Rehabilitation Redesign – Template for gap analysis
The NSW Rehabilitation Model of Care has 8 essential principles that apply to every aspect of a rehabilitation service. A principle has been defined as a statement
of intent of what is to be achieved. These principles encompass all six care settings: In-reach to acute, sub-acute inpatient, ambulatory care (day hospital),
ambulatory care (outpatients), ambulatory care (home based) and outreach.
The gap analysis tool is designed in context of the Model of Care. The following tables are indicative of the gap analysis to be undertaken and are intended to
inform Local Health Districts of the requirements of each care setting at a facility level. Each of the service check points is designed to underpin the good practice
principle and is taken from the newly developed Model of Care. Many of the check points include the page number from the Final Report where further
information may be obtained. It is also important to note that the analysis should not be limited to these check points.
The rating key is designed to indicate if the service check points for each good
practice principle are in place.
Rating Key

G
G
reen indicates that the Model of Care is currently being met.

range indicates that current practice does not meet the requirements of the
new Model of Care; however it would be possible to restructure services
within the current available resources.
Matches Model of Care
O
Does not meet Model of Care, restructure
of services is possible within current
resources
O

R
ed indicates that current practice does not meet the requirements of the new
Model of Care and services are unable to be restructured within the current
resources to meet the Model of Care. For this service check point to be met a
business case will need to be developed, which will need to include the
solution required to meet this gap.
R
For any questions or queries please contact:
Claire O’Connor, ACI Rehabilitation Network Manager Claire.oconnor@aci.health.nsw.gov.au
1
Does not meet Model of Care, restructure
of services will not be possible. A business
case will be required.
Service delivery site:
Type of care setting:
Date:
Principle 1 - Leadership
Leadership is displayed at all levels providing a strategic and operational sense of team and a commitment to the principles of rehabilitation care.
Service check points
Rating
Details of rating
a. Staff satisfaction with leadership (pg. 50 of Rehabilitation
Model of Care)
b. Performance of the unit overall, including examples of KPIs
collected, ie LOS/FIM (pg. 88 of Rehabilitation Model of
Care)
c. Implementation of innovations
d. Implementation of best practice
e. Quality improvement practices
f. Client/patient satisfaction
2
Principle 2 – Equitable access
Patients receive equitable access to rehabilitation services in the most appropriate setting and in a timely manner. (information available on pg.73 of Rehabilitation Model of
Care)
Service check points
Rating
Explanation of rating
a. A standardised referral system
b. Process for rehabilitation consultation and services
c. Waiting lists utilised
d. Waiting lists transparent
e. Early intervention practices for therapy to reduce
functional decline
f. Guidelines for establishing when patients are ‘ready for
rehabilitation’ against each care setting
g. Data available on total percentage of patients discharged
on an active rehabilitation program
h. Are specialised services accessible
i.
Is the ward/unit meeting benchmark comparisons (eg. #
NOF)
j.
Readiness for transfer criteria
k. Comprehensive discharge information for primary and
community care services
l.
Implementation of follow-up via appointment or telephone
3
Principle 3 – Multidisciplinary care teams
Patients have access to a ‘core’ multidisciplinary team who work collaboratively within an interdisciplinary framework. Access to non-core team specialist services
is available as required.
Service check points
Rating
Explanation of rating
a. Staffing levels meet AFRM standards, available at: (pg.77 of
Rehabilitation Model of Care)
http://www.racp.edu.au/index.cfm?objectid=02A65485-086ABFB5-353A30441DCB479F
b. A standard process for assessment by core multidisciplinary
teams (pg.74 of Rehabilitation Model of Care)
c. Assessment tools covering physical, psychological and
social needs (pg.74 of Rehabilitation Model of Care)
d. Referral process for specialist therapist consultations and
levels of prioritization for these services
e. Therapy available in this setting (pg.75 of Rehabilitation
Model of Care)
f. Data on available therapy intensity
g. Evidence of multidisciplinary care planning (ie a single care
plan with a common goal and no duplication)
h. Utilisation of case managers (pg.75 of Rehabilitation Model
of Care)
i. Evidence of communication between team (pg.74 of
Rehabilitation Model of Care)
j. Client/patient satisfaction
4
Principle 4 – Care Coordination
Patient care is communicated and coordinated between the multidisciplinary team and other care providers across the continuum of care. Patients and their cares
are encouraged to participate in goal settings and care planning.
Service check points
Rating
Explanation of rating
a. Utilisation of case managers
b. Case conferencing is multidisciplinary, documented,
frequent and supported by other informal communication
processes
c. Case coordinators or key person allocated to each client to
coordinate care across the continuum. A single point of
contact for the client, family, carer, the multidisciplinary
team and for other service providers
d. Data to support the provision of clinical handover
information between settings (pg.75 of Rehabilitation
Model of Care)
e. Protocolised care plans for patients with similar conditions
eg. Post hip and knee replacement
f. Client/patient satisfaction
g. Evidence of linkages across care settings (including
community and primary care eg ADHC)
h. Evidence of communication between team
i. Evidence of transfer of care planning
j. Clinical information sharing
5
Principle 5 – Patient centred care
Rehabilitation services are patient centred and delivered to promote an enablement model of care. Patient centred care ensures an ongoing understanding of an
individual’s needs and expectations.
Service check points
Rating
Explanation of rating
a. Goal setting: Patient centered and communicated in a
tangible way time limited and regularly reviewed (pg.55 of
Rehabilitation Model of Care)
b. Patient satisfaction with involvement in care planning and
delivery (pg.55 of Rehabilitation Model of Care)
c. Health literacy scale
d. Achieved goals (ie short and long term goals, patient
centric goals)
e. Evidence of patient/carer education programs and
communication (pg.75 of Rehabilitation Model of Care)
6
Principle 6 – Evidenced based care
Processes to promote the implementation of evidence and best practice are in place to support safe and effective care. Evidence based practice is supported
through professional development, teaching, quality research and quality assurance activities.
Service check points
Rating
Explanation of rating
a. Implementation of and adherence to evidence based
guidelines, participation in and outcomes from ‘guideline
audits’
b. Manage intensity of therapy: (pg.53-54 of Rehabilitation
Model of Care)

Type

Timing, duration, intensity

Continuity across care settings

Continuity over the weekend
c. Improvement in patient outcomes
d. Reduction in adverse events
e. Local processes for evaluating new practices and changes
in care prior to implementation
f.
Clinical governance processes
g. Continuing education for staff
h. Demonstrated participation in research and quality
activities
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Principle 7 – Appropriate care setting
Patients receive rehabilitation services in the most appropriate setting based on individual patient’s fit with the admission and discharge criteria for the relevant
care setting and the potential to achieve rehabilitation goals. (further information from page 56 - 69 of the final report)
Service check points
Rating
Explanation of rating
a. Set objective admission and discharge criteria across care
setting
b. Compliance with admission and discharge criteria across
care setting
c. Implementation of care pathways across multiple care
settings
d. % patients receiving care in the most appropriate setting
8
Principle 8 – Clinical process and outcome indicators
Consistent measurement process across rehabilitation services are in place to monitor and demonstrate patient outcomes that contribute to enhanced functional
independence.
Service check points
Rating
Explanation of rating
a. Re-entry – distinguishing between planned and unplanned
occurences
9