located on the University of Canberra campus on the corner of Aikman Drive and
Ginninderra Drive. UCPH will form part of a planned network of ACT Health hospitals and facilities
designed to meet the needs of our ageing and growing population.
Extensive planning has been undertaken to define the services to be provided at UCPH. This
planning information is publicly available in the Service Delivery Plan and Functional Brief, both of
which are available on the ACT Government Time to Talk website.
UCPH will deliver sub-acute care consisting of adult Mental Health inpatient rehabilitation and day
services, and adult and geriatric inpatient rehabilitation, day and ambulatory services.
UCPH will not have an Emergency Department and will not deliver acute services. Specialist
palliative care and psychogeriatric care will not operate from the site.
The Division of Rehabilitation, Aged and Community Care (RACC) will be a substantial provider of
services at UCPH. The development of the new UCPH facilities will enable significant
enhancement and increased capacity of RACC services in the ACT. Centralised care provision for
rehabilitation and geriatric services at UCPH will be facilitated by:

inpatient and ambulatory services provided from a single facility;

collocation and integration of rehabilitation services and specialised staff;

centralised specialised services with a greater critical mass enabling the maintenance of
specialised skills;

optimised sharing of knowledge and staff training; and

capacity to flex up/down rehabilitation specialised wards to meet changing patient demand.
The new facilities will also enable the provision of rehabilitation and geriatric day programs.
A Model of Care describes how clinical services are /will be delivered. While this document
describes the overarching Model of Care for RACC services throughout the ACT, it focuses on the
direct clinical services that will be provided at UCPH. However, some support services which are
integral to care provision (e.g. information and communications technology (ICT) and
administration/booking/scheduling) are also described in this document, where relevant.
Throughout the consultation process that was undertaken to complete this document, the
emphasis has been on developing an innovative model for future care provision and service
provision. The Model of Care proposed in this document has been developed to enhance existing
service strengths and address any weaknesses or gaps in existing service provision.
A similar process has already been undertaken for the adult Mental Health services to be provided
at UCPH. Consultation on these Models of Care took place in 2014, and these Models of Care
have now been endorsed.
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1.1
Consultation Process undertaken to inform this
document
This document has been developed in consultation with key ACT Health representatives through
the following consultation process:

Two Reference Group (RG) meetings (30 July 2014 and 28 January 2015).

Four rounds of User Group (UG) meetings
-
30-31 July 2014 to profile the current RACC activities;
-
1 October 2014 to develop the overarching future Model of Care for RACC at
UCPH;
-
10-11 December 2014 to develop the overarching future Model of Care for
RACC at UCPH; and
-
14-15 January 2015 to develop the Model of Service Delivery and Transition
Roadmap for UCPH.

Targeted consultation undertaken by ACT Health to develop the future Model of Care for
UCPH inpatients and ambulatory services (27 October 2014 – 21 November 2014).

Out of session feedback/clarification.
Membership of the RG and UGs included:

Executive Director, RACC, CHHS;

Executive Director, Clinical Support Services, CHHS;

Director of Nursing, Clinical Support Services, CHHS;

Senior Manager Security Operations, Business and Infrastructure, Strategy and Corporate;

Director Logistic Support, Business and Infrastructure, Strategy and Corporate;

Executive Director, Mental Health, Justice Health and Alcohol and Drug Services, CHHS;

Director Geriatric Medicine, RACC, CHHS;

Director Rehabilitation Medicine, RACC, CHHS;

Director of Nursing and Assistant Director of Nursing RACC, CHHS;

Director Acute Support, Clinical Support Services, CHHS;

Director Allied Health, RACC, CHHS;

Director Client Support Services, RACC, CHHS;

Director Community Care Program, RACC, CHHS;

Assistant Director Client Services, Security and Emergency, Business and Infrastructure,
Strategy and Corporate;

Clinical Nurse Consultant, 12B, RACC, CHHS;

Clinical Nurse Consultant Rehabilitation Independent Living Unit, RACC, CHHS;

Clinical Nurse Consultant Acute Care of the Elderly, RACC, CHHS;

Rehabilitation Nurse Practitioner, RACC, CHHS;

Physiotherapy Clinical Educator, RACC, CHHS;

Manager Speech Pathology, RACC, CHHS;
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
Manager Occupational Therapy, RACC, CHHS;

Manager Physiotherapy, RACC, CHHS;

Manager Community Care Physiotherapy, RACC, CHHS;

Manager Psychology and Counselling, RACC, CHHS;

Manager Social Work, RACC, CHHS;

Manager Exercise Physiology, RACC, CHHS;

Manager Aboriginal Liaison Officer Service, Clinical Support Services, CHHS;

Manager Pathology Collections; Pathology, CHHS;

Rehabilitation Care Coordinator, RACC, CHHS;

Manager Transitional Therapy and Care Program, RACC, CHHS;

Manager and other nominees, Clinical Support Services, CHHS;

Volunteer Manager Client Services, Security and Emergency, Business and Infrastructure,
Strategy and Corporate;

Manager E-Health and Clinical Records, E-Health and Clinical Records, Strategy and
Corporate;

Operational Director ACT-Wide Mental Health Service, Mental Health, Justice Health and
Alcohol and Drug Services, CHHS;

Clinical Nurse Consultant, Brian Hennessy Rehabilitation Centre, Mental Health, Justice
Health and Alcohol and Drug Services, CHHS;

Consumer representatives, ACT Mental Health Consumer Network;

Clinical Director ACT-Wide Mental Health Service, Mental Health, Justice Health and Alcohol
and Drug Services, CHHS;

Team Leader Adult Mental Health Day Service, Mental Health, Justice Health and Alcohol
and Drug Services, CHHS;

Representatives, Carers ACT;

Project Officer, Mental Health, Justice Health and Alcohol and Drug Services, CHHS;

Project Officers, Healthcare Consumers Association;

Consumer representatives, Healthcare Consumers Association; and

Project Officers and Manager, Health Services Planning Unit, HIP.
Reference documents utilised in developing this document are outlined in the Appendix.
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1.2
Acronyms and Glossary
1.2.1
Acronyms
Acronym
Meaning
ACAT
Aged Care Assessment Team
ACE
Acute Care of the Elderly (Canberra Hospital)
ACRU
Aged Care Rehabilitation Unit (Calvary Hospital)
ACTES
ACT Equipment Service
ACTPAS
ACT Patient Administration System
ADL
Activities of Daily Living
CALD
Culturally and Linguistically Diverse
CHC
Community Health Centre
CHHS
Canberra Hospital and Health Services
CHI
Central Health Intake
CRT
Community Rehabilitation Team
CSP
Clinical Services Plan
CTW
Clinical Technology Workshop
DARS
Driver Assessment and Rehabilitation Service
DORSS
Domiciliary Oxygen and Respiratory Support Scheme
EP
Exercise Physiology
ELS
Equipment Loan Service
FTE
Full Time Equivalent
GEM
Geriatric Evaluation and Management
GP
General Practitioner
HIP
Health Infrastructure Program
HITH
Hospital in the Home
LOMT
Limitations of Medical Treatment
MEWS
Modified Early Warning Scores
NDIS
National Disability Insurance Scheme
OT
Occupational Therapy
PAS
Patient Administration System (e.g. ACTPAS)
PSP
Preliminary Sketch Plan
P&O
Prosthetics and Orthotics
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Acronym
Meaning
RACC
Rehabilitation, Aged and Community Care
RACLN
Residential Aged Care Liaison Nurse
RADAR
Rapid Assessment of the Deteriorating At-risk
RILU
Rehabilitation Independent Living Unit (Canberra Hospital)
RG
Reference Group
SAGU
Sub-acute Geriatric Unit (Canberra Hospital)
SWAPS
Specialised Wheelchair and Posture Seating
TTCP
Transitional Therapy and Care Program
UCPH
University of Canberra Public Hospital
UG
User Group
VARS
Vocational Assessment and Rehabilitation Service
1.2.2
Glossary
Key terms used throughout this document are defined below.
Acute Care
An episode of acute care for an admitted patient is one in which the principal clinical intent is to do
one or more of the following:

Cure illness or provide definitive treatment of injury;

Perform surgery;

Relieve symptoms of illness or injury (excluding palliative care);

Reduce severity of illness or injury;

Protect against exacerbation and/or complication of an illness and/or injury which could
threaten life or normal functions;

Perform diagnostic or therapeutic procedures; and

Manage labour (obstetric).
Admitted Services
Admitted services are those which are provided to patients who require formal admission to
hospital and care within a hospital bed. Care provision may be overnight or day only.
Ambulatory Services
Ambulatory services are health services provided on an outpatient basis to patients who attend a
hospital or health care facility and depart after treatment on the same day.
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Care Plan
A care plan is a patient-centred plan agreed to with the patient and their family/support people with
the clinicians. It will identify care/treatment goals and timeframes, intensity of therapy required and
the multi-disciplinary team members or inreach services required.
Community Based Services
A range of RACC community based health services for people of any age including a range of
technical nursing services, allied health services, health promotion and self management of chronic
conditions. Service provision may be health centre based or provided within a range of community
settings e.g. patient homes, workplaces and public spaces.
Consultation Liaison Services
Consultation liaison services are services that are not managed by RACC but which provide
consultation services to RACC patients when necessary.
Geriatric Services
The provision of care for patients who have conditions associated with ageing. Care provision is
typically provided for patients over the age of 65 years or over the age of 50 years for Aboriginal
and Torres Strait Islander peoples; however, younger patients may be seen if they have a
condition which is associated with the ageing process. Patients aged above 65 years or 50 years
for Aboriginal and Torres Strait Islander peoples may access a range of clinical services of which
geriatric services are one.
Inpatient Services
Inpatient overnight services are provided to patients whose condition requires formal admission to
hospital. Patients receiving inpatient care require care within the hospital overnight in order to treat
their condition and/or safely undertake activities of daily living.
Note: there are some inpatient services where the patient does not reside in the hospital e.g.
Hospital in the Home (HITH).
Model of Care
The Model of Care describes how clinical services are/will be delivered to a patient or client.
The focus of the Model of Care description is on direct clinical service provision, however, aspects
of support services which are integral to care provision (e.g. information and communications
technology and administration/booking/scheduling) are also described as part of the Model of
Care.
This document describes the overarching future Model of Care for RACC services across the ACT,
but focuses primarily upon the RACC services to be provided at UCPH.
Rehabilitation
Rehabilitation is the provision of care that aims to:

Restore functional ability for a person following a period of illness or injury;

Enable restoration of function consistent with pre-injury/illness status and the constraints of
the medical prognosis; and
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
Develop compensatory functional skills to address deficits that cannot be reversed.
Sub-acute Care
Sub-acute care for RACC patients is the provision of specialised multi-disciplinary care in which
the primary need for care is optimisation of patient functioning and quality of life. A person’s
functioning may relate to their whole body or a body part, the whole person, or the whole person in
a social context, and to impairment of a body function or structure, activity limitation and/or
participation restriction.
UCPH will be a sub-acute facility providing adult rehabilitation and Geriatric Evaluation and
Management (GEM) services. Palliative care and psychogeriatric care will not be provided.
Emergency Department and other acute services will not operate from the site.
Other
Other terms/references used in this document are outlined in the table below.
Term
Meaning
Ward 11A
Canberra Hospital Acute Care of the Elderly (ACE) Ward – 26 beds
Ward 11B
Canberra Hospital Sub-acute Geriatric Unit (SAGU) – 18 beds
Ward 12B
Canberra Hospital Acute Rehabilitation Ward – 20 beds
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2
Profile of Current RACC Activities
Existing RACC services cover a comprehensive range of multi-disciplinary care services for
patients with rehabilitation, aged and community care needs, across the entire care continuum,
from inpatient to ambulatory settings. RACC services are currently provided throughout the ACT in
a number of locations including hospitals, community health centres and in the community in order
to best meet each patient’s care needs. Equipment Services provided by RACC are accessible to
all eligible patients (RACC and non-RACC).
Rehabilitation services are provided for adults (18 years and above) while geriatric services focus
on the provision of services to patients who are experiencing chronic or complex symptoms of
ageing. Geriatric services are typically provided for individuals over the age of 65 years, or over 50
years for Aboriginal and Torres Strait Islander peoples, however, younger patients may require
geriatric services if they have a condition which is associated with the ageing process (e.g.
functional decline and interdependent problems such as undernutrition, falls, skin tears, pressure
injuries, delirium etc.). Patients aged over 65, or aged over 50 years for Aboriginal and Torres
Strait Islander peoples may access a range of clinical services of which geriatric services are one.
Equipment Services are provided for patients of all ages. RACC community based services are
predominantly provided to adults noting, however, that community based physiotherapy and
podiatry services are currently provided to children and young people under the age of 18, and that
the Walk-in Centres provide care for people over 2 years of age.
An outline of existing RACC services is illustrated below.
Figure 1: Outline of Existing RACC Services


Acute*
Sub-acute*
AMBULATORY SERVICES^

Day Program*#

Rehabilitation & Aged Care
sessional programs

Community Based Services
AMBULATORY SERVICES^






Day Programs*#
Rehabilitation &
Aged Care
EQUIPMENT SERVICES+
sessional
programs
Equipment Loan Service

Community Based
ACT Equipment Scheme
Services
Domiciliary Oxygen & Respiratory Support
Scheme
ACT Continence Support Scheme
^ Services can be provided in a home-based setting if clinically appropriate
* Indicates Admitted services
# The day program is currently small and operating out of RILU
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+ Equipment Services are RACC services which may be accessed by non-RACC patients
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Existing RACC services are described below.
2.1
Inpatient Services
2.1.1
Inpatient Care Settings
Care settings for current RACC inpatient services include:


Canberra Hospital
-
Acute Rehabilitation Ward (Ward 12B) – 20 beds. The majority of these
patients have neurology/neurosurgery, vascular, multi-trauma and oncology
conditions.
-
Acute Care of the Elderly (ACE) Ward (Ward 11A) – 26 beds.
-
Rehabilitation Independent Living Unit (RILU) – 16 beds, includes inpatient and
day program.
-
Sub-acute Geriatric Unit (SAGU) (Ward 11B), established in 2014 – 18 beds,
comprising 10 sub-acute and 8 non-acute beds.
-
Geriatric
and
rehabilitation
consultation
service
(RACC
geriatrician/rehabilitation physician providing a consultative service to other
services).
-
Orthogeriatric consultation service (Geriatric consultative service for patients
over the age of 65, or over the age of 50 years for Aboriginal and Torres Strait
Islander peoples, admitted under orthopaedics).
Calvary Hospital
-

Sub-acute Aged Care and Rehabilitation Unit (ACRU) - 28 geriatric
rehabilitation beds. The majority of these patients have orthogeriatric, medical
and surgical conditions. RACC provides Senior Medical Officer cover. Nursing,
after-hours medical cover and the majority of allied health services are
provided by Calvary Hospital.
Rehabilitation consultation service (rehabilitation physician providing a consultative service)
-
One consultation service consults at Canberra Hospital and reviews referrals
from outside hospitals/doctors, primarily for referrals to Ward 12B and RILU.
-
A second consultation service covers Canberra and Calvary Hospital and
reviews referrals from outside hospitals/doctors to ACRU.
Following a period of admission to a public or private hospital, acute or sub-acute hospital care and
assessment by the Aged Care Assessment Team (ACAT), the Transitional Therapy and Care
Program (TTCP) is available to older people who may require up to 12 weeks of support and
therapy. It is provided either from the 15 bed Mullangarrie Unit, a low level care facility located in
Red Hill, or in the individual's own home.
RACC inpatient services are provided by a comprehensive range of multi-disciplinary staff
including medical, nursing, allied health and support staff. In addition to services provided by
RACC staff, RACC services at the Canberra Hospital and Calvary Hospital may access a number
of consultation liaison services including, but not limited to:

A range of medical consultation services e.g. cardiology, respiratory, orthopaedics
Consultation Liaison Psychiatry, palliative care;

Diabetes Educator;
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
Tissue Viability Team;

Infection Control;

After hours social work and emergency physiotherapy;

Dieticians;

Pharmacists;

Aboriginal and Torres Strait Islander Liaison Service;

Pastoral Care/Multi-faith services; and

Consumer Engagement Team.
In addition, volunteers and students provide services to RACC inpatients.
2.1.2
Inpatient Service Pathways
All RACC inpatients are admitted under a RACC specialist. RACC inpatient services are accessed
through a referral system. Medical referrals are accepted from acute, sub-acute, and primary
health care providers within ACT and regional NSW.
Due to the care needs of patients accessing rehabilitation and/or geriatric services the service
pathway for each of these services is different. Admissions to rehabilitation services are planned;
focus upon goal setting; may have a wait list; and are likely to have a potentially longer length of
stay that is time limited. Geriatric services tend to be more acute and medically driven (with the
majority of patients referred from emergency services) with a shorter length of stay. The patient
pathways are illustrated below.
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Figure 2: RACC Inpatient Services Pathway – Rehabilitation
Referral (submitted to clinician on-call or Registrar)
ACT/ NSW acute/ sub-acute services
General Practitioner
Access/ Initial Contact
Medical consultation
Assessment
Multi-disciplinary rehabilitation assessment
Multidisciplinary team (if appropriate)
Goal focused service provision
Transfer of Care or Discharge
-- Ambulatory services
-- Non-government Organisations
-- GP management
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-- Return to acute inpatient units
-- Interstate facilities
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Figure 3: RACC Inpatient Services Pathway – Geriatric Services
Referral (submitted to clinician on-call or Registrar)
GPs and other medical practitioners
Emergency Department (95% referrals)
Access/ Initial Contact
Geriatric consultancy service
Assessment
Comprehensive Geriatric assessment (single or multidisciplinary)
Care Delivery/ Treatment - ACUTE
Multidisciplinary team (if appropriate)
Goal focused service provision
Care Delivery/ Treatment - SUB-ACUTE
Multidisciplinary team (if appropriate)
Goal focused service provision
Transfer of Care or Discharge
-- Ambulatory services
-- Residential Aged Care Facility
-- Other Hospital
-- Home/ GP Management
-- TTCP
-- Death
Note: a patient may be transferred directly from the community to the RACC sub-acute inpatient
setting without a period of care within the acute setting.
Upon receipt of an appropriate referral for inpatient admission, patients are assessed by a Medical
consultant/Geriatrician to determine their eligibility for RACC inpatient services. Based on the
outcome of the initial assessment, patients are transferred to a Geriatrician or added to a RACC
rehabilitation waitlist which is prioritised based on clinical need. If not appropriate for RACC
inpatient services, patients are referred for ambulatory services, or an alternate treatment
approach is suggested.
Further information regarding the rehabilitation and geriatric services pathways is provided below.
2.1.2.1
Rehabilitation
Upon admission to the Rehabilitation Ward (12B)/ACRU/RILU a multi-disciplinary assessment is
undertaken with the patient and their family/support people (if appropriate) in order to determine
time limited treatment goals. This assessment includes consideration of care requirements and the
necessary members of the multi-disciplinary team to address the patient’s care needs.
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During the period of care delivery/treatment, all appropriate disciplines are involved. It is
sometimes necessary to involve different members of the multi-disciplinary team as the care needs
of the patient evolve over the course of their treatment. Integral to care provision is regular team
meetings and goal review and coordinated care provision including team nursing.
Once treatment within the inpatient setting has been completed, the patient is transferred for
ongoing care (i.e. RACC ambulatory services) or discharged from the service for follow-up with
their primary health care provider. RACC inpatients will frequently require transfer to other services
upon discharge from the inpatient setting. If a patient ceases to improve and is assessed as no
longer benefiting then an alternative treatment or care approach is determined. Transfer to other
services/settings upon discharge from RACC inpatient services may be undertaken.
At times patients may be admitted to a RACC setting for a trial of rehabilitation services. If patients
are assessed during an agreed trial period of rehabilitation and it is determined that the patient is
not able to benefit from further rehabilitation services, the patient may be transferred back to their
acute care setting for appropriate alternative care.
2.1.2.2
Geriatric Services
The ACE Ward (Ward 11A) is accessed predominantly via the Emergency Department. Older
patients, who, after review by Emergency Department staff and the Geriatric/Medical registrar, are
deemed to require hospital admission and the care of a Geriatrician, are discussed with the
Geriatrician on call and admitted to the ACE ward. If no bed is available in the ACE ward, patients
may be admitted to other outlying wards, but will continue to receive medical care from the geriatric
medical team.
Some patients are admitted to the ACE ward as a result of a consultation request from other units
(medical and surgical) within Canberra Hospital. If considered appropriate by the consulting
Geriatrician they will be transferred to the Geriatric Medicine team.
Orthogeriatric care is provided to all patients over the age of 65 or over the age of 50 years for
Aboriginal and Torres Strait Islander peoples, who are admitted under the care of Orthopaedic
surgeons at Canberra Hospital.
During the period of care delivery/treatment all appropriate disciplines are involved in care delivery.
It is sometimes necessary to involve different members of the multi-disciplinary team as the care
needs of the patient evolve over the course of their treatment. Integral to care provision is regular
team meetings and goal review and coordinated care provision including team nursing.
Once treatment within the acute inpatient unit is completed, the patient is transferred for ongoing
care (e.g. to either SAGU or ACRU, TTCP, or RACC ambulatory/community services) or
discharged from the service for follow-up with their primary health care provider. RACC inpatients
will frequently require transfer to other services upon discharge from the inpatient setting. If a
patient is no longer benefiting from RACC care then an alternative treatment or care approach is
determined.
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2.2
Ambulatory Services
2.2.1
Ambulatory Care Settings
RACC ambulatory services are currently provided from a number of locations including the
Canberra Hospital, Village Creek Centre, the Independent Living Centre, and six community health
centres (Belconnen, Tuggeranong, Gungahlin, Phillip, Canberra City and Dickson). Services are
provided in-centre or within the community where appropriate. Integration of services in community
health centres and in community settings is a key principle of current care delivery. Ambulatory
services currently consist of:

Ambulatory Services – Rehabilitation and Geriatric Services

Ambulatory Services – Community Services

Equipment Services
In addition to a range of RACC ambulatory services, RACC patients may also access hydrotherapy
at Canberra Hospital. The hydrotherapy facility is used by a wide range of patients (including nonRACC patients) of all ages. While the hydrotherapy service is currently provided by RACC
Exercise Physiologists and Acute Support Physiotherapy, the pool is managed by Acute Support
Physiotherapy.
Further detail regarding these services is provided below.
2.2.1.1
Ambulatory Services – Rehabilitation and Geriatric Services
Ambulatory services provided from Canberra Hospital include:

Rehabilitation Medicine outpatient clinics (general and specialised);

Geriatric Medicine outpatient clinics;

Rapid Assessment of the Deteriorating Aged at Risk (RADAR);

Memory Assessment Service;

Rehabilitation Nurse Practitioner Clinics (Canberra Hospital inpatients only);

Aged Care Nurse Practitioner;

Speech Pathology;

Psychology – including Clinical and Neuro-psychology; and

Exercise Physiology – gym and hydrotherapy programs.
Ambulatory services provided from the Village Creek Centre include:

Rehabilitation Medicine Multi-disciplinary Clinics;

Rehabilitation Nurse Practitioner Clinics;

Prosthetics and Orthotics (P&O);

Driver Assessment and Rehabilitation Service (DARS);

Vocational Assessment and Rehabilitation Service (VARS);

Specialised Wheelchair and Posture Seating Service (SWAPS); and

Transitional Therapy Care Program (TTCP) (office space only, Village Creek Centre).
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Ambulatory services provided from Community Health Centres include:

Community Rehabilitation Team (CRT) which provides specialised multi-disciplinary
neurological rehabilitation services from the Phillip and Belconnen Community Health
Centres and the Village Creek Centre.

Falls and Injury Prevention Program services

-
Office and consultation space at Belconnen Community Health Centre;
-
Office space at Canberra City Community Health Centre; and
-
Office and consultation space at the Independent Living Centre.
VARS clinic at Belconnen Health Centre.
Other community based ambulatory services include:

ACAT based in Curtin; and

Office and consultation space at the Independent Living Centre.
2.2.1.2
Ambulatory Services – Community Settings
Community based services include a wide range of nursing and allied health services provided
from the Community Health Centres and specialised equipment and therapeutic services based at
the Village Creek Centre. Services are provided within the health care facilities or within community
settings (e.g. homes, workplaces, and public spaces). The majority of care settings for community
based services are outlined in the following table.
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Table 1: Outline of RACC Community Services Based at Community Health Centres
Belconnen
Community Health
Centre
Tuggeranong
Community Health
Centre
Gungahlin Health
Centre
Phillip Health Centre
Canberra City Health
Centre
Community Nursing
including specialised
clinics
Community Nursing
including specialised
clinics
Community Nursing
including specialised
clinics
Community Nursing
including specialised
clinics
Community Nursing
including specialised
clinics
Physiotherapy
including specialised
clinics
Physiotherapy
including specialised
clinics
Physiotherapy
including specialised
clinics
Physiotherapy
including specialised
clinics
Physiotherapy
including specialised
clinics
Physiotherapy
Podiatry
Podiatry
Podiatry
Podiatry
Podiatry
Podiatry
Social Work
Social Work
Nutrition
Nutrition
Nutrition
Nutrition
Nutrition
Occupational Therapy
Dickson Community
Health Centre
Occupational Therapy
Health Promotion
including Self
Management of
Chronic Conditions
(office space only)
Walk-in Centre
Walk-in Centre
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Other community based services include:

Independent Living Centre (Weston);

Community Nursing – Domiciliary After-Hours (LINK office space only, Gaunt Place,
Canberra Hospital site);

Clinical Technology Services based at the Village Creek Centre
2.2.1.3
-
P&O;
-
SWAPS; and
-
Clinical Technology Workshop (CTW) Service.
Equipment Services
Equipment Services provided to eligible RACC and non-RACC patients include:

ACT Equipment Service (ACTES) – long term loan equipment;

Equipment Loan Service (ELS) – short term loan equipment;

Domiciliary Oxygen and Respiratory Support Scheme (DORSS); and

ACT Continence Support Scheme.
Note: In the future, these services will remain at Village Creek Centre and an ELS (satellite only)
will be incorporated into UCPH.
2.2.2
Ambulatory Service Pathways
RACC ambulatory services are accessed through a referral system. This includes referrals from
inpatient services, General Practitioners (GPs) and primary health care providers, other medical
specialists, and non-RACC community based service providers within ACT and NSW. Self referrals
are also accepted. The flow of RACC referrals for the majority of services is illustrated below.
Figure 4: RACC Referrals
Referrals: self-referral,
Calvary Hospital, GPs,
interstate
Community Health
Intake
Community Based
Services
Referrals: inpatient and
internal RACC referrals
Referrals for Rehabilitation
and Aged Care Ambulatory
Services
RACC Intake
Rehabilitation and Aged
Care Ambulatory
Services
Note: The above figure illustrated the flow of referrals for the majority of RACC services. There are
some services for which referrals are received directly by the individual service e.g. DARS may
accept referrals from the Road Traffic Authority.
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The majority of referrals to RACC ambulatory services are submitted to the ACT centralised
Community Health Intake (CHI) service. CHI accepts and distributes referrals to the appropriate
service. Referrals received through CHI that are for rehabilitation and geriatric services within
RACC are forwarded to RACC Intake where screening and assessment is undertaken to ensure
eligibility for RACC services, and to direct the referral to the correct program within RACC.
Screening may also be undertaken by individual clinicians where appropriate. The majority of
referrals for community based services are accepted directly from CHI.
Upon acceptance of a referral by the appropriate RACC service, all patients are assessed by the
relevant single discipline/service or through a multi-disciplinary process in order to ensure that the
referral is appropriate, to determine priority, and clearly establish treatment requirements.
Care delivery and treatment of patients is then tailored towards the specific needs of each
individual. The provision of care varies extensively throughout the different services and may
include:

Single discipline or multi-disciplinary team (in-centre and community based);

Provision of continuing treatment (ongoing reassessment, evaluation, planning and provision
of care) e.g. management of intravenous lines, wound management/dressings, post
chemotherapy monitoring and central line care, end of life care, progression of mobility and
reduction of gait aids, increased independence in self care;

Time limited goal focused service provision e.g. rehabilitation;

Single episode of care and provision of advice or equipment e.g. Independent Living Centre,
ACTES, DORSS; and

Referral to non-RACC services where appropriate.
Following a period of care delivery/treatment, patients will be transferred from RACC. Ongoing
care/treatment may be required and therefore referrals to ongoing care providers will be provided
e.g. to interstate providers, non-government organisations, GPs etc. Alternatively if the patient has
no further care/treatment requirements, they may be discharged with no planned follow-up.
2.3
RACC Benefits/Strengths of Current Services and Areas
for Improvement
2.3.1
Strengths/Benefits of Current Services
There are a number of strengths of the current RACC inpatient and ambulatory services. These
include:

Provision of a comprehensive range of inpatient and ambulatory services for people
experiencing disability following illness or injury.

Provision of patient centred care.

Robust multi-disciplinary team and single discipline services including specialised skills to
address
the
needs
of
different
presenting
conditions
(e.g.
specialised
neurology/neurosurgical rehabilitation services; an expanding range of community based
technical nursing services).

Established priority systems that aid the intake process.

Discharge planning with planned transition and continuity of services throughout the RACC
care continuum and to other services is usually achieved, including transition to nongovernment organisations and other health care providers.
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
Services are generally structured into specialised streams so that expert, high quality
evidence based care is provided.

Provision of local specialised and customised equipment services from custom built
workshop facilities at Village Creek Centre e.g. medical grade footwear, specialised seating.

Provision of hydrotherapy services to patients including community-based patients – note
that while RACC does not currently run hydrotherapy services both RACC Exercise
Physiologists and Acute Physiotherapists provide the service.

Public awareness of some services is well established e.g. Falls and Injury Prevention
Program.

Education and training of staff is a priority, enabling attraction and retention of staff and
provision of high quality care.

RACC services continue to evolve and develop over time to respond to changing care needs
e.g. introduction of the motor neurone disease and spasticity clinics; changes to walk-in
centre hours of operation; changes to service mix within community health centres.

Availability of experienced and skilled administration staff that are embedded in some teams,
providing a significant contribution to effective and efficient service delivery.

Workforce with a broad skill mix including extended scope practitioners and support workers.

Enhanced service provision through the RACC volunteer team.

RACC service provision incorporates nursing, allied health and medical student placements,
facilitating the training and skills development of the future workforce.
2.3.2
Areas for Improvement
There are some aspects of the current services for which there is room to improve service
provision. Areas for improvement include the following:

The transition between different parts of the service (inpatient and ambulatory services) is
not seamless and could be enhanced. Delays can be attributed to the following:
-
Repeated assessments/goal setting may occur due to slow transmission of
referral information. This has the potential to increase length of stay for
patients.
-
Clinical records, including diagnostic information, for different services are
stored differently (paper and electronic records using a variety of systems that
are not all compatible or integrated).
-
There is limited flexibility within the current structure to balance acuity needs
(i.e. it can be difficult to meet the clinical/therapeutic needs of different patients
as there is limited ability for the staff profile mix to flex up and down).

Allied health services are only available during standard business hours within inpatient
settings.

There are issues relating to access and timing of rehabilitation services e.g. patients with
chronic neurological conditions are generally seen by different clinicians in different teams.
There is an opportunity to provide maintenance/review rehabilitation services including
planned comprehensive review and a longer continuum of care.

Currently there is limited access to coordinated, specific multi-disciplinary services for frail,
aged patients.

Access to some consultation services is limited e.g. access to the Aboriginal and Torres
Strait Islander team for community based clients.
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
The intake process for ambulatory services typically involves both CHI and RACC Intake or
may be direct to the service providers, potentially delaying the transfer of information
between CHI and RACC Intake.

The Acute Rehabilitation Ward (Ward 12B) is currently operating at 100% occupancy and
additional capacity is required.

Real time knowledge of waitlists for community based services is not well understood. There
is potential to develop a clearer analysis of waitlists and to establish objective measures to
monitor and manage waitlists.

Slow or limited non-urgent transport for inpatients

-
The Canberra Hospital Patient Transport Vehicle (PTV) is booked for dedicated
times for non-urgent patient transport and is currently fully utilised.
-
RILU has a bus which addresses some of the day patient transport needs
(between RILU and the Canberra Hospital).
Slow or limited non-urgent transport for ambulatory patients
-
Volunteer transport utilises mainly private vehicles and also a minivan to assist
ambulatory patients attending appointments.
-
Some ambulatory patients also use taxi buses/multi-taxis.
-
Some patients are not able to attend sessions at the clinically desired
frequency due to limited transport options.

While administrative support is provided to a range of teams it is not provided consistently
throughout the service.

Organisation wide reforms will need to be incorporated in future Models of Care e.g. review
of allied health, and centralised inpatient administration.

There are different care coordination and planning processes utilised across RACC which
can make coordination and communication challenging.

Long waitlists to access some community based services impacts upon service continuity.

There is potential to optimise use of telehealth and tele-monitoring.

The clinical records system is paper-based and often difficult to access across disciplines
and teams. There is a need for a central, e-Records system across the service.

Management of delirium patients could be strengthened.

There are staff shortages in some disciplines e.g. Geriatricians.

Provision of end of life and advanced care planning could be strengthened.
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2.4
Known Innovations to be incorporated for future RACC
Services
Known innovations that may be incorporated into future RACC services are:

Centralised care provision for the rehabilitation and geriatric services care continuum, where
possible:
-
Inpatient and outpatient care provided from a single facility;
-
Collocation and integration of rehabilitation services and specialised staff e.g.
closer working relationship between RILU day services and CRT;
-
Centralised specialised services with a greater critical mass enabling the
maintenance of specialised skills (e.g. physiotherapists with specialised
amputee gait training skills);
-
Optimised sharing of knowledge and staff training;
-
Capacity to flex up/down rehabilitation specialised wards to meet changing
patient demand; and
-
CTW Service space collocated with a greater critical mass of services will
improve P&O capacity and provide inpatient/ambulatory patient intervention in
a timely manner.

Implementation of day programs at UCPH.

Enhanced patient centred care through service delivery innovations noted below:

-
Improved transmission of referral and clinical record information through
integrated electronic systems that are easily accessible;
-
Established multi-disciplinary intake process for RACC sub-acute services for
both inpatient and ambulatory services; and
-
Early and consistent establishment of care plans (including most appropriate
care setting).
Flexible service delivery (i.e. shift hours for different clinicians may vary based on clinical
need) including:
-
To enable interventions early in the day such as a shower assessment, or late
in the day such as a consultation or education session with family members
who can attend after work;
-
To enable the possibility of rehabilitation service provision over the weekend
where this is supported by evidence (e.g. to extend to a 6 day program or to
enable prompt initial assessment for a patient admitted on Friday or over the
weekend); and
-
Establishing a more flexible workforce may require consideration of therapy
assistant positions to support the provision of flexible allied health hours.

Optimised administrative and other support staff models to ensure that the workload for all
staff is ideally suited to their skill set and role description (i.e. minimise the volume of
administrative tasks that clinicians are required to undertake).

Consideration of dedicated FTE to cover leave for allied health and allied health assistant
staff to enable continuity of service provision for efficiency, efficiency in care provision and
reduced length of stay.

RACC rehabilitation staffing to be in accordance with best practice standards and industrial
requirements.
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
Incorporate new therapeutic technologies and other treatment advances consistent with
evidence based practice and in consultation with benchmark facilities e.g. upper limb
robotics.

Incorporate other new technologies such as automated queuing and systems for ambulatory
services patients, to check-in for services etc. (such as the Queue Flow system due to be
installed at the Belconnen Community Health Centre).

Develop sub-acute services away from an acute campus, in a less clinical environment with
access to outdoor space, enhancing the patient perception of progress towards rehabilitation
and supporting the recovery model.

Optimised online information services so that patients and family/support people can be fully
informed of available services and their location.

Centralised integrated intake, booking and scheduling consistent with a whole of organisation
approach.

Optimised use of videoconferencing for remote consultation e.g. specialised motor neurone
disease clinics.

As the ACT is a small jurisdiction with a relatively small pool of resources, it is proposed that
in the future greater links with adjacent health services (i.e. NSW Health and regional NSW
counterparts) as well as primary care providers be established in order to share knowledge
and resources.

RACC services will be accessible by patients throughout the ACT, including those with
permanent and significant disability who may be eligible for National Disability Insurance
Scheme (NDIS) funding. RACC services may have a significant interface with NDIS for some
patients e.g. in transitioning a patient with long term disability from health to community
dwelling, provision of equipment for patients with permanent/long-term disability.
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3
Overarching Future Model of Care for RACC
Services across the ACT
An overarching Model of Care has been developed to inform the future delivery of RACC services
across the ACT. This overarching Model of Care covers the entire Rehabilitation, Aged and
Community Care service in the ACT.
The vision for the future of all RACC services is to provide an integrated and coordinated territory
wide range of rehabilitation, aged and community care services across the entire continuum of
care. This reflects the reality that patients accessing RACC services may commence treatment at
any point along the care continuum and may move between different settings as required to meet
their care needs. Strong links between all RACC services with relevant external services will be
maintained to enable provision of the most appropriate clinically indicated care for all.
A high level outline of the RACC continuum of care is illustrated below.
Figure 5: RACC Continuum of Care
Community Based Services*
Community Based
Services
Acute Inpatient Services
Sub-acute Inpatient Services
Rehabilitation and
Aged Care
Ambulatory Services – Day Programs*
Ambulatory Services – Sessional therapy/services*
Community Based Services*
Community Based
Services
* Indicates Ambulatory Services
RACC services will continue to include a range of inpatient and ambulatory services (noting that
services for patients at UCPH will be provided at UCPH and in other health settings in the ACT.
Services provided in facilities external to UCPH will be integral to care delivery and will be
accessible to UCPH patients as clinically indicated).
The overarching Model of Care for RACC services across the ACT will be characterised by:
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
Enhanced person centred care with appropriate family/support people involvement.

Provision of the ‘right’ care in the ‘right’ place at the ‘right’ time.

Provision of flexible and adaptable care which is responsive to changing patient needs over
time.

Accessible community based services covering a broad range of primary health care and
other needs of patient of all ages.

Provision of specialised multi-disciplinary acute and sub-acute rehabilitation services to adult
and older patients within inpatient and ambulatory settings.
3.1
Description of Service
The future Model of Care for RACC services across the ACT is characterised by enhanced patient
centred care with patient/family/support people involved in comprehensive assessment, planning
and decisions affecting patient care (if family/support people are available, and if the patient has
given consent to family/support people to do so). RACC services across the ACT will include a
comprehensive range of multi-disciplinary and single discipline therapeutic services for patients
with rehabilitation, aged and community care needs. Care provision will include a broad range of
care delivery options for patients, including collaboration with services external to RACC.
RACC services across the ACT will continue to integrate ACT Health's rehabilitation and geriatric
services, including prevention, assessment, diagnosis, treatment, support and rehabilitation for
older people and people experiencing disability following an illness/injury. Rehabilitation services
will be provided for adults (18 years and above) and geriatric services will focus on the provision of
services for patients who are experiencing chronic or complex symptoms of ageing. Geriatric
services are typically provided for individuals over the age of 65 or over the age of 50 years for
Aboriginal and Torres Strait Islander peoples, however, younger patients may require geriatric
services if they have a condition which is associated with the ageing process (e.g. functional
decline and inter-dependent problems such as undernutrition, falls, skin tears, pressure injuries,
dementia etc.) Individuals aged above 65 or above 50 years for Aboriginal and Torres Strait
Islander peoples may access a range of clinical services of which geriatric services is one.
In addition to rehabilitation and geriatric services, a key component of RACC services across the
ACT will be the provision of a range of primary health care services including health promotion, self
management, illness prevention, treatment and care of the sick, palliation, community
development, rehabilitation and consumer empowerment for patients.
RACC services across the ACT will include a comprehensive range of inpatient and ambulatory
services to cover the complete care continuum. Care provision will be based upon comprehensive
assessment, and will be goal oriented, time limited and evidence based.
3.1.1
Overarching Principles
Key principles of the future Model of Care for RACC services across the ACT will include:

Safe and high quality care
-
Services will be evidence based.
-
Services will be provided in the ACT where there is an appropriate level of
demand to ensure ongoing clinical competence, or will be referred elsewhere
as necessary.
-
Safety for patients, family/support people and staff will be paramount and
include provision of safety measures, such as dual access to clinical spaces
where necessary and use of duress alarms; procedures to support safe
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medication management; appropriate provision of security staff presence and
systems; appropriately trained staff including first aid procedures;
implementation of quality improvement procedures and systems; standardised
care across facilities.

-
Clinical areas will be designed in a way which facilitates safe care including
uniform efficient design of inpatient units to aid orientation, flexibility of use and
cohorting of patients (grouping of like patients). Safe care will also be optimised
through the placement of staff spaces that enable observation of patient and
visitors in key clinical and gathering areas.
-
Integrated care to improve quality, access, user satisfaction, effectiveness and
efficiency.
-
Continuity of care comprised of organised and coordinated care with a steady
flow of patients through the various elements of the system/services.
Enhanced person centred care
-
Care will be delivered in the right place at the right time for all patients.
-
The person will be the driver of their care and when available, family and
support people will be encouraged to be involved. Care provision will consider
the needs of the family/support people. It is acknowledged that some patients
will not be able to drive their own care. An alternative approach will be agreed
with the patient/family/support people and the clinical team if necessary.
-
The extent to which the patient story has to be retold will be minimised.
-
Key components of the patient pathway including assessment, goal setting and
reviews, care planning and discharge planning will be undertaken using a
collaborative approach between the patient, their family/support people and the
care delivery team.
-
Patients, families and support people will be well-informed through
provision of understandable and accessible educational health information
community resources. Resources will be provided in simplified language
structure to make information accessible to persons of all literacy levels,
provide clear, focused and usable information.
-
Care will be provided using effective communication characterised by plain
language and clear verbal communication. Messages will be tailored to the
needs and preference of the receiver.
-
Care provision will respect and promote patient and family/support people
choice.
-
Care provision will empower individuals to actively participate in the planning
and implementation of their care by embedding health literacy into all aspects
of care so that individuals can take appropriate actions and make effective
decisions for their own health.
-
Goal setting will focus upon the social, economic and cultural factors
influencing health of the individual.
-
Efficient administration systems will include centralised integrated booking and
scheduling for ambulatory services (consistent with a whole of organisation
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and
and
and
29 /69
approach); options for making and coordinating appointments such as phone
(a ‘one telephone number’ approach), internet and person to person contact.



-
Services will be culturally competent, safe and appropriate for Aboriginal and
Torres Strait Islander peoples1.
-
Services will be accessible in culturally safe and appropriate ways to people
from Culturally and Linguistically Diverse (CALD) communities, and will
increase health literacy2.
-
Advanced care planning will be encouraged.
Early intervention
-
Early assessment of patients will occur in the most appropriate setting and at
the most appropriate time.
-
Communication between all services will be optimised (e.g. between GPs and
Community Based Services, between acute and rehabilitation inpatient
services). Clear eligibility criteria will guide appropriate and timely referrals.
Appropriate service provision in ambulatory settings will aim to avoid hospital
admission where possible.
-
Early intervention will include the provision of inreach services provided by
rehabilitation teams into acute care with the possibility of shared care service
provision between medical/specialised acute care and rehabilitation. An acute
illness may be treated in parallel with commencement of rehabilitation to
prevent functional decline during acute illness. Early discharge planning will
reduce discharge delays..
-
Integration between all care providers will enable provision of services that may
prevent an acute or inpatient admission or enable appropriate admission.
-
Targeted health promotion programs will provide an opportunity for community
clinicians to focus on preventative health as well as early intervention,
particularly to vulnerable or at risk cohorts.
Enablement
-
Fundamental to the Model of Care is an enablement approach which
addresses all aspects of care needs for individuals including the physical,
psychological, social and spiritual.
-
Treatment will occur at every point of contact with the patient and will be
focused on the achievement of meaningful tasks for individuals.
-
Within the context of rehabilitation this model seeks to ensure that each
individual is internally motivated, rather than externally motivated, to achieve
their goals.
-
Services will be provided within an enabling environment which includes
effective way finding.
Multi-disciplinary and collaborative services
-
A coordinated and integrated approach to the provision of health services will
include:
1
National Aboriginal and Torres Strait Islander Health Plan 2012-2023
Towards Culturally Appropriate and Inclusive Services: A Co-ordinating Framework for ACT Health 20142018
2
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

o
referral systems to support a seamless transition between services;
o
clearly defined roles for each multi-disciplinary team member with
efficient and effective communication between team members;
o
use of a single electronic health record;
o
holistic coordination of care involving the individual;
o
use of shared, bookable and multipurpose clinical spaces where
appropriate; and
o
professional education which is multi-disciplinary where possible.
-
RACC care provision will incorporate collaboration with external service
providers such as GPs, non-government organisations, community and public
transport providers.
-
Community based services may be multi-disciplinary or single discipline
utilising a collaborative approach with engagement of the patient, their treating
team and the non-government sector.
-
Linkages between services and coordination of services will be facilitated
through a systems approach.
-
The workforce will be configured to deliver integrated care.
-
Organisation of services will support accountability and funding arrangements.
Accessible to all ACT residents
-
Service delivery will be timely, equitable and appropriate.
-
Environments that are easily accessible for people of all ages and abilities will
be provided (e.g. parking that is appropriate for people with a disability,
wheelchair access throughout facilities etc.). This will include careful design for
way finding and selection of signage, central telephone number to access
services, and a central entry point for services.
-
Service accessibility will be optimised including ‘one stop shop’ concept:
o
access to services at a time that addresses care needs (e.g. urgent
access to counselling as well as flexible hours of service); and
o
easy patient access to relevant components of health records.
-
Access to services will be timely and fair utilising a waitlist and priority booking
system and ensuring effective communication to patients and their families.
-
Access to services will be facilitated through appropriate access to transport
services (for inpatients to the RACC transport services and for ambulatory
patients to relevant transport providers).
Culturally appropriate and inclusive services
-
Environments will be provided that are sensitive to a variety of cultures with
appropriate selection of artwork and support spaces etc.
-
Appropriate access to interpreter services will be monitored and reviewed
when necessary.
-
RACC care provision will be provided consistent with the approach outlined in
the Health Directorate Reconciliation Action Plan 2012 – 2015 for which the
vision is “For Aboriginal and Torres Strait Islander peoples living in the ACT
and region to enjoy a quality of life, life expectancy and health status equal to
all Canberrans. Key focus areas identified within the Reconciliation Action Plan
include:
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
improved communication and collaboration;
o
creation of a culturally aware and sensitive healthcare environment that
contributes to closing the unacceptable gaps; and
o
Aboriginal and Torres Strait Islander employment, recruitment and
development.
-
RACC care provision will include ongoing engagement with Aboriginal and
Torres Strait Islander communities as appropriate when developing services,
and reporting mechanisms to capture Aboriginal and Torres Strait Islander
issues and to monitor progress of related initiatives.
-
RACC care provision will be provided consistent with ACT Health’s Towards
Culturally Appropriate and Inclusive Services, A Co-ordinating Framework for
ACT Health 2014–2018 for which the key objective is to “provide a coordinating framework to guide ACT Health in delivering culturally appropriate
and inclusive services and information, based on national and international
best practice”. A key focus of the framework is the delivery of services and
information which are accessible in culturally safe and appropriate ways to
people from CALD communities, and to increase health literacy.
-
RACC care provision will include ongoing partnering with consumers and
engagement with CALD communities as appropriate when developing
services.
Efficient, cost effective evidence based care
-

o
Ensuring efficient and effective allocation of resources based on priority needs
and evidence based practice:
o
grouping of patients with like needs;
o
placing services close to where patients are located;
o
simplifying administration processes;
o
decreasing waiting times;
o
minimising the number of people involved in patient care; and
standardised operational procedures across the organisation where
appropriate.
-
RACC staff will be encouraged to undertake education, practical skills training
and research.
-
Research will be undertaken as an integral component of care delivery in
conjunction with education partners where appropriate
-
The latest research and best practices are incorporated into care provided
through the establishment of a centre of excellence in rehabilitation and
geriatric services, with strong collaborative arrangements for teaching and
research.
-
Efficient care will be enabled through the careful configuration of clinical
spaces and through effective way finding design features.
Appropriate use of Information, Communication and Technology (ICT)
-
Incorporating the most contemporary systems for:
o
patient management (patient information, referral, registration, ticket
and queuing systems and care coordination);
o
patient access to information;
o
telemedicine and videoconferencing;
RACC UCPH Model of Care V4.0
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o
telemetry and wireless technology; and
o
facility systems (scheduling of rooms, equipment monitoring and
tracking, safety and security, building management etc.).
-
Access to ICT systems to be facilitated through adequate provision of fixed and
mobile devices (e.g. tablets).
-
ICT systems will integrate with ACT Health and other systems to enable
transfer of information between RACC and non-RACC services e.g. nongovernment organisations, to enable the transition of care.
-
ICT systems will enable integration between patient booking and scheduling
systems, ACT Patient Administration System (ACTPAS) and queuing systems.
-
ICT will also accommodate future therapeutic technologies e.g. Occupational
Therapy home assessment undertaken remotely in conjunction with the
patient/family to review a patient’s home environment, use of robotic limbs etc.
-
Care is responsive and active via communication with patients and family
members, utilising effective means such as creation of customised information
sheets printed in real time and telehealth.

Efficient and cost effective.

Specific to UCPH
-
Services will be provided within facilities that are carefully designed, and facilitate way
finding through features such as location of staff immediately on arrival to the unit and
distributed throughout the unit. Key gathering areas will have access to views, natural
light and external access. Facilities will be as comfortable and welcoming as possible
through the use of high levels of natural light, easy way finding and creation of a noninstitutional feel. The facility will be designed to be as ‘homelike’ and familiar as possible
and provide opportunities for both privacy and communal activities. Patients will be able
to store and lock personal items in lockable bedside lockers.
-
Services will be provided in a welcoming environment and include waiting areas
designed to limit noise and provide appropriate privacy and accommodation for larger
family groups; a single reception point for accessing ambulatory services; clinical spaces
that are safe and friendly and optimise use of natural light.
-
Provision of ‘smart kiosks’/patient flow management system (e.g. integrated multimedia
queue management or similar system) for ambulatory services to enable patient
registration, checking appointments, updating contact information; use of notification
devices for use by patients awaiting their appointment time (allowing patients to move
around the centre whilst waiting).
-
The planning of the facility will ensure convenient and efficient movement of patients
who may attend multiple appointments with various clinicians on each visit.
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3.1.2
Care Settings
Services provided to RACC patients across the ACT will be delivered in a number of settings
including:

Acute inpatient services (acute geriatric services, inreach rehabilitation services);

Sub-acute inpatient services (adult and older person’s rehabilitation);

Rehabilitation and geriatric ambulatory services – day programs;

Rehabilitation and geriatric ambulatory services – sessional therapy/services; and

Community based services.
Selection of the care setting will be based upon the ability to best meet the care needs of each
patient and provide the most efficient care. The approach to care provision will be to provide
services to the patient as close to their home as possible whilst also best meeting their complex
care needs and treatment goals. Dedicated and appropriately skilled staff will provide services
within each of the care settings.
A decision regarding the most appropriate care setting will be determined for each patient based
on:

Acuity and severity of illness/injury and associated functional ability and care requirements

Complexity and intensity of care requirements
-

e.g. RACC community based services will provide a number of single discipline
services, UCPH will provide a range of specialised multi-disciplinary services
Treatment/care goals
-
e.g. geriatric services will emphasise the importance of hospital avoidance and
transition of services.

Family/support people structure within the community

Requirement for specialised equipment/facilities to provide necessary treatment e.g.
exercise/therapy equipment, hydrotherapy, CTW Service, P&O assessment tools and
equipment modification equipment, specialised DARS and VARS assessment tools etc.
Wherever care is provided, patients will have access to a range of therapeutic and recreational
spaces to spend break time, including indoor and outdoor areas.
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4
RACC Services to be provided at UCPH
This section of the document focuses on the RACC services to be provided at UCPH, noting
however that other RACC services provided off-site are integral components of the overall care
continuum in the future. The RACC services provided off-site that will support the Model of Care at
UCPH are therefore also outlined in this section. It should be noted that patients of UCPH may
access a range of services that are not provided by RACC (e.g. other medical consultation
services).
The UCPH facilities have been designed to accommodate future growth in services and it is
envisaged that occupancy within the inpatient areas and ambulatory service areas will gradually
become full over time as demand for services increases. An outline of RACC services to be
provided at UCPH is illustrated below.
Figure 6: Outline of RACC Services to be provided at UCPH
INPATIENT SERVICES

Sub-acute*
INPATIENT SERVICES
AMBULATORY SERVICES^

Day Programs*

Sessional
therapy/services
CLINICAL SERVICES BASED OFF-SITE THAT WILL
PROVIDE A SERVICE TO UCPH

Clinical Technology Workshop Service

Driver Assessment & Rehabilitation Service

Prosthetics & Orthotics

Exercise Physiology

Rapid Assessment of the Deteriorating Aged at Risk

Specialised Wheelchair & Posture Seating Service

Transitional Therapy and Care Program Assessor

Vocational Assessment & Rehabilitation Service
^ Services can be provided in a home-based setting if clinically appropriate
* Indicates admitted services
Service elements, the care continuum and care delivery team for RACC inpatient and ambulatory
services are described below. These key aspects of the RACC Model of Care will continue to be
evaluated over time to ensure that service provision is best suited to meet the needs of the target
population and remains consistent with contemporary evidence based care into the future.
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4.1
Inpatient Services
4.1.1
Service Elements
The future Model of Care for RACC inpatient services will include an expanded range and capacity
of services by specialised multi-disciplinary teams. An outline of the service streams for RACC
sub-acute inpatient services at UCPH is provided in the Appendix.
Service streams have been developed to ensure that multi-disciplinary teams with specialised
therapeutic expertise can be established to best meet the care needs of patients and to facilitate
continuity of service. Different streams will have different patterns of service delivery. Inpatient and
ambulatory service streams are aligned to facilitate continuity between services. It should be noted
that the service stream for some patients may be unclear due to complex needs (e.g. younger
adult with early onset dementia). Patients will be allocated to the service stream which best meets
their clinical needs, as determined by the multi-disciplinary team, and where necessary specialised
staff may be consulted across the different service streams.
Key components of RACC inpatient services to be provided at UCPH are:


UCPH rehabilitation inpatient units will provide adult and geriatric rehabilitation services:
-
Neurological Rehabilitation Unit – providing care for patients with a range of
neurological conditions including but not limited to stroke, brain injury, spinal
cord injury, motor neurone disease, multiple sclerosis and Guillain-Barre
syndrome.
-
General Rehabilitation Unit – providing care for patients with a range of
conditions including but not limited to: amputations, deconditioning and
disability associated with medical illness, surgery or trauma.
-
Older Person’s Rehabilitation Unit – older age appropriate rehabilitation
services for patients who are likely to have a range of medical co-morbidities
associated with ageing. Care provision will include GEM services. Patients may
have the following conditions/co-morbidities: cognitive impairment, hip and
other fractures post surgery or non-operative management, orthogeriatric
conditions, deconditioning, Parkinson’s Disease.
-
Slow Stream Rehabilitation Unit – rehabilitation services for patients with
limited tolerance or ability to participate in rehabilitation. Patients may have the
following conditions: non weight bearing restrictions, patients who require
maintenance services whilst awaiting completion of home modifications or
placement into residential aged care. Note: clear protocols will ensure that this
rehabilitation unit does not become an overflow ward for other units.
Canberra Hospital acute and sub-acute inpatient units:
-
Acute Care of the Elderly Ward (Ward 11A) providing comprehensive multidisciplinary treatment programs for patients with acute conditions related to
aging. The specialised ACE team will work with patients, their family/support
people to develop a care plan that addresses individual patient needs.
-
Sub-acute Geriatric Unit (Ward 11B) providing comprehensive multidisciplinary treatment programs for patients with sub-acute conditions related
to aging. Care provision will include GEM and care awaiting placement. These
beds will be retained at the Canberra Hospital for the provision of GEM
services for patients who need to remain in an acute setting.
-
A range of consultation services will continue to be provided by RACC
including the rehabilitation medicine consultation service, orthogeriatric
consultation service (shared care service between orthopaedics and geriatrics),
RACC UCPH Model of Care V4.0
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RACC geriatric consultation services, Residential Aged Care Liaison Nurses
(RACLN, providing support through the process of application to Residential
Aged Care Facilities), Aged Care Assessment Team (ACAT), SWAPS,
Prosthetics and Orthotics and Veteran’s Liaison Service.
-
The in reach multi-disciplinary rehabilitation assessment process will enable
continuation of rehabilitation in an appropriate setting.
In addition, services that will also be accessible to RACC inpatients include, but are not limited to:

A range of medical consultation services e.g. cardiology, respiratory, orthopaedics, surgical,
endocrinology, Consultation Liaison Psychiatry, palliative care;

Diabetes Educator;

Tissue Viability Team;

Infection Control;

Aboriginal and Torres Strait Islander Liaison Service; and

Consumer Engagement Team.
4.1.1.1
RACC Sub-acute Inpatient Units at UCPH
Further detail regarding services to be provided within the UCPH sub-acute inpatient/rehabilitation
units is provided below.
Adult Rehabilitation
Rehabilitation will focus on assessing each person’s activity performance, participation and
environmental considerations and treating their impairments and restrictions. Care provision will
address each person’s health and wellbeing, mobility capacity, ADL performance (including their
vocation), communication and cognitive capacity, community participation and environmental
considerations. It will include a wide range of interventions as clinically indicated and may include
cognitive activities, independent practice, recreational and leisure activities and self management
of medication (where appropriate through the use of secure medication storage within bedside
lockers).
Rehabilitation services will be based on individualised rehabilitation assessments and agreed
goals. Patients accepted for rehabilitation will have a demonstrated potential to benefit from the
service. Patients will be allocated to one of the inpatient units based on their presenting condition
and their rehabilitation needs and tolerance. Both fast stream and slow stream rehabilitation
programs will be provided as noted above.
Older Person’s Rehabilitation including Geriatric Evaluation and Management (GEM)
In addition to the specialised requirements detailed for adult rehabilitation, particular care needs
recognised for the older patient will be embedded into care delivery where appropriate. Older
person’s rehabilitation, including GEM, will be characterised by specialised assessment which
addresses the multidimensional problems associated with the ageing process. Care provision will
address physical, social and psychological needs of individuals and facilitate patient participation
with a view to optimising health and well-being and community participation. Patient participation
will be optimised through assessment of individual interests and tailoring of therapy to align with
individual preferences where appropriate. Provision of care within an enriched environment will be
of particular relevance to the older patient.
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Care provision will incorporate the key principles for the care of older patients, as detailed within
Best Care For Older People Everywhere, The Toolkit 2012 (Government of Victoria) as
appropriate:

Person-centred care and advance care planning;

Assessment;

Communication;

Mobility/vigour/self-care;

Nutrition and swallowing;

Cognition, delirium, dementia and depression;

Continence;

Medication;

Skin integrity;

Pain; and

Palliative approach to care.
GEM care will be provided as a key component of the older person’s rehabilitation service and will
include specialised assessment and treatment which addresses the multidimensional problems
associated with ageing. GEM has been developed to ensure that older people at risk of functional
decline, and those with functional deficits and the ability to reverse their functional decline, receive
specialised care and leave hospital in the shortest possible time, with the highest level of function,
independence, dignity and individual participation that can be achieved.
Other aspects of care provision specific to older person’s rehabilitation needs may include
provision of less intense rehabilitation over a longer period of time, assessment of nutritional and
oral health status, assessment of status of cognition, continence and skin integrity.
Discharge to the usual place of residence will be the primary goal of management, but transfer to
an alternative long term facility such as residential aged care or extended care may be required.
A secure courtyard will be accessible from the inpatient unit accommodating GEM patients to
provide a safe environment where patients who may be confused and at risk of wandering are able
to spend time. It will also be possible to ‘close’ each of the inpatient units and to use bed sensor
alarms in each bedroom.
Deteriorating Patients
While patients accommodated within a sub-acute hospital setting will be of a lower medical acuity,
processes and protocols are required to be able to safely manage the deteriorating patient. This
may be required for the following:

Medical emergency e.g. in the event of acute coronary and cerebral events, falls, delirium
and other unanticipated events.

Non-urgent deterioration e.g. increased pain or wound breakdown.
With regards to the management of medical emergencies, UCPH will not have a Medical
Emergency Team (MET) however; will have a first response team for which an operational model
is to be determined. The operational model will be informed by a review of deteriorating patient
data and deteriorating patient program on existing wards and consultation with other stand alone
facilities. Management of the deteriorating patient may include:
RACC UCPH Model of Care V4.0
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
The establishment of a first response team comprised of nominated medical and nursing
staff who respond in the event of a medical emergency.

Assessment, intervention and monitoring by medical and nursing staff within the patient’s
clinical area.

Appropriate escalation of care e.g. high level emergency would require a call to the ACT
Ambulance Service, and management may include transfer to an acute facility.

Nurses will have additional skills in managing deteriorating patients. As standard practice all
nursing staff are required to be credentialed in Basic Life Support and competent in the use
of Modified Early Warning Score (MEWS) or equivalent tool.
It will also be important to consider pre-emptive advanced care and/or end-of-life care planning and
limitations of medical treatment (LOMT) planning for all patients in particular those admitted to the
Older Person’s Rehabilitation Unit.
As noted above, it is anticipated that the patients at UCPH will be of a lower medical acuity.
However it will be possible that patients may deteriorate and therefore appropriate policies will
need to be established for the proper care and managements of dying patients.
Patient Tracking
Mechanisms for tracking patients who are at risk of falls or wandering will be used when clinically
indicated. These may include out of bed sensors, ankle and arm bands. These sensors will be
connected to the nurse annunciator panel or to hand held devices carried by nursing staff.
4.1.2
Inpatient Care Continuum/Patient Pathway
The RACC patient pathway, incorporating timely access into services and seamless transition
between services, will be reliant upon a robust and integrated system including administration,
clinical and clinical support functions.
In developing the key principles of the RACC patient pathway, a number of example patient
pathways have been developed to assess the needs of different groups of patients accessing
RACC services in a range of care settings. The RACC patient pathway may be quite different for
different patients depending upon their clinical needs.
The figures below provide a high level outline of the RACC referral/intake process for a new RACC
and an existing RACC patient.
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Figure 7: RACC Referral/Intake Process for a New Patient
Referral
Central Intake
(Administrative)
RACC Sorting
(ClinicIan
Assessment)
Not appropriate for RACC
(feedback and
recommendation to
referrers)
Direct to specific
RACC service
RACC Screening Assessment utilising
concise assessment tool to determine
appropriate care setting and stream
Assessment and
Treatment
Specific RACC
Service
GP/ primary
health referrer
links
Assessment and
Treatment
Note:
1. Centralised integrated intake process for whole of organisation
2. The RACC sorting process will incorporate a coordinated centralised booking
and scheduling process to enable booking of relevant clinicians and rooms
3. The assessment process will not be duplicated. All relevant information from
screening assessment will be incorporated into RACC service assessment.
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Figure 8: RACC Referral/Intake Process for an Existing RACC Patient
Referral/Handover
Direct to specific
RACC Service
RACC Screening Assessment utilising
concise assessment tool to determine
appropriate care setting and stream
Assessment and
treatment
Specific RACC
service
GP/ primary
health referrer
links
Assessment and
Treatment
Note:
1. Referral/handover process will ensure transfer of all relevant patient information so
that there is no duplication of assessment
2. The RACC sorting process will incorporate a coordinated centralised booking and
scheduling process to enable booking of relevant clinicians and rooms
Further detail regarding the referral/ intake process and subsequent phases of the patient pathway
is described below.
A generalised patient pathway accessing RACC services is outlined below.
Figure 9: Generalised RACC Patient Pathway
Referral
Submitted
Referral submitted
to centralised
intake
(Administrative).
Screening/
Sorting of
Referrals &
Waitlist
Referrals sorted
by RACC
(Clinician
assessment).
RACC UCPH Model of Care V4.0
RACC
Assessment
Care Delivery/
Treatment
Assessment
undertaken
through single or
multi-disciplinary
process.
Single or multidisciplinary team
care as
appropriate.
May include
additional RACC
referrals.
Transfer of
Care or
Discharge
Transfer to
services outside
of RACC or
discharge from
care.
41 /69
4.1.2.1
Referral Submitted
Education and communication strategies will ensure that referrals to services are undertaken in a
timely and appropriate fashion. The importance of early referral and commencement of appropriate
care in a timely manner will be emphasised.
All RACC referrals will be submitted through a centralised integrated intake point consistent with a
whole of organisation approach in order to undertake the administrative processing of referrals.
4.1.2.2
Screening/Sorting of Referrals and Waitlist
All referrals submitted to RACC will be screened/sorted to ensure that they have been submitted to
the appropriate service. Inpatient referrals will be sorted by RACC clinicians.
General eligibility criteria for the RACC sub-acute inpatient units at UCPH will be:

Aged 18 years and older.

Medically stable.

Psychiatrically stable.

Clear rehabilitation goals.

Willing and able to participate in rehabilitation process that may include multiple therapy
sessions per day as clinically indicated.
Specific eligibility criteria include:



Neurological Rehabilitation Unit
-
Target population including but not limited to stroke patients, those with brain
injury, and those with Motor Neurone Disease, late effects of polio, multiple
sclerosis, cerebral palsy, spina bifida, and those with early symptoms of
Parkinson’s Disease.
-
Ability to participate in at least 3 therapy sessions per day as clinically
indicated.
General Rehabilitation Unit
-
Target population including but not limited to amputees, those with
musculoskeletal disorders, and post-orthopaedic surgery patients.
-
Ability to participate in at least 3 therapy sessions per day as clinically
indicated.
Older Person’s Rehabilitation Unit
-
Target population including but not limited to those with cognitive impairment,
delirium, falls, medical fractures, orthogeriatric patients, deconditioned patients,
and those with more progressed Parkinson’s Disease.
-
Aboriginal and Torres Strait Islander peoples aged 50 years and over; nonAboriginal and Torres Strait Islander peoples aged 65 and over; and prioritised
for people aged 80 and over although admissions outside of the age groups
will be considered if the patient has progressive Parkinson’s Disease and/or
co-morbidities typically associated with ageing.
-
Reasonably likely to be discharged home or to a low level residential aged care
facility.
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
Require complex, interdisciplinary assessment or comprehensive geriatric
assessment.
Slow Stream Rehabilitation Unit
-
Target population including but not limited to those with non-weight bearing
restrictions, and patients who require maintenance services whilst awaiting
completion of home modifications or placement into residential care.
-
Ability to participate in at least 2 therapy sessions per day as clinically
indicated.
-
Must have planned and accepted place of discharge prior to admission to the
unit.
Other considerations regarding each patient’s ability to benefit from RACC sub-acute inpatient
services include:

The patient has a recent impairment of functional ability due to illness or injury;

The patient has a condition that is likely to be responsive to rehabilitation;

The patient has reasonable prospects for functional gain within a reasonable timeframe;

The patient requires the input of a multi-disciplinary rehabilitation program to achieve
functional gain; and

The patient cannot be managed in a more appropriate lower level of care (for example,
cannot be safely and effectively managed in a community based rehabilitation program).
Admission to the RACC sub-acute inpatient units at UCPH will be effective and responsive. A
multi-disciplinary team will determine whether the patient can be accepted for admission or not. If
accepted, the patient will go onto a waitlist which is developed based on clinical priority and need
to ensure equitable and fair access to services. Waitlist times will be minimised and the right care
will be provided in the right place at the right time for all patients.
Pre-admission meetings will be held daily in order to:

Discuss the active waitlist;

Determine the most appropriate sub-acute inpatient rehabilitation unit for each patient;

Determine the priority for admission; and

Triage NSW patients to rehabilitation units in NSW where appropriate.
Pre-admission meetings will include the Access Management Unit and clinical input. The Access
Management Unit at Canberra Hospital and UCPH will work closely to facilitate this process. In the
future it is anticipated that the waitlist system will transition to a live PAS-based waitlist system.
Once a patient is moved from the waitlist to assessment and commencement of treatment a
centralised booking and scheduling process will be utilised to coordinate the appropriate care team
and access to appropriate clinical spaces to commence care delivery.
4.1.2.3
RACC Assessment
Each patient will be allocated to a service stream that bests suits their care needs. A robust
handover system is required for all patients coming from an acute facility as the treating team will
be different at UCPH.
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A multi-disciplinary assessment and individual rehabilitation plan will be developed for each patient
within 24-72 hours of admission on a weekday in consultation with the patient, their family, support
people and significant others.
For patients admitted on weekends, the multi-disciplinary assessment and individual rehabilitation
plan will be developed for the patient as soon as possible after admission, generally within 48
hours if admitted on a Saturday and within 24 hours if admitted on a Sunday.
The assessment process will consider all relevant handover information and there will be no
duplication of assessment. If an assessment has been undertaken previously and treatment goals
set, then these will be utilised in developing the ongoing care plan. Relevant community health
providers (e.g. GPs) may be involved in the initial assessment, goal setting and discharge planning
processes. This will enable timely access to information regarding the patient’s ongoing and
historic needs including possible chronic conditions that require regular reviews.
The RACC assessment will determine the care requirements for each individual which is to be
agreed with the patient (their family/support people if appropriate) and the relevant clinicians.
Agreed care plans will identify care/treatment goals and timeframes and inform the
commencement of care.
4.1.2.4
Care Delivery
Upon admission to an inpatient unit, care delivery will commence as soon as possible and may be
provided by a single discipline or comprehensive multi-disciplinary team according to the clinical
needs of the patient. Whilst UCPH will be a sub-acute facility, some acute services may be
provided for stable patients if clinically indicated (e.g. intravenous antibiotics, blood transfusion).
Care delivery will be patient focused, goal orientated and time limited in accordance with the
agreed care plan. Care provision involving multi-disciplinary teams and/or extended timeframes
(e.g. complex multi-disciplinary rehabilitation inpatient services) will include regular review of care
plans to ensure ongoing appropriate care provision. Regular team meetings, based on clinical
need, will be held to review each patient’s progress and to update individual rehabilitation plans
and goal sheets in consultation with the patient and their family/support people.
A care coordinator or key link person will be allocated according to clinical need for patients
undergoing multi-disciplinary care programs. The care coordinator/key link person will be the first
point of contact for the patient and their family/support people (if appropriate). They will also lead
the process of review and update of care plans.
A care coordinator will be allocated to patients with more complex care needs. The care
coordinator role will focus upon ensuring that care provision is provided seamlessly between
different disciplines and care settings including links to community health services e.g. GP, nongovernment organisations.
A key link person will be a member of the treating team who is nominated as the key contact.
Allocation of a care coordinator or key link person will be determined based on individual need.
Multi-disciplinary care provision will include medical, nursing, allied health and support staff, as
appropriate. The majority of patients will attend therapy several times a day to undertake a
program of assessment and rehabilitation activities with allied health and nursing staff. Therapy
sessions will be programmed weekly to inform the patient and their family/support people of their
rehabilitation schedule to facilitate appropriate participation of family/support people in the patient’s
care as well as to inform appropriate visiting times. Therapy sessions may be undertaken in a
range of areas including gyms, bathrooms, outdoor areas and hydrotherapy etc.
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ADL assessment and treatment sessions will be undertaken in the ADL kitchen, bathroom and
laundry spaces, in the community (e.g. home visit and social integration sessions held in a
shopping centre, gymnasium or other space) and other clinical/therapy areas as appropriate.
Patients will be encouraged to spend the majority of their day in the living and day therapy spaces
provided within the inpatient areas. Patient bedrooms will be utilised as an after-hours space for
patients. Appropriate rest periods will also be encouraged and patients and their family/support
people will have access to a range of spaces to spend their leisure time (lounge, recreation and
outdoor spaces). Some functional retraining sessions including patients and possibly their
family/support people may be undertaken within the patient bedrooms.
Patients will be expected to dress in day clothes and have meals in the dining room, undertake
ADL, and practise in ADL spaces. Access to hot and cold beverage making facilities will be
provided for patients and their family/support people.
It may be necessary to monitor the movement of some patients in order to ensure their safety. If
necessary, this will be undertaken in the least intrusive way possible e.g. through use of wrist or
arm band linked to a hand held device carried by nursing staff.
In order to support a smooth transition back to living in the community after a period of extended
rehabilitation, there will be provision of a ‘transition’ unit that can accommodate a family
member/support person. This unit will have a bedroom with a dedicated adjacent beverage bay
and sitting area to allow patients to practice functional skills and for family/support people to
practice providing care to the patient.
Throughout the course of care delivery/treatment, the care needs of patients will change. The
majority of RACC inpatients will move from inpatient services to other RACC care settings e.g. to a
day program. Referrals within RACC will be submitted directly to the relevant RACC service. The
focus will be upon timely referral to ongoing services so that the transition between services is as
seamless as possible including minimised wait times between services and limiting the extent to
which patients need to undergo repeated assessments. This requirement will be facilitated through
the use of integrated records systems.
Transition from RACC inpatient services to other RACC care settings will also be supported
through:

The provision of flexible care delivery (e.g. leave passes for patients to spend time at home
over the weekend practicing their return to living at home prior to formal discharge from
inpatient services to ambulatory services);

Forward planning of services including integration with domiciliary services, equipment loan
services and advanced life care planning;

Access to the transition unit within UCPH (independent living space with self contained
kitchen and living space).
Booking and scheduling of appointments for ambulatory services will be undertaken by a
centralised integrated process consistent with a whole of organisation approach.
Throughout the course of care delivery patients may need to access services external to UCPH or
RACC e.g. orthopaedic consultation, dialysis services, palliative care consultation. Efficient and
effective communication between RACC and other services will be enabled through integrated
records systems. Patient access to external services (e.g. inpatient requiring dialysis) will be
enabled through the provision of a flexible and reliable patient transport system.
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After-hours Admissions and Discharges
After-hours and weekend admissions will be accepted but planned ahead where possible. It is
anticipated that after hours and weekend admissions will not be high frequency due to the lower
acuity of patients generally being admitted to a sub-acute facility, however those patients destined
for the Older Person’s Rehabilitation Unit may be higher acuity and/or more functionally
dependent. Weekend discharges may occur but will be planned ahead where possible.
Good quality and well-managed handover at all times will be a key feature of the service. Nurses
will have additional skills in managing deteriorating patients and there will be 24 hour medical
cover. These features of the service will support admissions and discharges during business hours
and after-hours/on weekends.
An excerpt on effective clinical handover, modified to provide the UCPH context, is provided from
Chris Poulos’ report, below:
Clinical handover (provision of discharge summary) will need to occur at two, and potentially three,
interfaces:
1. Handover will first occur when the patient is initially transferred from acute care (or another
facility) to UCPH;
2. Handover will occur when the patient is discharged from UCPH to community or other
accommodation;
3. Handover may also occur if the patient is transferred back to acute care during their UCPH
admission (and then may be transferred back to sub-acute care again).
There are a number of systems available, occurring at a range of interfaces, to ensure that clinical
handover is effective and timely.
After-Hours Care Delivery
After hours and on weekends, there will be rostered medical coverage. The Rostered Medical
Officer (RMO) will not be an intern and will cover all wards and have advanced life support skills,
similar to day staff. A consultant (Rehabilitation Physician or Geriatrician) will be available on-call.
In addition to 24 hour nursing cover, the After-hours Manager will also have appropriate skills for
supporting deteriorating patients.
Allied health staff will have flexible hours of service which may include extended hours coverage.
4.1.2.5
Transfer of Care or Discharge
Following completion of a period of RACC inpatient care patients may be transferred on to other
services or discharged as follows:

Patient achieves all of their treatment goals and further input is not required.

Patient achieves all of their sub-acute inpatient treatment goals and is ready to progress to
another care setting (e.g. TTCP, day or sessional programs).

Patient is no longer benefiting from treatment and may be referred on to alternative care or
discharged from the service.

Patient chooses to access services in another area or through alternate means such as
private treatment.
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
A patient may experience an acute illness or injury which results in transfer back to acute
services external to RACC.
The transfer of care process from the RACC sub-acute inpatient units will include:

Allocation to a care stream where appropriate (for day programs or sessional programs).

Allocation of care coordinator/key link person where appropriate.

Review of progress/achievement of goals.

Setting of goals for next stage (in collaboration with the appropriate stream).

Identification of best path/level of intensity.

Identification of services – referrals made to RACC services based off-site.

Follow-up support and involvement of GP, other community service providers (e.g.
domiciliary services, Meals on Wheels, community pharmacy) and the NDIS as appropriate.
This will include provision of a comprehensive and timely discharge summary to the patient’s
GP.
4.1.3
Inpatient Care - Service Delivery Team
As previously noted, care provision for RACC inpatients will be provided by a multi-disciplinary
team according to each patient’s care needs based on providing an optimised staff skill set so that
the ‘right staff’ are undertaking the ‘right roles’. Due to the varying care needs of patients admitted
to each of the inpatient units, the staff profile will be developed to suit the specific requirements of
each unit.
The medical staff will include:

A rehabilitation registrar and geriatric registrar will be allocated to the inpatient units and
ambulatory services and outreach programs.

Accreditation for advanced training in geriatric medicine should be provided for registrar roles
in geriatric rehabilitation in both inpatient and community settings.

All inpatient registrar positions should be supported by junior medical officers.
Nursing care for RACC inpatients will be provided by a comprehensive team including nursing staff
with general, specialised and geriatric rehabilitation skills, utilising a team nursing model.
A range of allied health staff with general (e.g. rotating junior staff) and specialised skills will be
integral to care delivery.
Multi-disciplinary team members will include the following clinicians:

Allied Health Assistant;

Medical;

Nursing including Assistants in Nursing;

Nutrition;

Occupational Therapy;

Pharmacy;

Physiotherapy;

Psychology and Counselling;
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
Social Work; and

Speech Pathology.
The core clinical team for each patient will be determined based on individual clinical need. The
number and type of specialised staff will be determined based on casemix within each of the
rehabilitation units. Some services may be provided on a sessional basis as clinically indicated e.g.
nutrition, pharmacy.
Care provision will incorporate flexible service delivery e.g. shift hours for different clinicians based
upon clinical need i.e. some allied health clinicians may commence their shift earlier or later than
others in order to accommodate the needs of patients and their families.
In addition to the core clinical team, patients may access services from a range of other services
including:

RACC services based off-site.

Other clinical and non-clinical support services staff based at UCPH including Veteran’s
Liaison Service and Pastoral Care/Multi-faith services (further description regarding clinical
and non-clinical support services is provided in the UCPH Model of Service Delivery
document)
Note: Pharmacy staff will be part of the multi-disciplinary team, reflective of the issues around
polypharmacy and the need to provide medication reviews, education and medication
management.
As noted in the list above, RACC staffing will include assistant roles (e.g. allied health assistant,
nursing assistant) which will support a flexible workforce and contribute to the provision of services
in the right place at the right time. As patient needs progress the care delivery team may change.
Specialised staff will be provided to best address the different service requirements of the patient.
Transition between different services and care delivery teams will be enabled through efficient and
effective handover processes, supported by integrated ICT systems. The treating doctor for
patients will be maintained throughout the duration of care, where possible, in order to facilitate
continuity of care.
Care delivery will be provided by a flexible workforce with the ability to offer extended hours of
treatment in order to accommodate special care needs (e.g. an education session with family
members outside of their working hours, provision of inpatient rehabilitation or community based
services over the weekend). The workforce will also have capacity to provide services in the
community or community health centre settings in response to patient care needs.
Ongoing professional development, training and research will be considered a priority to ensure
that RACC services are provided consistently throughout the ACT and continue to be delivered in
accordance the latest evidence based practice.
Students and volunteers will be integral to the core RACC staff profile. Student placements for all
disciplines will be encouraged to support partnerships with affiliated universities and other teaching
institutions. Volunteers will continue to provide an invaluable service to RACC patients including
but not limited to a strong presence in the main entrance providing assistance with way finding and
patient transport and assisting with therapy sessions.
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After-hours Management
Management of the hospital after-hours will be required to undertake the following:

Coordinate relief and casual nursing staff required to work in clinical areas across the
hospital on a shift by shift basis. Relief and casual staff will present to the unit for
deployment. The unit will receive all staff requests to replace unplanned personal leave.

Central coordination for nursing services after-hours e.g. management of deteriorating
patient after-hours, staffing issues/replacing sick leave, provision of clinical support etc.

Coordinate all after-hours fire emergency and maintenance situations affecting infrastructure

Coordinating all after-hours internal and external requests for admissions

Communications to the unit will be via pager, telephone, mobile phone, face to face and
email.
4.1.3.1
UCPH Workforce Project
A workforce project involving a broad range of stakeholders has been established by ACT Health
to identify innovative clinical workforce design approaches for UCPH. This project is ongoing and
will respond to the agreed Model of Care for UCPH services, and address workforce design and
development requirements. Key outputs of the workforce project to date include:

Workforce innovation in sub-acute care speciality services: a literature review, November
2013.

University of Canberra Public Hospital (UCPH) Workforce Innovation Forum 13 December
2013, Record of Discussion.

University of Canberra Public Hospital (UCPH) workforce planning workshop overview:
Rehabilitation and Aged Care, 6 June 2014, Record of Meeting.
Key findings to date include consideration of innovations such as role enhancement, substitution,
delegation, and completely new roles e.g. allied health practitioners and nurses working in
advanced or expanded roles, allied health and rehabilitation assistant roles, and a range of support
worker roles.
4.2
4.2.1
Ambulatory Services – Day Programs and Sessional
Therapy/Services
Service Elements
The provision of day programs at UCPH will represent a predominantly new service for RACC
(currently there is only a limited rehabilitation day service provided through RILU). The
rehabilitation and geriatric day programs and sessional therapy to be provided at UCPH will be
characterised by specialised services provided by dedicated care streams. The day program will
provide an alternative to inpatient care.
Such services generally could not be provided in the community setting due to the nature of
specialised requirements and intensity of care provision (as can be provided in the day programs).
An outline of the RACC future Model of Care for ambulatory services is provided in the Appendix.
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Key features of all day programs will include the following:

Within each of the service streams, a range of specialised multi-disciplinary services will be
provided based on individualised rehabilitation plans including goals and indicative
timeframes.

Treatment will focus upon functional improvement, delivered through a goal directed, time
limited, coordinated program.

Full and half day programs will be provided by specialised care teams with the provision of a
number of therapy sessions per visit, typically provided over 2-5 sessions per week
according to individual patient needs. Therapy sessions may be provided in centre or within
the community (e.g. patient’s home, workplace or public spaces) and may include individual
and group sessions as appropriate.

Care provision will be based in centre and within the community (e.g. patient’s home,
workplace or public spaces) and may include individual and group sessions as appropriate.

Appropriate break and meal times will be incorporated into the program.

The duration of the program will be determined based on individual goals and care needs.

In addition to the provision of services which are focused upon therapeutic intervention to
improve function, patients may also be referred to these services for geriatric medical
assessment.

Patient selection will be well targeted to ensure that patients who require geriatric medical
assessment will have access to the necessary diagnostic services (medical imaging and
senior medical input etc.).
As illustrated in the RACC UCPH Service Stream summary (see Appendix), day programs and
sessional therapy will be provided in the following service streams:

Neurology Stream – recently acquired conditions;

Neurology Stream – progressive and chronic conditions;

General Stream; and

Older Person’s Stream.
Service streams will be established to ensure that multi-disciplinary teams with specialised
therapeutic expertise can best meet the care needs of patients and facilitate continuity of service.
These service streams are described below and are reflective of the inpatient service streams to
facilitate continuity between services. Where necessary specialised staff may be consulted across
the different service streams.
Day Programs
Further detail regarding the features of the different service streams for day programs is provided
below.

Neurology stream with two sub-streams
-
Providing care for patients with recently acquired conditions including
acquired and traumatic brain injury, stroke, spinal injury and newly diagnosed
Parkinson’s disease.
-
Providing care for patients with chronic and progressive conditions such
as multiple sclerosis; Huntington’s disease; long term spinal cord injury,
traumatic brain injury or stroke management; and motor neurone disease. Care
provision may include less intense, long duration services that are more likely
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to be home based. Relevant community health providers will be involved in
assessment, initial goal setting and discharge planning.

General stream providing care for patients with complex acute and chronic conditions
including upper limb or lower amputation, musculoskeletal pain or injury including multitrauma, joint replacement and fractures.

It is noted that a number of diagnostic groups may be aligned with different streams as
clinical needs will vary at different stages, for example
-
Spinal cord injury rehabilitation vs. long term management – during the
rehabilitation phase care provision may focus more upon neurological care
whilst long term management may focus more upon musculoskeletal care.
-
Long term care for a patient with Parkinson’s Disease may be most closely
aligned with geriatric services to address issues such as depression,
psychosis, dementia, sleep disturbances and medication management.
Alternatively care provision may be best addressed by the progressive and
chronic neurological condition specialised stream.

Older person’s stream providing care for patients with conditions related to the ageing
process with a focus upon the treatment of frailty and functional decline. Another
characteristic of older person’s care is that conditions may be slowly resolving with changing
medical problems and ongoing functional impairment, requiring rehabilitation/restorative care
at a less intensive level, but over a longer period of time. Other aspects of care provision
specific to geriatric rehabilitation needs may include assessment of nutritional and oral health
status, assessment of status of cognition, continence and skin integrity.

The tolerance of geriatric patients will be carefully assessed in developing the optimal day
rehabilitation program for these individuals.

Geriatric Day Program patients may also access clinics to address the major geriatric
syndromes of falls and mobility problems, continence, memory loss/dementia and others as
appropriate, via the Memory Assessment Service, Fall Injury Prevention Service, DARS and
P&O as indicated.
Note: there is some overlap between the above inpatient and ambulatory services streams with the
existing TTCP. Eligibility criteria for these services will be more clearly defined to ensure that in the
future there is no duplication of services.
Sessional Therapy/Services
Rehabilitation and geriatric sessional therapy/services will provide a range of services for patients
who generally require less intensive intervention than those patients attending the day programs.
Patients may attend for single discipline sessional therapy or single session service (e.g. one-off
multi-disciplinary assessment) which is scheduled according to clinical need. Care provision will be
within the service stream described above.
Future care provision will include an enhanced and expanded range of services including the
following changes to service provision:

Additional services provided at UCPH e.g. geriatric medicine and aged care nurse
practitioner outpatient clinics;

Relocation of Community Rehabilitation Team (to be part of the future Day Programs) and
Falls Injury and Prevention Program from Belconnen CHC to UCPH;

Relocation of Memory Assessment Service from Canberra Hospital to UCPH;

Relocation of speech pathology (adult and geriatric) and psychology (adult) ambulatory
services from Canberra Hospital to UCPH;
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
Relocation of some clinics from the Village Creek Centre to UCPH including:
-
Rehabilitation Medicine Outpatient Clinics;
-
Rehabilitation Medicine Multi-disciplinary Outpatient Clinics; and
-
Rehabilitation Nurse Practitioner Clinics.
In addition to the provision of single discipline sessional therapy, there will be a number of services
which are likely to be provided on a sessional basis. These include:

Rehabilitation Ambulatory Services:
-
Rehabilitation Medicine Outpatient Clinics;
-
Rehabilitation Medicine Multi-disciplinary Outpatient Clinics e.g. spinal review
amputee clinic, spasticity clinic;
-
Rehabilitation Nurse Practitioner Clinics; and
-
Clinical services based off-site that will provide a service to UCPH.
 P&O;
 DARS;
 SWAPS Service; and
 VARS.

Geriatric Ambulatory Services:
-
ACAT;
-
Aged Care Nurse Practitioner;
-
Falls and Injury Prevention Program;
-
Geriatric Medicine Outpatient Clinics;
-
Memory Assessment Service;
-
RACLN; and
-
Clinical services based off-site that will provide a service to UCPH.
 Rapid Assessment of the Deteriorating Aged at Risk (RADAR); and
 TTCP.
RACC sessional therapy/services will include a range of specialised services provided
predominantly from the UCPH site, however, home based services may be provided when
clinically indicated. These services will be characterised by the provision of complex specialised
care which cannot be provided within the community setting. Sessional therapy/services may be
integrated with day program services e.g. Memory Assessment Service or Falls and Injury
Prevention Program assessment may be a component of a day program.
Rehabilitation and Geriatric Sessional Allied Health
Rehabilitation and geriatric outpatient services at UCPH will include a comprehensive range of
specialised allied health services provided on a sessional therapy basis and as part of a multidisciplinary team. Allied health services provided will include:

Nutrition;

Occupational Therapy;

Physiotherapy;
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
Psychology and Counselling;

Social Work; and

Speech Pathology.
Rehabilitation Medicine Outpatient Clinics
This service will be staffed by experienced Rehabilitation Physicians who will provide a specialised
consultative service for a range of disabilities occurring in association with medical conditions.
Rehabilitation Medicine Multi-disciplinary Outpatient Clinics
This service will be staffed by experienced Rehabilitation Physicians and a multi-disciplinary team
to provide a specialised consultative service to patients with a range of complex disabilities
following illness or injury e.g. spinal review clinic, spasticity clinic, amputee clinic.
Rehabilitation Nurse Practitioner Clinics
The Rehabilitation Nurse Practitioner will work within multi-disciplinary teams to provide specialised
rehabilitation services to patients with needs and health issues associated with complex
neurological conditions such as spinal cord injury and brain injury. The role includes clinical
assessment, treatment, referrals, and development of nursing management care plans, discharge
planning and follow-up as required. Consultations will be conducted within inpatient units and in
nurse practitioner clinics.
Aged Care Assessment Team (ACAT)
ACAT will comprehensively assess the care needs of frail older people and facilitate access to
available care services appropriate to their care needs. ACAT determine eligibility for a range of
Australian Government subsidised aged care services.
Aged Care Nurse Practitioner
Aged care nurse practitioners will work as part of multi-disciplinary process to assess and
determine management care plans, including implementation, referrals, discharge planning and
evaluating outcomes to ensure the best possible outcomes for older people. Services will include
education and advice to patients, family/support people, other health professional on the
assessment and management of aged related conditions.
The nurse practitioner may provide outreach services into the community.
Falls and Injury Prevention Program
The Falls and Injury Prevention Program will provide multi-disciplinary assessment and
interventions for older people who have experienced falls or who are at risk of falls. A range of
services will be provided:

Prevention and early intervention;

Providing and developing local community education activities and resources;

Providing individual advice and information;

Education programmes for medical and other healthcare staff; and

Stepping On (a community based education program for clients over 70 years).
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Geriatric Medicine Outpatient Clinics
This service will be staffed by experienced Geriatricians and nursing staff who will provide a
specialised consultative service for conditions associated with ageing. Services will include
screening and preventative services to address risk factors for these conditions e.g. cognition, falls,
memory loss.
Memory Assessment Service
The Memory Assessment Service will consist of a multi-disciplinary clinic which aims to determine
an early diagnosis of cognitive changes. Clinics will be staffed by Geriatricians, Registered Nurses,
Occupational Therapists, Social Workers and Neuropsychologists.
The clinic will provide expert clinical diagnosis; education, support and information regarding
appropriate treatment; assistance with future planning; and will link clients and their family with
appropriate service providers.
Residential Aged Care Liaison Nurse (RACLN)
The RACLN will support clients and their families through the process of application to Residential
Aged Care Facilities by providing advice and information on Aged Care Facilities across the ACT
Region.
4.2.2
Ambulatory Services Care Continuum/Patient Pathway
The patient pathway for RACC services will be coordinated with timely movement of patients into
and between services. Access, admission, referral, treatment and discharge pathways for RACC
services will be standardised where appropriate and include:

Submission of referral;

Screening/sorting of referrals and waitlist;

RACC assessment;

Care delivery/treatment; and

Transfer of care or discharge.
Further detail regarding each component of the patient pathway specific to ambulatory services is
provided below.
4.2.2.1
Referral Submitted
Education and communication strategies will be incorporated to ensure that referrals to services
are undertaken in a timely and appropriate fashion. The importance of early referral and
commencement of appropriate care in a timely manner will be emphasised.
All RACC referrals will be submitted to a centralised integrated intake point consistent with a whole
of organisation approach.
Referrals for RACC day program services may be received from RACC and non-RACC sources
including:

Interstate facilities;

ACT hospitals (public and private);

Self/family;
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
Rehabilitation Medicine/Geriatrician;

GPs;

ACAT;

RADAR; and

Other sources.
4.2.2.2
Screening/Sorting of Referrals and Waitlist
All referrals submitted to RACC will be screened/sorted to ensure that they have been submitted to
the appropriate service. Referrals will be screened/sorted by a clinician in order to:

Confirm that a referral to RACC is appropriate;

Determine whether the referral can be submitted directly to a particular RACC service; or

Determine that a RACC ‘subjective assessment’ (using a concise assessment tool) is
required to determine the care needs of the patient (care setting, service setting and multidisciplinary team requirements).
If accepted for admission the patient will go onto a waitlist based on clinical priority and need, to
ensure equitable and fair access to services. Priority access to ambulatory services will be given to
patients transitioning from inpatient services.
Regular meetings will be held to discuss the active waitlist and determine the priority of
admissions. Waitlist times will be minimised. The right care will be provided in the right place at the
right time for all patients.
Once a patient is moved from the waitlist to assessment and commencement of treatment a
centralised booking and scheduling process will be utilised to coordinate the appropriate
clinician/care team and access to appropriate clinical spaces to commence care delivery.
4.2.2.3
RACC Assessment
Each patient will be allocated to a service stream that best meets their care needs. A robust
handover system is required for all patients coming from inpatient services as the treating team will
be different in the ambulatory services setting.
A multi-disciplinary assessment and individual rehabilitation plan will be developed for each patient
within one week of admission in consultation with the patient, their family/support people and
significant others.
The assessment process will consider all relevant handover information and there will be no
duplication of assessment. If an assessment has been undertaken previously and treatment goals
set, then these will be utilised in developing the ongoing care plan. Relevant community health
providers (e.g. GPs, Parkinson’s Disease Liaison Nurse, and Alzheimer’s Australia) may be
involved in initial assessment, goal setting and discharge planning. This will enable timely access
to information regarding the patient’s ongoing and historic needs including possible chronic
conditions that require regular reviews.
The RACC assessment will determine the care requirements for each individual which is to be
agreed with the patient (their family/support people if appropriate) and the relevant clinicians.
Agreed care plans will identify care/treatment goals and timeframes, intensity of therapy required
and inform the commencement of care. The care plan will also confirm the team members together
with any inreach services required.
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4.2.2.4
Care Delivery
Care delivery will commence as soon as possible in any of the RACC care settings. Care may be
provided by a single discipline or comprehensive multi-disciplinary team according to the patient
care needs.
Care delivery will be patient focused, goal orientated and time limited in accordance with the
agreed care plan. Regular team meetings will be held to review each patient’s progress and to
update individual rehabilitation plans and goal sheets in consultation with the patient and their
family/support people.
Care delivery will include therapy sessions as clinically indicated together with rest and meal
breaks. Access to hot and cold beverage making facilities and to recreational/lounge space will be
provided for patients and their family/support people. It is proposed that a ‘lunch box’ type meal will
be provided to people a full day program. Family/support people may access the
recreational/lounge space whilst the patient is in a therapy session.
Care provision may be provided within gymnasium and other clinical spaces including a
therapeutic mobility garden. A separate leisure/recreational outdoor space will also be accessible
by patients, their family/support people and staff.
The care coordinator/key link person will be allocated for each patient according to patient needs.
The care coordinator/key link person will be the first point of contact for the patient and their
family/support people (if appropriate) and will aim to:

Enhance patient centred therapy;

Increase and improve communication and information sharing between the treating team, the
client and their family (if appropriate);

Improve transition between different RACC service settings and between RACC care and
other services providers e.g. GP, non-government organisations, NDIS;

Assist with the integration of services for the patient; and

Lead the process of review and update of care plans.
A care coordinator will be a dedicated care coordination role (separate to the multi-disciplinary
clinical roles), providing input for a number of patients and will be allocated to patients with more
complex care needs. The care coordinator role will focus upon ensuring that care provision is
provided seamlessly between different disciplines and care settings including links to community
health services e.g. GP, non-government organisations.
A key link person will be a member of the treating team who is nominated as the key contact.
Allocation of a care coordinator or key link person will be determined based on individual need.
Multi-disciplinary care provision will include medical, nursing, allied health and support staff, as
appropriate. Throughout the course of care delivery/treatment, patient care needs will change. It
may therefore be necessary for patients to move between different RACC care settings. Where this
is required, patients will be referred to the relevant RACC service via the centralised integrated
intake point. Timely referral to ongoing services will ensure that the transition between different
RACC services is as seamless as possible, including minimal wait times between services and
limiting the extent to which patients need to undergo repeated assessments. This requirement will
be facilitated through the use of integrated records systems.
It may also be necessary for input from RACC clinical services based off-site (refer to section 4.3)
to be provided at any point during the care continuum. Staff from RACC clinical services based offsite will provide care to patients in collaboration with the ambulatory services team. Access to
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consultation liaison services e.g. orthopaedic surgeon, may also be required. Efficient and effective
communication between RACC and other services will be enabled through an integrated records
system.
Transition between different RACC care settings will also be supported through the provision of
flexible care delivery e.g. provision of some day program services in centre or within the
community.
Booking and scheduling of appointments for ambulatory services will be undertaken by a
centralised integrated process consistent with a whole of organisation approach.
4.2.2.5
Transfer of Care or Discharge
Following completion of a period of rehabilitation patients will be transferred on to other services or
discharged as follows:

Patient achieves all of their treatment goals and further input is not required;

Patient achieves all of their ambulatory services treatment goals and is ready to progress to
another care setting (e.g. RACC community based services or other community health
services e.g. YMCA Exercise Group, Alzheimer’s Australia, Parkinson’s Disease Liaison
Nurse, community pharmacy);

Patient is no longer benefiting from treatment and may be referred on to alternative care or
discharged from the service; and

Patient chooses to access services in another area or through alternate means such as
private treatment.
Early discharge planning with appropriate involvement of equipment services, community health
providers and other services will be key to efficient and effective care provision within the
specialised setting of UCPH. This will include provision of comprehensive and timely discharge
summary information provided to the patient’s GP. This may also include timely facilitation of
access to the National Disability Insurance Scheme or Lifetime Care and Support for eligible
patients.
4.2.3
Ambulatory Services - Service Delivery Team
As previously noted, care provision for RACC day programs will be provided by a multi-disciplinary
team according to each patient’s care needs based on providing an optimised staff skill set so that
the ‘right staff’ are undertaking the ‘right roles’.
The following medical staffing is proposed:

A rehabilitation registrar and geriatric registrar will be allocated to the inpatient units and
ambulatory services and outreach programs.

Accreditation for advanced training in geriatric medicine should be provided for registrar roles
in geriatric rehabilitation in both inpatient and community settings.
Nursing care for RACC inpatients will be provided by nursing staff with general and specialised
rehabilitation and geriatric services skills.
A range of allied health staff with general (e.g. rotating junior staff) and specialised skills will be
integral to care delivery.
Multi-disciplinary team members will include the following clinicians:
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
Allied Health Assistant;

Medical;

Nursing including Assistants in Nursing;

Nutrition;

Occupational Therapy;

Pharmacy;

Physiotherapy;

Psychology and Counselling;

Social Work; and

Speech Pathology.
The core clinical team for each patient will be determined based on individual clinical need. The
number and type of specialised staff will be determined based on casemix within each of the
ambulatory service streams. Some services may be provided on a sessional basis as clinically
indicated e.g. nutrition, pharmacy.
Care provision will incorporate flexible service delivery e.g. shift hours for different clinicians based
upon clinical need i.e. some allied health clinicians may commence their shift earlier or later than
others in order to accommodate the needs of patients and their families.
In addition to the core clinical team, patients may access services from a range of other services
including:

RACC services based off-site but will provide a service at UCPH.

Other clinical and non-clinical support services staff based at UCPH including Veteran’s
Liaison Service and Pastoral Care/Multi-faith services (further description regarding clinical
and non-clinical support services is provided in the MOSD.
As noted in the list above, RACC staffing will include assistant roles (e.g. allied health assistant,
nursing assistant) which will support a flexible workforce and contribute to the provision of services
in the right place at the right time.
As patients needs progress the care delivery team may change. Specialised staff will be provided
to best address different service requirements within different care settings. Transition between
different services and care delivery teams will be enabled through efficient and effective handover
processes, supported by integrated ICT systems. The treating doctor for patients will be
maintained throughout the duration of care, where appropriate, in order to facilitate continuity of
care.
Care delivery will be provided by a flexible workforce with the ability to offer extended hours of
treatment in order to accommodate special care needs (e.g. education session with family member
outside of their working hours, provision of inpatient rehabilitation or community based services
over the weekend). The workforce will also have capacity to provide services in the community or
health centre settings in response to patient care needs.
Ongoing professional development, training and research will be considered a priority to ensure
that RACC services are provided consistently throughout the ACT and continue to be delivered in
accordance the latest evidence based practice.
Integral to the core RACC services staff profile will be students and volunteers. Student
placements for all disciplines will be encouraged to support partnerships with affiliated universities
and other teaching institutions.
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Volunteers will continue to provide an invaluable service to RACC patients including but not limited
to a strong presence in the main entrance providing assistance with way finding and patient
transport and assisting with therapy sessions.
4.2.3.1
UCPH Workforce Project
A UCPH Workforce Project has been established to inform workforce requirements for UCPH.
Development of the care delivery team will be informed by the workforce project.
4.3
Therapeutic and Recreational Spaces at UCPH
Therapeutic and recreational spaces in the new facilities will be positioned to facilitate optimal use.
For instance, the shared therapy spaces will be embedded within the inpatient units and the two
gymnasiums will be located slightly closer to the neurological and general rehabilitation inpatient
units as these patients will be the highest users of these spaces.
Throughout the course of treatment, whether care is delivered in an inpatient or ambulatory setting,
consideration will be given to the provision of environmental enrichment for patients in order to
facilitate motor, sensory, social and cognitive activity.
In addition to standard rehabilitation therapies delivered on the ward, patients may receive
environmental enrichment through:

Participation in therapy or leisure activities in a communal enrichment area which could
include a computer with an internet connection, diverse reading material, jigsaw puzzles,
board games, etc;

Attending a dining area for eating meals;

Rehabilitation team members encouraging family members to bring in hobbies and activities
that the patient enjoyed prior to their illness or injury; and

Rehabilitation team members encouraging patients to attend the communal enrichment area.
These principles will guide the provision of environmental enrichment for patients within a safe and
enabling environment. Environmental enrichment will be incorporated where relevant into the
provision of care for RACC inpatients with consideration of the following:

The needs of different patient cohorts will vary and may overlap;

For example, someone without cognitive impairment may use indoor spaces differently
compared to someone with cognitive impairment related to dementia, compared to someone
whose cognitive impairment is related to neurological events such as post-stroke or acquired
brain injury; and

Each individual will choose how they spend their leisure time.
Design of the new facilities will support appropriate management of patients with cognitive
impairment including dementia. The new facilities will provide an environment which:

Is safe and secure (including outdoor space, the ability to ‘close’ each of the inpatient units
and the ability to use bed sensor alarms in each bedroom);

Has effective and intuitive way finding;

Minimises unwanted stimulation;

Highlights helpful stimuli;

Provides opportunities for both privacy and community; and
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
Is domestic and familiar.
It is proposed that further assessment of these factors be undertaken to understand how these
principles interrelate with environmental enrichment as well as other best practice principles for
indoor spaces in a sub-acute rehabilitation facility. These factors are informing design development
of the new facilities as well as future care delivery processes.
In addition to selection of appropriate therapeutic and recreational indoor spaces, a therapeutic
outdoor space will be accessible by all people attending UCPH. This space will include:

Mobility training spaces – a range of surfaces and mock community type situations to
practice moving around, such as grass, gravel, ramps, curbs, steps etc.;

ADL training spaces – raised garden beds for those in wheelchairs to garden, clotheslines to
practice hanging washing on the line etc.; and

A secure courtyard for people with cognitive impairment including dementia.
4.4
RACC Clinical Services Based Off-Site from UCPH
RACC clinical services based off-site are services which may provide input for RACC patients in
any care setting. They will provide services to UCPH inpatients and ambulatory patients based on
clinical need. Where clinically relevant, services will be provided to patients at UCPH, however, the
majority of services will be provided to patients on an outpatient basis at Village Creek.
In order to provide these services to UCPH patients there will be some satellite spaces included at
UCPH. Satellite space is a designated space located at UCPH for a service which is based off-site.
Those services that do not require designated satellite space will access shared consult/treatment
spaces at UCPH when necessary.
RACC clinical services based off-site which may provide a service to UCPH patients will include:

CTW Service;

DARS;

Exercise Physiology (EP);

Podiatry

P&O

RADAR;

SWAPS;

TTCP Assessor; and

VARS.
These services are described below.
Clinical Technology Workshop Service
The Clinical Technology Workshop Service will provide the following:

Maintenance and repairs of assistive mobility devices;

Manufacture and modification of all prosthetics and orthotic devices;

Manufacture and modification of all specialised wheelchair and seating;

Installation of off-the-shelf seating components; and
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
Wheelchair servicing and maintenance.
Service provision will be provided by technical officers in consultation with clinicians.
Driver Assessment and Rehabilitation Service (DARS)
DARS will provide advice, assessment, rehabilitation and training for patients wishing to return to
driving following injury or illness with associated disability. This service will be staffed by
occupational therapists and driving instructors.
Services will include either on-road assessment, off-road assessment, or a combination of both, as
clinically required. Supervised practical driving training can also be undertaken where required.
Exercise Physiology (EP)
EP is a member of the multi-disciplinary team and will provide specialised exercise prescription
and self management education to patients accessing services at UCPH where there is an
identified need.
Podiatry
The Podiatry service at UCPH will provide assessment and intervention to inpatients and
ambulatory patients where there is an identified need and as part of a multi-disciplinary team. The
general public (non-UCPH based patients/consumers) will not have direct access to this service;
rather they would access alternative community or hospital services.
Intervention will range from biomechanical assessments, custom made and pre-fabricated foot
orthoses, orthotic modifications, footwear review and prescription, general treatment, nail surgery
and treatment of non complicated foot wounds. The service will also offer health promotion/health
education provision through Footsure Health Promotion and may be delivered by the Podiatry
Assistant.
Management and clinical governance will be provided within RACC. The UCPH service will
operate under a different service model to the Podiatry service that is available currently from the
RACC Community Care service offered at ACT Health Centres.
The UCPH Podiatry service will be time limited and goal oriented. When intervention is completed,
UCPH Podiatry patients may be referred on as appropriate, to other podiatry providers e.g. DVA
and NDIS providers, other private practitioners or RACC’s Community Care Podiatry Service
provided from the Community Health Centres.
Prosthetics & Orthotics (P&O)
P&O will provide a range of services for patients including:

Assessment and prescription of orthotic and prosthetic devices;

Production of orthotics and prosthetics;

Supply of pre-fabricated devices;

Assessment and fitting of custom and depth footwear; and

Fitting of devices and training in functional use.
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Rapid Assessment of the Deteriorating Aged at Risk (RADAR)
The RADAR service assess and treat patients who are aged 65 years or over (younger patients
may be seen if already known to the aged care team or in residential aged care facility) or over 50
for Aboriginal and Torres Strait Islanders. This is a time limited intervention.
Patients will be referred to the service as they have suffered a decline in function/ability, which the
referring doctor anticipates will result in a likely hospital admission within the next two weeks. The
person does not appear to require immediate hospital admission for acute illness. There is a high
likelihood that the person will be able to stay in their usual place of residence while the reason for
the deterioration in health is managed.
The RADAR service will be provided by an allied health, medical and nursing team (including aged
care nurse practitioner) who will remain in close in contact with the GP and will liaise with available
services (pathology, imaging, hospital in the home, allied health, ACAT) to ensure that timely
investigation and multi-disciplinary management is available for the older person in the appropriate
environment. This may include referral to any of the RACC ambulatory services or inpatients if
clinically appropriate. This could include admission to other health facilities.
Transitional Therapy & Care Program (TTCP)
TTCP will continue to function as a national service for older people who are at the end of their
acute or sub-acute hospital stay. TTCP will provide up to 12 weeks further transitional therapy and
care to recover to full functional capacity, to return home and make arrangements for long term
care.
The TTCP service will continue to be collaboratively managed by ACT Health, RACC services and
BaptistCare. RACC staff will be based at the Village Creek Centre and provide services to patients
at the Mullangarrie Unit (Red Hill).
A TTCP Assessor will visit UCPH to assess patient for eligibility to this service.
Specialised Wheelchair and Posture Seating Service (SWAPS)
The SWAPS Service is a tertiary level consultancy service that works with clients, family/support
people and their treating therapists to assess, prescribe and fit wheelchair and seating systems for
clients with complex posture and seating needs. This can be through the utilisation of
commercially available products, or the manufacture of customised components.
The service also provides the fitting of both commercial and custom systems in conjunction with
the Clinical Technology Workshop Service.
Vocational Assessment and Rehabilitation Service (VARS)
VARS will provide services for rehabilitation patients who require assistance with vocational and
avocational work issues as a result of their changed function following injury or illness. Services will
include assessment, facilitation and support/training (e.g. computer skills etc.).
This service will be staffed by occupational therapists and teachers.
4.5
Hydrotherapy
Hydrotherapy services will be provided at UCPH. Equitable access, based on clinical need, will be
available to eligible patients throughout the ACT. It is envisaged that in the future there may be an
increase in the number of inpatients accessing hydrotherapy.
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The provision of hydrotherapy services will be based on individualised assessments and treatment
programs. All patients attending hydrotherapy will have a land based assessment prior to
commencement of their program. Hydrotherapy treatment sessions will be conducted in group and
individual scheduled sessions to best meet the needs of each patient. Sessions will be led by
physiotherapy, exercise physiology, allied health assistants or by approved external providers
under contractual arrangements. External providers will apply to utilise the pool and an appropriate
memorandum of understanding will be negotiated/agreed with those external providers.
Hydrotherapy treatment will be patient focused and goal orientated and may include the following:

Water assisted or resisted strengthening and range of motion exercises;

General endurance training and reconditioning; and

Functional retraining in buoyancy assisted environment.
Patients attending hydrotherapy sessions will be reviewed regularly to ensure that rehabilitation
goals remain current. Following completion of a supervised hydrotherapy program, patients may be
discharged or referred to other services.
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5
RACC Community Based Services
RACC will continue to provide a wide range of multi-disciplinary community based services for
patients throughout the ACT. Future service provision will include enhanced integration of RACC
services (through collocation and use of technology), enhanced range of services, expanded
access to services including a focus on opportunistic care and health promotion, strengthened
governance that supports proactive approaches, assimilation and integration between care
providers across community centres.
RACC community based services will be provided from a number of facilities to enable the
provision of services that are easily accessible to patients. The configuration and service mix for
community based services will continue to change and adapt in the future to meet service demand.
Selection of the most appropriate care setting will be determined based upon individual patient
care needs and may include the provision of services within health care facilities or within the
community. A key enabler for the provision of health centre based services will be the provision of
a flexible and reliable patient transport system.
Care provision across the different sites will be standardised and based upon contemporary
evidence based care. These services are summarised in the table below.
Table 2: Outline of Future RACC Community Based Services
Type of Service
Service Base/Location
Aged Care Assessment Team (ACAT)
UCPH
ACT Continence Support Scheme
Village Creek Centre
ACT Equipment Service (ACTES)
Village Creek Centre
Community Nursing – Domiciliary Care (multiple Belconnen CHC
technical nursing services)
Tuggeranong CHC
Phillip CHC
Canberra City CHC
Community Nursing – Domiciliary
(multiple technical nursing services)
After-Hours Gaunt Place
Community Nursing – Ambulatory Care Clinics
Belconnen CHC
Tuggeranong CHC
Gungahlin CHC
Phillip CHC
Canberra City CHC
Community Nursing – Continence Clinic
Belconnen CHC (incl. specialised clinic)
Tuggeranong CHC
Phillip CHC
Canberra City CHC
Community Nursing – Stoma Clinic
Belconnen CHC
Phillip CHC
Tuggeranong CHC
Canberra City CHC
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Type of Service
Service Base/Location
Community Nursing – Wound Clinic
Belconnen CHC
Gungahlin CHC
Phillip CHC
Tuggeranong CHC
Clinical Technology Workshop (CTW) Service
Village Creek Centre
Domiciliary Oxygen
Scheme (DORSS)
and
Respiratory
Support Village Creek Centre
Equipment Loan Service (ELS)
Village Creek Centre
Falls and Injury Prevention Program
UCPH
Independent Living Centre
Health Promotion including Self Management of Canberra City CHC (office only)
Chronic Conditions
Memory Assessment Service
UCPH
Nutrition
Belconnen CHC
Tuggeranong CHC
Gungahlin CHC
Phillip CHC
Canberra City CHC
Community Occupational Therapy
Belconnen CHC
Phillip CHC
Independent Living Centre
Community Physiotherapy
Belconnen CHC
Tuggeranong CHC
Gungahlin CHC
Phillip CHC
Dickson CHC
Physiotherapy – Pelvic Floor Clinic
Belconnen CHC
Physiotherapy – Continence Clinic
Phillip CHC
Podiatry
Belconnen CHC
Tuggeranong CHC
Gungahlin CHC
Phillip CHC
Canberra City CHC
Dickson CHC
Prosthetics and Orthotics (P&O)
Village Creek Centre
Rapid Assessment of the Deteriorating Aged at Risk Canberra Hospital
(RADAR)
Residential Aged Care Liaison Nurse (RACLN)
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UCPH
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Type of Service
Service Base/Location
Social Work
Belconnen CHC
Tuggeranong CHC
Specialised Wheelchair
(SWAPS) Service
and
Posture
Seating Village Creek Centre
Transitional Therapy and Care Program (TTCP) Village Creek Centre (office space only)
Assessor
Walk-in Centre
Belconnen
Tuggeranong
Note:
1. The Community Rehabilitation Team currently based at Belconnen and Phillip CHCs will
provide ongoing services as part of the future Day Programs at UCPH.
2. The above outline regarding community based services is accurate as at October 2014. The
provision of community based services will continue to adapt in response to service demand.
Further detail regarding the Model of Care for individual community based RACC services will be
developed.
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6
Appendices
6.1
Reference Documents
Reference documents that have informed the development of this report include:

ACT Health Strategy and Corporate, eHealth & Clinical Records, 6/2/13, V1.1.

ACT Health CSP 2014-2018 Draft March 2014.

ACT Health Ambulatory Care Framework 2012.

Directions Paper – A Professional Approach to Administration Support to Ambulatory Care
Services, April 2014.

Service Models and Projected Service Demand for Adult Rehabilitation and Aged Care
Services 9/10/12, Christopher Poulos.

Subacute Planning Workshop 9/11/12 (dated 4/1/13), Christopher Poulos.

ACT Health Community Health Centres Model of Care Part 1 October 2009, V3.1.

ACT Health Community Health Centres Model of Care Part 2 September 2009, V4.

Towards Culturally Appropriate and Inclusive Services – a Coordinating Framework for ACT
Health 2014-2018.

Health Directorate Reconciliation Action Plan 2012 – 2015.

University of Canberra Public Hospital Services Delivery Plan, 28 August 2013.

ACT Health Workforce innovation in sub-acute care speciality services: a literature review,
November 2013.

ACT Health University of Canberra Public Hospital (UCPH) Workforce Innovation Forum 13
December 2013, Record of Discussion.

University of Canberra Public Hospital (UCPH) workforce planning workshop overview:
Rehabilitation and Aged Care, 6 June 2014, Record of Meeting.

NSW Health Guide to Role Delineation of Health Services, Third Edition 2002, available at
http://www.health.nsw.gov.au/services/Publications/guide-role-delineation-healthservices.pdf).
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6.2
Outline of UCPH Service Streams and RACC Services
Rehabilitation and Aged Care UCPH Service Streams
INPATIENT UNITS
NEUROLOGICAL REHABILITATION UNIT
GENERAL REHABILITATION UNIT
OLDER PERSON'S REHABILITATION UNIT
SLOW STREAM REHABILITATION UNIT
Stroke
Acquired Brain Injury (ABI)
Traumatic Brain Injury (TBI)
For patients with a range of conditions
Amputee
Musculoskeletal Disorders
For patients with a range of medical comorbidities associated with ageing
For patients with limited ability or tolerance to
participate in rehabilitation
Geriatric Evaluation and Management (GEM)
Non-weight bearing restrictions
Motor Neurone Disease
Post orthopaedic surgery
Cognitive impairment
Maintenance while awaiting completion of
home modification or residential placement
Multiple Sclerosis
Falls
Cerebral Palsy
Spina Bifida
Newly diagnosed Parkinson's Disease
Late effects of Polio
Medical fractures
Ortho-geriatric patients
Reconditioning
Parkinson's Disease
Specialist multi-disciplinary team*
Generally tolerate a higher intensity program
Lower intensity rehabilitation services
Specialist multi-disciplinary team*
Specialist multi-disciplinary team*
GENERAL
OLDER PERSON'S
Specialist multi-disciplinary team*
AMBULATORY SERVICES
NEUROLOGICAL
Recently Acquired Conditions
Chronic and Progressive Conditions
CVA
ABI
TBI
Newly diagnosed Parkinson's Disease
Multiple Sclerosis
Huntington's Disease
Motor Neurone Disease
Long term SCI management
Long term ABI management
Long term CVA management
Amputee
Multitrauma
Orthopaedic
Musculoskeletal
Deconditioning
Parkinson's Disease
Dementia
Reconditioning
GEM
Falls
Specialist single/ multi-disciplinary team*
Specialist single/ multi-disciplinary team*
Specialist single/ multi-disciplinary team*
Specialist single/ multi-disciplinary team*
Clinical Services based off-site but will provide a service to UCPH patients: Clinical Technology Workshop (CTW) Service, Driver Assessment and Rehabilitation Service (DARS), Exercise Physiology (EP), Podiatry,
Prosthetics and Orthotics (P&O), Rapid Assessment of the Deteriorating Aged at Risk (RADAR), Specialised Wheelchair and Posture Seating (SWAPS) Service, Transitional Therapy and Care Program (TTCP), Vocational
Assessment and Rehabilitation Service (VARS).
Hydrotherapy will be accessible f or UCPH inpatient and ambulatory patients based on individual clinical need.
*Specialist staff aligned to service streams will include: allied health assistants, medical, nursing (including nursing assistants),nutrition, occupational therapy, pharmacy, physiotherapy, psychology & counselling, social work , speech pathology and
students. The core clinical team will be determined for each patient based on individual clinical need. Specialist single/ multi-disciplinary teams may include specialist clinics.
Note: the above diagnoses are indicative of the lik ely conditions to be appropriate for care within each of the specialist streams, the lists are not exhaustive and selection of the appropriate care setting and service stream will be based on individual
clinical need.
Rehabilitation and Aged Care UCPH - Outline of Future Services
Specialist Multi-disciplinary Team
Members - UCPH Inpatient and
Ambulatory Services
UCPH Clinics
Clinical Services based off-site that
may provide a service to UCPH
patients*
Non-clinical Support Services
Community Based Services
Allied Health Assistant
Aged Care Assessment Team (ACAT)
Clinical Technology Workshop (CTW)
Service
Aboriginal Liaison Officer
ACT Continence Support Scheme
Medical
Aged Care Nurse Practitioner
Driver Assessment and Rehabilitation
Service (DARS)#
Pastoral Care/Multi-faith
ACT Equipment Service (ACTES)
Nursing including Assistants in Nursing
Falls and Injury Prevention Program
Exercise Physiology (EP)
Veteran's Liaison Service
Aged Care Assessment Team (ACAT)
Nutrition
Geriatric Medicine Outpatient Clinics
Podiatry
Domiciliary Oxygen and Respiratory
Support Scheme (DORSS)
Occupational Therapy
Geriatric Rehabilitation Medicine
Outpatient Clinics
Prosthetics and Orthotics (P&O)
Others including Cleaning, Waste
Management, Linen, Food Services and
Supply
Pharmacy
Memory Assessment Service
Rapid Assessment of the Deteriorating
Aged at Risk (RADAR)
Equipment Loan Service (ELS)
Physiotherapy
Rehabilitation Medicine Outpatient
Clinics
Specialised Wheelchair and Posture
Seating Service (SWAPS)
Falls & Injury Prevention Program
Psychology & Counselling
Rehabilitation Multi-disciplinary
Outpatient Clinics
Transitional Therapy and Care Program
(TTCP)
Health Promotion including Self
Management of Chronic Conditions
Social Work
Rehabilitation Nurse Practitioner Clinics
Vocational Assessment and
Rehabilitation Service (VARS)#
Memory Assessment Service
Speech Pathology
Students
Community Nursing
Nutrition
Occupational Therapy
Physiotherapy
Rapid Assessment of the Deteriorating
Aged at Risk (RADAR)^
Residential Aged Care Liaison Nurse
(RACLN)
Social Work
Transitional Therapy and Care Program
(TTCP)^
Walk-in-Centre
* These services will remain based off-site and provide services to UCPH patients when clinically indicated
# DARS and VARS will be fully integrated with the services provided at UCPH
^ RADAR and TTCP may provide inreach assessment services to patients attending UCPH inpatient and ambulatory services
Hydrotherapy will be accessible for UCPH inpatient and ambulatory patients based on individual clinical need.