TBI Residential
Rehabilitation Service
Operational Guidelines
Contract Start Date : 1 April 2014
Supporting Client Transitions
Emergency
Response
Inpatient
Acute Care
Residential Rehabilitation
Community
Services
This is a living document and will be updated and finalised with contracted
suppliers as and when required.
Version - .06
10 February 2016
Contents
Introduction ........................................................................................................................................ 4
Purpose ............................................................................................................................................ 4
Service Overview .............................................................................................................................. 4
Service Objectives ............................................................................................................................ 5
Useful contact numbers .................................................................................................................... 5
Responsibilities ................................................................................................................................. 5
DHB .................................................................................................................................................. 5
Supplier ............................................................................................................................................ 6
ACC .................................................................................................................................................. 7
Relationship Responsibilities ............................................................................................................ 8
Eligibility Criteria ............................................................................................................................... 8
Cover ................................................................................................................................................ 9
Age-limit ........................................................................................................................................... 9
Medically Stable ............................................................................................................................. 10
Supporting Client Transitions ......................................................................................................... 11
Population Responsibility (Coverage) ............................................................................................. 11
Entering Rehabilitation - Admission............................................................................................... 15
Process Map 1 - Admission ............................................................................................................ 15
Admission - Process Table ............................................................................................................. 15
Notifications, Referral, Approvals & Purchase Orders ..................................................................... 17
Forms ............................................................................................................................................. 18
Rehabilitation ................................................................................................................................... 19
Process Map 2 – Rehabilitation Planning ........................................................................................ 19
Process Table................................................................................................................................. 20
Service Expectations ...................................................................................................................... 21
Emerging Consciousness Service (ECS) ..................................................................................... 21
Residential Rehabilitation ............................................................................................................ 22
Day Rehabilitation ....................................................................................................................... 22
Managing Rehabilitation ................................................................................................................. 22
Planning and Implementation ...................................................................................................... 22
Rehabilitation Plan....................................................................................................................... 23
Reporting by Exception ............................................................................................................... 23
Monitoring Rehabilitation Efficacy ................................................................................................ 23
Discharge Planning ..................................................................................................................... 24
Clinical Measures ........................................................................................................................ 24
Supporting family & whānau ........................................................................................................... 26
Interruptions to Rehabilitation ......................................................................................................... 26
Unplanned absence..................................................................................................................... 27
Self Discharge ............................................................................................................................. 27
Leaving Rehabilitation - Discharge................................................................................................. 28
TBIRR Operational Guidelines v6
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Process Map 3 - Discharge............................................................................................................. 28
Process Table................................................................................................................................. 28
Long Term Equipment .................................................................................................................... 30
Home Trials and Weekend Leave ................................................................................................... 30
Supporting Transition ...................................................................................................................... 30
Post Discharge Specialist Assessments ......................................................................................... 31
Service Administration .................................................................................................................... 31
Rehabilitation Complexity Scale (Appendix B) ................................................................................ 31
Service level expectation description .............................................................................................. 32
Documentary Evidence - Recording Keeping.................................................................................. 34
ACC Documentation Audits ......................................................................................................... 35
Inclusive and Exclusive ............................................................................................................... 35
Consumables .............................................................................................................................. 35
Equipment ................................................................................................................................... 36
Other Types of Medical Assessments and Treatments ................................................................ 36
Quality Management....................................................................................................................... 37
Internal Quality Checks ............................................................................................................... 37
Australasian Rehabilitation Outcomes Centre (AROC) ................................................................ 39
Quality Forums ............................................................................................................................ 39
Research Participation ................................................................................................................ 39
Service Monitoring ....................................................................................................................... 39
Quarterly Reporting ..................................................................................................................... 40
Service Level Agreement ................................................................................................................ 40
Customer satisfaction survey .......................................................................................................... 40
Annual Reporting ............................................................................................................................ 41
Appendices ...................................................................................................................................... 43
Appendix A – Field List for the TBIRR Quarterly Discharge Report ................................................ 43
Appendix B – Rehabilitation Complexity Scale version 8 ................................................................ 46
Appendix C – Satisfaction Surveys ................................................................................................. 52
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Introduction
This operational guideline supports the service specification for the Traumatic Brain Injury Residential
Rehabilitation Service (TBIRR or “the service”). The operational guidelines provide a greater level of
detail on the operation of the service including the philosophy, relationship and partnership
expectations within the service. References to the TBIRR Service Specification have been provided to
assist the reader. Any reference to a clause includes any sub clauses where appropriate.
The under pinning philosophy is that the client, their family and whānau, ACC and the supplier are in a
close working relationship aimed at achieving the maximum level of independence for the client.
Purpose
The purpose of the TBIRR is to provide specialist rehabilitation services that will support clients who
have sustained a moderate to severe traumatic brain injury (TBI) to return to active and meaningful
participation in their community and, if appropriate, their place of work in a planned, timely, well
supported and sustainable manner.
(Part B Clause 1.1)
Both the service specification and the operational guidelines should be read in conjunction with each
other. To assist references to specific clauses in the TBIRR Service Specification have been
provided.
(Part B Clause 1.3)
If there is any disagreement between the service specification and the operational guidelines then the
service specification takes precedence.
(Part B Clause 1.2)
Service Overview
The Service will provide specialist TBI rehabilitation that is targeted and holistic with an
interdisciplinary approach to the client’s rehabilitation needs through the development and
implementation of an agreed Rehabilitation Plan.
The TBIRR Service comprises three specialist rehabilitation services designed to meet the client’s
needs:

Emerging Consciousness - High intensity residential neurological stimulation rehabilitation
for clients who have a disorder of consciousness in order to maximise their opportunity to
return to consciousness through tailored therapies and to preserve their function.
(Part B Clause 2.1.1)

Residential Rehabilitation - High intensity inpatient (residential) rehabilitation that will support
clients to return to participation in their community and, if appropriate, their place of work in a
planned, timely, well supported and sustainable manner. (Part B Clause 2.1.2

Day Rehabilitation – High intensity outpatient (non-residential) rehabilitation, as an alternative
to inpatient rehabilitation, that will support clients to return to participation in their community
and, if appropriate, their place of work in a planned, timely, well supported and sustainable
manner.
(Part B Clause 2.1.3)
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Service Objectives
ACC will measure the success of the Service based on the following objectives:

All clients discharged from the service return to active and meaningful participation in their
work and/or community, or achieve a measurable improvement in their cognitive and functional
abilities that maximises their independence and quality of life. (Part B Clause 3.1.1)

The rehabilitation services provided are planned, timely, client centric, supportive of the client,
family and whānau, efficient and effective
(Part B Clause 3.1.2)

Clients, their family and whānau are satisfied with the service and are well informed about the
impacts of the Client’s injury and have the appropriate strategies to manage these impacts.
(Part B Clause 3.1.3)
Useful contact numbers
Provider helpline
Health Procurement
Ph: 0800 222 070
Ph: 0800 400 503
providerhelp@acc.co.nz
health.procurement@acc.co.nz
The provider helpline staff can answer queries
relating to provider numbers, ARTP updates and
general enquiries.
Health Procurement can advise on appropriate
documentation in relation to applying for
contracts.
Responsibilities
DHB
The District Health Board (DHB) DHB supplier is responsible:
to…
for…
Clients

providing high quality acute care

ensuring the client, family & whānau are informed of all options and
strategies

ensuring timely and accurate decisions by working with the TBIRR supplier
and ACC to ensure the early cover process outlined in the administrate
requirements are described in the Accident Services: A Guide for ACC and
DHB Staff 21 Jan 2014 (ASG) are complied with
(ASG section 5.6.1.1)

Transfer the client from the acute setting to the rehabilitation facility

Notifying them immediately they are aware they client is likely to require
residential rehabilitation
(Part B Clauses 4.1.2, 4.1.4, 6.1.1)

Ensuring the assessment and decision making when planning the client’s
continuum of care (Part B Clauses 4.1.2, 4.1.4)

Ensuring there is a good working relationship between the TBIRR supplier
and ACC that smooth’s the client’s transition between services
Supplier
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to…
for…
ACC

Lodging the ACC45 promptly (within 3 working days)

Ensuring the ACC45 has a correct diagnosis and list of injuries

Ensuring the diagnosis is supported with clinical information such as
reports, tests and assessments.
(SAG Clause 5.6.1)
Supplier
The Supplier is responsible:
to…
for…
clients

Ensuring they receive high quality rehabilitation services (Part B Clause 1 )

Providing a comprehensive experienced interdisciplinary team (Part B Clause
9.4 )

Providing a key worker who (Part B Clause 8.2)
o facilitates the client’s transfer from the acute setting
o coordinates the rehabilitation programme
o facilitates the clients transfer to the next stage of service after
discharge
o is the main point of contact and communication with the client, client’s
family and whānau

Ensuring the client’s family and whānau have a good understanding of
brain injury and its impacts in relation to their injured family member (Part B
Clauses 8.3.10)

Developing a Rehabilitation Plan that is individually tailored, culturally
appropriate, outcome focused and reflects the client’s goals and ensuring
the plan also includes
o
Goals that are specific, measurable, achievable, realistic and time
framed
o
a therapy plan within the Rehabilitation Plan which outlines the
inputs required to meet the short, medium and long term goals of the
client
o
a discharge plan which includes the transition supports
(Part B Clause 8.3)
DHB

Transporting the client to any outpatient visit and any activity provided as
part of the rehabilitation programme.
(Part B Clause 8.6.1.17)

Working closely with them to determine if the client meets the eligibility
criteria
(Part B Clauses 6.5)

Ensuring DHB have sent to ACC all the appropriate clinical information to
make a cover decision such as an up to date ACC45 and or ACC18,
clinical notes, lab results, MRI, CT reports that identify the client’s injuries.
(SAG Clause 5.6.1.1)?? Check

Ensuring ACC has made a cover decision that reflects the injury and
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to…
for…
rehabilitation needs of the client prior to discharge
(Part B Clause 8.1)

Discussing with ACC Branch and National Serious Injury Service the
assignment of the appropriate case management staff to facilitate the
client’s transition and rehabilitation.

Acknowledging the notification

Assessing the client’s readiness for rehabilitation in conjunction with acute
service clinical staff (Part B Clause 4.1.2)

Assisting with the identification of all clients with moderate to severe TBI
(Part B Clause 8.1.1.1)
ACC

Notifying ACC of when the client transfers from DHB to the rehabilitation
facility
(Part B Clause 7.1.2)

Providing with an opportunity to be involved in the rehabilitation and
discharge planning
(Part B Clause 8.3.1)

Notifying of any changes to the client’s rehabilitation plan where those
changes would impact the client’s needs on discharge. (Part B Clause 8.3.8)

Providing regular progress reports on the client’s rehabilitation programme
(no less than monthly)

Assessing the inputs provided (retrospectively) based on the recorded
inputs of care, nursing, therapy types, therapy levels and medical care
using the Rehabilitation Complexity Scale.
(Part B Clause 8.4.1.2)

Providing, from the time of admission, an up to date discharge plan which
outlines the likely supports required
o
Attendant care
o
Community rehabilitation
o
Housing modifications
o
Rehabilitation Equipment
(Part B Clauses 8.3.8 & 8.9)
other service
providers

Communicating openly and supportively to ensure the client has a
seamless transition
(Part B Clause 8.9.5)

Ensuring that post discharge supports have had the opportunity to engage
with the client’s family and whānau prior to the client’s discharge.

Providing advice where appropriate to ensure the client receives a high
standard of service
(Part B Clauses 8.10)
ACC
ACC is responsible:
to…
for…
clients

Ensuring the client, family and whānau is fully aware of the client’s options

Making timely decisions so their rehabilitation is not delayed
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
Ensuring the management of their case is a high priority

Ensuring the service supplier is providing a high quality standard of service

participating in the client’s rehabilitation planning and decision making so
the client’s rehabilitation programme is not delayed

Ensuring discharge process is supported and ensuring the client’s
transition into the community is seamless, smooth and supportive
employers

Working with the employer on the client’s behalf to support a planned
return to work
other service
providers, eg

Ensuring suppliers have the opportunity to make contact and coordinate
areas of responsibility and transition arrangements
Home &
Community
Support,

Ensure the appropriate supports are arranged as agreed and in a timely
fashion
suppliers
Training for
Independence
Relationship Responsibilities
There is an expectation that:

Suppliers and ACC staff will work together to ensure the client receives the appropriate
rehabilitation
(Part B Clause 8.3)

All parties will respect each other’s area of expertise

Suppliers are experts in the rehabilitation of brain-injured clients and are responsible for achieving
the service outcome for the client within the context of the TBI Residential Rehabilitation service
(as defined in the services specification)

ACC staff are expert at managing the complex mix of rehabilitation services, entitlements, and
compliance relating to claims
Eligibility Criteria
(Part B Clause 4.1)
The Supplier is responsible for ensuring the client meets the following eligibility criteria before entering
the TBIRR service:




Have an accepted ACC claim for personal injury with a clinical diagnosis that indicates a moderate
to severe TBI acquired through trauma or hypoxia, in accordance with the Evidence Based Best
Practice Guideline – Traumatic Brain Injury: Diagnosis, Acute Management and Rehabilitation
2006 (available on the ACC website); and,
Have been assessed as requiring Traumatic Brain Injury Residential Rehabilitation; and,
Are aged over 16 or of a suitable maturity to participate in adult rehabilitation services; and,
Are Medically Stable.
For those clients who have not regained consciousness and will be entering the emerging
consciousness service must:
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
Be assessed as either post-coma unresponsiveness or minimally conscious as defined in the
Wessex Head Injury Matrix and / or Coma Recovery Scale
Cover
ACC will assess the client’s clinical diagnosis and approved cover for their moderate to severe
traumatic brain injury. Without a cover decision, the client cannot transfer to residential rehabilitation.
The classification can be done using either Read or ICD coding supported by clinical documents.
(Part B Clause 4.1.1)
Clinical diagnosis - severity of injury
The Evidence-based Best Practice Guideline – Traumatic Brain Injury; Diagnosis, Acute Management
and Rehabilitation July 2006, outlines the definitions for moderate and severe TBI which will help
determine eligibility for the TBIRR service. Clients diagnosed with a moderate to severe TBI are
suitable for the service. The table below is used to categorise TBI acutely.
Severity of injury
Glasgow coma scale (GCS)
Duration of post-traumatic
amnesia (PTA)
Moderate
9-12
1-6 days
Severe
3-8
7 days or more
(Source: Evidence best practice guideline – traumatic brain injury: diagnosis, acute management and
rehabilitation 2006 (TBI Guidelines)
Note:
Where the GCS and PTA do not correlate, then the client will be assigned to the greater of the two
severity categories.
It is expected that the TBIRR supplier will support the cover decision process by maintaining contact
with DHB to promote, encourage and prompt their timely notification to ACC of clinical information to
allow the cover decision to be made. The TBIRR supplier will also stay in contact with ACC to ensure
timely decision making to facilitate the appropriate transition of a client to rehabilitation once all criteria
are met.
(Part B Clause 6.5)
Age-limit
While the entry point for admission into the service is age 16 and over, there is flexibility to allow for
younger clients who are more mature than their years and are clearly more young adults than children,
in every respect, and would be better placed in an adult service. Any decision about the suitability of
the service for clients aged less than 16 years old must be discussed and agreed between the parties
 the client and their family/whānau
 Acute Service
 TBIRR Supplier
 Paediatric service provider contracted under the ACC Child and Adolescent Rehabilitation
Service
 ACC
The final decision remains the discretion of ACC.
TBIRR Operational Guidelines v6
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(Part B Clause 4.1.3)
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Medically Stable
Clients must be assessed as medically stable by the DHB providers, in order to enter TBIRR service.
Medically stable means that the client:

Is medically ready for rehabilitation that will significantly improve their functioning, and increase
pre-injury related vocational and social activities

Has stable vital signs

Does not have an acute and/or unstable potentially life-threatening medical condition (ie does not
need DHB, which are not paid for under this contract but are provided and paid for under Public
Health DHB (PHAS) funding

Does not have non-neurological medical sequelae of TBI requiring further acute medical treatment

Does not have non-neurological medical co-morbidities that need acute medical management.
Admission to any service for Clients who are not breathing independently must be agreed by DHB, the
supplier and ACC. The above criteria should also be read in conjunction with the Accident Services: A
Guide for ACC and DHB Staff 21 Jan 2014.
(Part B Clause 4.1.4 )
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Supporting Client Transitions
TBIRR Supplier Responsibility
Supporting Client Transitions
Emergency
Response
Inpatient
Acute Care
Residential Rehabilitation
Community
Services
The supplier is responsible for ensuring the client, family and whānau transition between services is
seamless and supported.
(Part B Clause 8.1)
Transition
The meaning of “transition” in this context is:
 discharging from DHB and admission to TBIRR
 discharging from TBIRR to community services
Seamless
Transitions
The meaning of “seamless” in this context is: smooth and continuous, with no
apparent gaps or spaces between one part and the next.
The supplier is responsible for smoothing transition processes so the client, family
and whānau perceive the transition to be seamless.
This is achieved by ensuring strong coordination and communication between
everyone in the process.
Supported
The meaning of “supported” in this context is: give assistance to; bear all or part
of the weight of; hold up.
The supplier is responsible for providing services that ensures the client, family and
whānau are supported during transition and rehabilitation.
This is achieved by ensuring that
 their needs for information and emotional support are met.
 ACC has provided the appropriate entitlements
 other community supports have been accessed where needed such as
mental health, drug & alcohol, chronic health management etc.
Population Responsibility (Coverage)
Suppliers are responsible for large areas of the New Zealand population via their primary relationship
with the Ministry of Health’s District Health Boards DHB. The service responsibilities are slightly
different depending on whether the client is in
 an acute trauma centre
 a regional DHB hospital
 in the community.
ACC, MoH/DHB’s and ambulance services have an agreed destination and disposition policy that
directs where clients will be delivered by ambulance services.
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Clients with serious injuries will be delivered to the optimal place of care which, depending on the
nature of their injuries, may not be the local DHB hospital. It is expected that the majority of clients
entering this service will be admitted to a trauma centre because of the nature and severity of their
injury.
Clients with less serious injuries may well be transported to the local DHB for assessment and
treatment.
Each regional trauma centre has an association with the DHBs in its wider region. This following table
shows the TBI supplier, Trauma Centre and District Health Boards.
(Part A Clause 2)
Supplier
ABI
Rehabilitation
- Auckland
- Wellington
Laura Fergusson
Trust
- Christchurch
Southern DHB
- Isis Unit
Trauma Centres
Auckland DHB
(Auckland Hosp) – Neurology
District Health Boards
Northland DHB
Waitemata DHB
Counties Manukau DHB
(Middlemore Hospital) – Orthopaedic & plastic
(burns)
Waikato DHB
Bay of Plenty
Lakes DHB
Tairawhiti DHB
Hawkes Bay DHB
Capital and Coast DHB (Wellington Hospital)
Taranaki DHB
Whanganui DHB
Midcentral DHB
Wairarapa DHB
Hutt DHB
Nelson Marlborough DHB
Canterbury DHB
West Coast DHB
South Canterbury DHB
Southern DHB
Southern DHB
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The Supplier will provide the following level of support within DHB in the following ways;
Client
Identification
Trauma Centres
Assist acute staff with the identification of traumatic brain
Injuries in inpatient ACC clients.
-
Regional DHB
Respond to DHB or ACC notification of a potential client.
(Part B Clause 8.1.1.1 )
Support
-
(Part B Clause 8.1.1.2 )
-
Knowledge,
Information and
Decision Making
-
(Part B Clause
- 4.1.2
- 6.5.2
- 8.1.1.2
- 8.6.1.1)
-
-
-
-
Relationships &
Administration
-
Facilitate client and family decision-making regarding
rehabilitation through education, information and emotional
support.
Maintain a supportive relationship with the client, their
family and whānau including before and after an ACC case
owner has been assigned.
Participate in regular reviews (ward rounds) with the
medical team and provide a comprehensive assessment of
the clients’ readiness for rehabilitation, where appropriate.
Where necessary participate in the development of
individualised rehabilitation plans for clients presenting with
a TBI where they will have an extended stay in the acute
setting.
At the DHB’s request, provide rehabilitation advice to DHB
staff for clients with mild to moderate TBI.
Provide effective and efficient transition planning that will
ensure clients receive a seamless transition to TBI
residential rehabilitation
Have a good knowledge of community supports available
and have knowledge of the available ACC contracts so that
informed recommendations can be made.
Provide advice on discharge options and post discharge
rehabilitation needs for Clients not requiring residential
rehabilitation.
Establish and maintain good quality relationships with
o DHB: trauma co-ordinators, trauma team, ED, ICU
and ward staff
TBIRR Operational Guidelines v6
5 August 2014
Once notified
- Facilitate client and family decision-making regarding
rehabilitation through education, information and emotional
support.
- Maintain a supportive relationship with the client, their
family and whānau including before and after an ACC case
owner has been assigned.
- Provide a comprehensive assessment of the client’s
readiness for rehabilitation. This assessment will be by
o A review of clinical information currently available in
DHB, and/or
o A clinical case review with medical, nursing and allied
health staff either face to face or via other means as
appropriate, and/or
o Physical hands on assessment with the client
- Where necessary participate in the development of
individualised rehabilitation plans for clients presenting with
a TBI where they will have an extended stay in the acute
setting.
- At the DHB request provide rehabilitation advice to DHB
staff for clients with moderate TBI that are likely to transition
to TBIRR.
- Provide effective and efficient transition planning that will
ensure a seamless transition to TBI residential
rehabilitation.
- Have a good knowledge of community supports available
and have knowledge of the available ACC contracts so that
informed recommendations can be made. Where time
permits and as requested by either DHB or ACC, advice on
discharge options and post discharge rehabilitation needs
for Clients not requiring residential rehabilitation.
- Establish and maintain good quality relationships with
o DHB: trauma co-ordinators, trauma team, ED, ICU
and ward staff
Page 13 of 55
-
-
-
-
-
Trauma Centres
o ACC: case owners, case coordinators
Support a seamless transition from DHB to residential or
community rehabilitation by promoting coordination
between the acute setting, ACC and the rehabilitation
facility.
Be responsible for ensuring the client transfers to the
rehabilitation service in a timely and appropriate way as
measured by AROC.
Follow up with the acute service to ensure all ACC45 forms
are submitted to ACC within the agreed timeframes and
include the required clinical information to enable accurate
and timely cover decisions.
Development of annual service level agreements between
District Health Boards DHB, ACC and the rehabilitation
supplier to outline roles, responsibilities and expectations
Regular business reporting to DHB and ACC on the
operation of the Transition Service
TBIRR Operational Guidelines v6
5 August 2014
-
-
-
-
-
Regional DHB
o ACC: case owners, case coordinators
Support a seamless transition from DHB to residential or
community rehabilitation by promoting coordination
between the acute setting, ACC and the rehabilitation
facility.
Be responsible for ensuring the client transfers to the
rehabilitation service in a timely and appropriate way as
measured by AROC.
Follow up with the acute service to ensure all ACC45 forms
are submitted to ACC within the agreed timeframes and
include the required clinical information to enable accurate
and timely cover decisions.
Development of annual service level agreements between
District Health Boards DHB, ACC and the rehabilitation
supplier to outline roles, responsibilities and expectations
Regular business reporting to DHB and ACC on the
operation of the Transition Service
Page 14 of 55
Entering Rehabilitation - Admission
The process for entering rehabilitation includes the client, their family & whānau, the supplier and
ACC. This map outlines the coordination, communication and process to be followed.
Process Map 1 - Admission
For clients progressing from DHB or living in the community to residential rehabilitation (initial
presentation or relapse).
Client is injured
Maybe sent to ED in crisis
GP / Other identify needs
DHB Acute
services
Early Cover
Assess
Medical
Stability
Diagnose the
level of brain
injury
Submit ACC45
& Clinical Notes
for clients likely
to go to TBIRR
Assess need and
readiness for
residential
rehabilitation
Notify
of allocation
Acute
services
arrange
transition
Seek prior approval
for Emerging
Consciousness
Service
Notify ACC of
transfer to
residential
rehabilitation
Case owner
considers prior
approval for ECS
Case owner
notified
Transition
to TBIRR
Notify
Decision
Registration
Process
ACC45
Allocated
case owner
ACC Early Cover Process
Admission - Process Table
An important part of the TBIRR service is supporting the client’s transitions into and out of the TBIRR
service. This process table is based on the previous process map and provides a higher level of
description.
Table 1 – Admission Process
Step
Action
Client Injured
The initial TBI acute injury will require admission to the DHB hospital for
acute management.
DHB
DHB will
(Part B Clause 4.1.2)


Diagnose the client’s injury and assess the severity based on
GCS, PTS and other clinical assessments
provide DHB which may include emergency department and
surgery, intensive / critical care, neurology and or orthopaedic
wards.
Early Cover Process
Submit ACC45 and clinical notes for clients likely to go to TBIRR
(DHB)
(SAG Clause 5.6.1)
The acute service will
TBIRR Operational Guidelines v4
Monday, 30 June 2014
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Step
Action
 ensure the ACC45 is submitted promptly (within 3 days of
admission)

email the clinical information to ACC’s cover team to enable the
cover decision proactively so as to minimise the delay in transfer
notify the TBIRR supplier of a likely admission
Where a client is discharged home the acute service should follow the
usual discharge process.
Registration and Cover
(ACC)
Allocate case owner
(ACC)
Assess Medically
Stability
(DHB)
Community Admission
(GP, Supplier)
ACC receives the appropriate documentation and makes a cover
decision. The claim is then sent to the ACC Branch for a case manager
to be allocated.
The Branch allocates a case owner who then makes contact with the
DHB and the TBIRR supplier to confirm the cover decision.
The DHB’s medical specialist will assess the client’s medical stability
using the criteria in the service specification. Where the client is
deemed medically stable the DHB will arrange for the assessment of
readiness to rehabilitate with the TBIRR supplier.
Clients who are in the community can be admitted to the TBIRR service
where it has been identified that they need


a period of residential stay to provide intensive rehabilitation to
re-establish activities of daily living that will enable their return to
the community, or
a comprehensive assessment programme, requiring the
participation of the full interdisciplinary team, that is best
undertaken in a stable environment
The TBIRR service does not provide a crisis admission service as an
alternative to mental health services.
Clients may present to DHB acute service and the process described in
the Accident Services: A Guide for ACC and DHB Staff 21 Jan 2014.
(ASG)
Assess need and
readiness for residential
rehabilitation
(Supplier)
The TBIRR supplier will assess the client to determine that the
admission criteria is met and that the client is ready for rehabilitation.
Where the client is entering the emerging consciousness service the
client will need to be assessed by a neurologist or clinical
neuropsychologist using the Wessex Head Injury Matrix. (As specified
in the service specification).
For day rehabilitation clients it is important they are assessed as safe to
discharge and that their post discharge supports are identified and in
place prior to discharge.
Seek prior approval
For Emerging
Consciousness Service
The Supplier will provide the appropriate referral to ACC seeking prior
approval for clients entering the emerging consciousness service.
Notify ACC of Transfer
A client who meets the eligibility criteria can transfer to residential
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Step
Action
rehabilitation when appropriate. ACC should be notified by the supplier
promptly. A specific report is not required.
Arrange Transition
The DHB will organise the transfer of the client to the rehabilitation
facility.
(DHB)
Notifications, Referral, Approvals & Purchase Orders
There are no purchase orders in this service but ACC retains the right to be informed and to approve
services.
Service
Residential
Rehabilitation
Prior approval - No
Purchase order - No
Referral, Approval & Notification
The client is able to be transferred to rehabilitation once they meet all the
eligibility criteria. If the client does not have cover for the brain injury then
they cannot transfer to this service.
The Supplier is responsible for ensuring that ACC has been notified of the
transfer within 24 hours. The notification can be via email to the designated
case owner.
The supplier will provide a full rehabilitation plan within 10 days of the client’s
admission.
No prior approval is required. A purchase order is not required.
Day Rehabilitation
Prior approval - No
Purchase order – No
Extension Approval - Yes
Entitlement to 14 days of rehabilitation is automatic if the client meets the
admission criteria. Once cover has been given the DHB and the supplier will
notify ACC of the transfer within 24 hours.
The supplier must seek an extension by submitting a rehabilitation plan within
ten days of admission.
No prior approval is required. A purchase order is not required.
Emerging
Consciousness
Prior approval - Yes
Purchase order – No
A referral must be submitted to ACC on the prescribed form for prior
approval. The appropriate clinical notes should be provided to support timely
decision making. ACC will provide a decision within 2 days.
The supplier will provide a full rehabilitation plan within 10 days of the client’s
admission.
Approval is required prior to the client’s transfer to rehabilitation. A purchase
order is not required. A maximum length of stay within the emerging
consciousness service of 90 days.
Community Referrals
Prior Approval - No
Purchase order – No
Where the client is in need a high intensity residential rehabilitation the
supplier must seek approval on the referral form and include the appropriate
supporting documentation within two days of the client’s admission. ACC will
provide a decision within 2 days. ACC may elect to provide services under
other ACC contracts.
(Part B Clause 7.4)
Approval is required. A purchase order is not required.
This table summarises when case owners need to provide approval.
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TBII Service
Service Item
Codes
ACC Approval
Purchase
Order
Emerging Consciousness
TRE02-04
Prior to admission
No
Residential Rehabilitation
TRR01-05
After admission (Rehab Plan)
No
Prior to absence (Rehab Plan)
Unplanned: After the fact (ACC6232)
After admission based on
rehabilitation plan (for longer than 14
days)
Bed Retention
TRR10
Day Rehabilitation
TRD01
Day Rehab Overnight stay
TRD10
Unplanned: After the fact
No
Advice & Support
TRR20
After the fact
No
No
No
Planned Absences
All planned absences must be agreed prior to occurrence even though a purchase order is not
required. Any absence is considered an interruption to rehabilitation therefore the supplier must
explain the impact of the absence on the client’s rehabilitation.
Unplanned Absences
Unplanned absences require approval (after the fact) and prior to invoicing. The supplier should
provide an updated rehabilitation plan (outlining the impact of the absence on the client’s rehabilitation
programme and, if appropriate, what therapy will be provided to re-establish the client’s rehabilitation
programme.
Forms
This service uses the following ACC forms.
ACC1511 Referral Form
The form is completed by the supplier to request prior approval to admit a minimally conscious client
to the emerging consciousness service.
The clinical assessment of consciousness using the Wessex Head Injury Matrix (WHIM).
ACC6232 - Interruption of Rehabilitation
The form is completed by the supplier whenever the client’s rehabilitation has been interrupted.
Both forms request basic data that should be supplemented with additional information when
appropriate. ACC needs the right information to be able to make timely and accurate decisions that
support the client.
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Rehabilitation
Best practice rehabilitation requires the supplier to maintain a current, robust individual plan to guide
the delivery of client’s rehabilitation programme. The supplier is expected to review and refine the
therapy programme weekly to maximise client engagement and outcomes achieved.
Process Map 2 – Rehabilitation Planning
For Clients in residential rehabilitation including emerging consciousness and day rehabilitation
Transition from
Acute or
Community
Assess the clients
rehabilitation needs
Develop and draft the
rehabilitation plan with
IDT, client, family & whanau
and ACC
Set a length of stay target
based on the AROC ANSAP
classification
Draft
rehabilitation
therapy plan
Provide
rehabilitation
therapy
Review the services
delivered regularly
(weekly)
Revise
therapy plan
as required
Assess the
client’s service
needs weekly
using RCS.
Submit the
plan to ACC
Bill
electronically
ACC
Participate in
rehabilitation
planning
Review & agree
Rehab Plan
TBIRR Operational Guidelines v4
Process
electronic
invoices
Monday, 30 June 2014
Update
Rehabilitation
Plan
Submit the
plan to ACC
when
changes
require ACC
action
Client Ready
to Discharge
Confirm
arrangements
Review Rehab
Plan. Arrange
discharge
supports when
required
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Process Table
The following is a description of the previous process map.
Step
Assess the Client’s needs
Action
The TBIRR supplier will undertake a full bio-psycho-social assessment
of the client using the appropriate clinical tools to provide a
comprehensive picture of the client’s strengths, abilities and
opportunities etc.
The TBIRR supplier will work with the client, family/whānau to identify
areas that are important to the person (cultural, religious and spiritual
beliefs).
Develop and draft a
rehabilitation plan
(Part B Clause
- 8.3.1
- 8.9.1
Based on the assessment of the client’ needs the supplier will develop a
rehabilitation plan with the interdisciplinary team, the family/whānau and
ACC
A comprehensive rehabilitation plan includes

short, medium and long term goals

therapy required to achieve those goals

discharge plan including expected discharge date, destination and
supports required to achieve a safe discharge
Note: The Rehabilitation Plan is not an ACC form or specified template.
Submit the Rehabilitation
Plan to ACC
The rehabilitation plan should be submitted to ACC within 10 days of
the client’s admission.
(Part B Clause 8.3.2)
Draft the therapy plan
(Part B Clause 8.3.6)
The therapy plan should link to the client’s goals and outline the:

specific rehabilitation therapies the client will participate in including
the different disciplines (OT, PT, SLT, therapy assistant, etc)

amount of time the client will participate in therapy on a daily basis
(7 day plan)

expected gain from those therapies
Provide rehabilitation
therapies
The client’s daily plan should reflect the rehabilitation and therapy plan
and the therapies should be provided according. The therapies should
be provided 7 days a week and the rehabilitation activities are varied to
maintain & reflect the client’s interest.
Record all services
provided
The supplier will ensure that all services delivered in the rehabilitation
programme will be recorded to support the RCS funding. Records of
care, nursing and therapy (types & intensity) and medical must be kept.
Inadequate recording keeping may, at ACC’s discretion, result in a
retrospective change to funding.
Review all services
provided
The weekly review of the client’s service inputs record is undertaken by
a member of the interdisciplinary team. The review will include an
assessment of the client’s cognitive and physical functioning function to
gauge the efficacy of the therapy.
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Step
Update the therapy and
rehabilitation plan
Action
Based on the results of the therapy, the therapy and rehabilitation plans
are refined and adapted to ensure the client’s recovery.
Submit the up to date
Rehabilitation Plan to
ACC
The updated Rehabilitation plan should be submitted to ACC only when
the goals have changed the Client’s ACC entitlements, services and
supports e.g.

The discharge date has been amended

The client’s discharge destination has changed

The client’s needs on discharge have changed
The full rehabilitation plan does not need to be provided if there is a
change in the client’s level of need as assessed by the Rehabilitation
Complexity Scale.
Progressing to discharge
See the Transition discharge map
Service Expectations
Each of the three services are aimed at meeting the needs of different client groups. This requires
slightly different programme responses. The following sections outline the different expectations.
Emerging Consciousness Service (ECS)
The ECS is for clients who are in a unconscious state but are not in a coma. The supplier is expected
to have expertise in this area and will ensure the ECS provides a comprehensive rehabilitation,
nursing and medical service that includes
-
Stabilising the basal functions such as
-
Nutrition
Skin integrity
Pulmonary function
Infection control
Weaning and removal of technical aids such as tracheal tube and catheters
-
An environment with a structured day rhythm and diverse activities, which when combined leads to an
everyday life pattern
-
Active therapy involvement including diverse therapies including but not limited to physical and
occupational therapies and if indicated speech therapy
-
An individualised stimulation programme that provides the systematic presentation of diverse sensory
and/or cognitive stimulation
-
An inclusive family program that includes intensive social work and support of the direct relatives
providing education, professional support during the grieving process, and guidance in the post
treatment trajectory.
-
Research and program evaluation
The supplier will ensure the development of ECS is based on international best practice.
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Residential Rehabilitation
This service is for the majority of the moderate to severe TBI clients who require high intensity, high
quality, comprehensive neurological rehabilitation, nursing and medical service in a specialist
residential facility. The service is not limited to the minimal expectation described in the service
specification
High intensity refers to the number of hours and the types of therapy provided. The supplier will
ensure the client receives the maximum intensity of tailored therapy that enables the client to achieve
their goals in the most effective and efficient way.
Day Rehabilitation
This service is for clients who would benefit from a residential rehabilitation service but may choose
not to be resident in the rehabilitation facility. The rehabilitation programme is managed and delivered
to the same expectation and standards as though the client is resident.
Managing Rehabilitation
Planning and Implementation
The supplier’s interdisciplinary team will meet regularly to assess, discuss and plan the client’s
rehabilitation programme. Research shows that best practice rehabilitation has
-
active management of the client’s rehabilitation including the monitoring and adaption of therapy
inputs
-
a focus on high intensity therapy that maximises neuro-plasticity to achieve the best gains for the
person.
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Rehabilitation Plan
The Rehabilitation Plan is living document that represents the current plan for the client at the time of
submission. While there is no ACC specified template for the Rehabilitation Plan but it will include the
following sections:
(Part B Clause 8.3.9)
The appropriate clinical assessments that evidence the client’s physical and
cognitive function and support the client’s need for specialist neurological
rehabilitation.
Goals
Long, medium and short term SMART rehabilitation goals
Assessments
(Part B Clause 8.3.4)
Therapy Plan
(Part B Clause 8.3.6)
Discharge Plan
(Part B Clause 8.3.8)
Specific, Measureable, Achievable, Realistic Time framed and aspirational to maximise
the client’s motivation.
Current therapy plan to achieve the client’s goals outlining the specific therapy
inputs by type, intensity and the expected gains.
The discharge plan will grow more detailed and accurate as the client’s
rehabilitation progresses. The plan will include:
- Date of discharge based on AROC benchmarking
- Client’s place of discharge or transition
- Potential supports required including any trials
o Care/Support
o Rehabilitation
o Community Assessments
o Equipment
o Access/Housing
o Transportation
- Non ACC supports such as
o Mental health services
o Chronic health services such as diabetes, cardiac etc
o Housing NZ
o Work and Income
o Any other agency required to ensure a durable discharge
Reporting by Exception
It is expected that the supplier and case owner will work closely together to keep each other informed
of the client’s progress against the agreed goals. Once there is an agreed Rehabilitation Plan in place
the supplier is expected to report when there is an exception to the rehabilitation plan. (Part B Clauses
8.3.7, 8.3.8)
Monitoring Rehabilitation Efficacy
The supplier is expected to undertake regular clinical assessment appropriate to the needs of the
client to monitor the client’s progress. Those assessments will assist in measuring the efficacy of the
rehabilitation programme and will assist in the refinement of the client’s therapy plan on an on-going
basis. (Part B Clause 8.3.9)
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Discharge Planning
Discharge planning should commence early into the client’s admission to the service.
The supplier will, using their extensive knowledge and experience, discuss potential outcomes and
discharge options with the client, family/whānau and ACC.
(Part B Clause 8.9)
See Leaving Rehabilitation – Discharge.
Clinical Measures
The suppliers will uses the appropriate clinical that meets the assessment and measurement needs.
ACC does require that specific measures are completed to assist in the management of the client’s
case. The assessment tools available to the suppliers may include but are not limited to the following
list. ACC may request a copy of the full assessment.
(Part B Clause 8.3.9)
Name
Description
Glasgow Coma Scale
(GCS)
Measures the level of consciousness in the acute setting. Provides an
indicator of severity but is a poor predictor of client outcome.
Wessex Head Injury Matrix
(WHIM)
Provides accurate assessment of clients in and emerging from coma
and in the vegetative and minimally conscious states.
The 62-item observational matrix can be used to assess the patient
and set goals for rehabilitation from the outset of coma. Designed to
pick up minute indices demonstrating recovery and provide objective
evidence, the WHIM provides a sequential framework of tightly defined
categories of observation covering:



Communication ability
Cognitive skills
Social interaction
The matrix can be used to collect data by observation and by testing
tasks used in everyday life.
Modified Oxford Post
Traumatic Amnesia Scale
(MOPTAS)
12-item test measuring
- orientation (8 items)
- anterograde memory (4 items)
Note: ACC TBI Guidelines suggest this measure has some qualitative
advantages to the Westmead PTA
Westmead Post Traumatic
Amnesia Scale
(Westmead)
To measure the period of post-traumatic amnesia for patients with a
closed head injury.
Functional Independence
Measure (FIM)
TBIRR Operational Guidelines v4
-
May be useful for people with a history of psychiatric illness,
developmental or intellectual disability, substance abuse, previous
head trauma or nervous system disease – but its usefulness for
these groups remains undetermined.
- Can be used with people with complex communication needs.
- Not suitable for people with penetrating or missile head trauma, as
well as the brain damage caused by hypoxia or stroke.
Provides a uniform system of measurement for disability based on the
International Classification of Impairment, Disabilities and Handicaps;
measures the level of a patient's disability and indicates how much
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Name
Description
assistance is required for the individual to carry out activities of daily
living.
Contains 18 items composed of:
 13 motor tasks
 5 cognitive tasks (considered basic activities of daily living)
Tasks are rated on a 7 point ordinal scale that ranges from total
assistance (or complete dependence) to complete independence
Scores range from 18 (lowest) to 126 (highest) indicating level of
function
Scores are generally rated at admission and discharge
Dimensions assessed include:










Eating
Grooming
Bathing
Upper body dressing
Lower body dressing
Toileting
Bladder management
Bowel management
Bed to chair transfer
Toilet transfer








Shower transfer
Locomotion (ambulatory or
wheelchair level)
Stairs
Cognitive comprehension
Expression
Social interaction
Problem solving
Memory
Functional Assessment
Measure (FAM)
12 items added on to FIM to enhance its utility for the brain injury
Overt Behavioural Scale
(OBS)
Measures verbal and physical aggression, sexually inappropriate
behaviour, repetitive behaviour and degree of initiative and wandering
and absconding.
Goal Attainment Scale
(GAS)
Measures if and how well the goal was achieved.
Northwick Park
Rehabilitation Complexity
Scales (RCS)
Assess staff input needs in care, nursing, therapy (number and
intensity) and medical.
Galveston Orientation and
Amnesia Test (GOAT)
Measures orientation to person, place, and time, and memory for
events preceding and following the injury.
Lawton’s Activities of Daily
Living (Lawtons)
Measures client self management.
Northwick Park
Dependency Measure –
Nursing (NPD-N)
Identifies the level of attendant care needed.
Northwick Park
Dependency Scales Therapy (NPD-T)
Identifies therapy requirements.
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Name
Description
Mayo Portland Adaptability
Index (MPAI)
Measure that covers Activity and Participation
Neuro-behavioural
Functioning Inventory
(NFI)
Covers depression, memory, attention, communication, aggression
and motor issues. An alternative at this point would be the Overt
Behaviour Scale but this does not include all of the areas covered by
the NFI.
Sydney Psychosocial
Reintegration Scale (SPRS)
Measure looking at community integration, including vocational and
non-vocational activities, interpersonal relationships and ability to live
independently.
Agitated Behaviour Scale
(ABS)
Measures the nature and extent of agitation during the acute phase of
recovery. It allows serial assessment of agitation by treatment
professionals who want objective feedback about the course of a
client’s agitation.
Quality of Life Measure
(SeQOL, BICROs,
QOLIBRI) (SEIQoL)
A measure of goal attainment.
Supporting family & whānau
The very best client outcomes are achieved when the client is highly motivated and well supported.
When the family/whānau are involved and committed to the rehabilitation programme the opportunity
for achieving the best outcomes is greatly improved.
The supplier will ensure the client’s family/whanau
- Understand their injured family member’s brain injury and the opportunity for recovery.
- Have all the facts so they can make good decisions
- Are empowered to participate in the rehabilitation planning
Interruptions to Rehabilitation
An interruption to rehabilitation is any situation in which the client is not actively participating in TBIRR
funded rehabilitation. In all situations ACC must be informed of the interruption. Depending on the
circumstances ACC may have to approve the interruption such as home trials or readmission to DHB.
(Part B Clause 8.7)
Type of Interruption
Significant complications
requiring readmission to
DHB
Description
Return to Acute
Clients receiving TBIRR services may occasionally develop a
complication or unrelated illness that requires readmission to DHB (e.g.
pneumonia, pulmonary embolism, myocardial infarction, further
emergency surgery, acute psychiatric illness). The service schedule
categorises this as a “significant complication”.
Note:
ACC does not fund acute treatment under this agreement. Funding will
be provided either through Ministry of Health as acute treatment, or a
public health acute service section 7 of the Injury Prevention and
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Type of Interruption
Description
Rehabilitation Compensation Act
When a significant complication requires readmission to DHB the
Supplier will:


arrange the transfer as clinical appropriate
notify ACC by sending an ACC6232 within 2 working days to the
ACC client service staff member
The Supplier will notify ACC when the client is clinically stable and
ready to resume rehabilitation.
Payment during client readmission to DHB
For the first two consecutive days that the client is away from the
vendor’s facility ACC will pay the Supplier at the applicable service level
set out in the service specification.
Any subsequent days that the client is away, up to a maximum of 5
days, will be paid at the bed retention rate. No prior approval is required
for the subsequent 5 days if the supplier has sent ACC written
notification of the significant complication.
The client can be absent for up to seven days before the supplier must
discharge them from the service. They may be admitted later but are
considered to be a subsequent admission not a continuation of the early
admission.
Unplanned absence
The supplier must have a policy in place for staff to follow which
describes the process if a client is absent without leave, i.e. the client
has left the facility without telling anyone.
This will include:

Initiating a search for the client

Notifying the ACC client service staff, family/whānau, and the
appropriate authorities in a timely manner.
The supplier will keep ACC client service staff informed of the client’s
status during the absence period. If the client is deemed to have selfdischarged, the supplier must complete and forward all required
discharge reports.
Self Discharge
Where a client has indicated an intention to discharge and leaves against advice this is considered a
discharge not an absence.
If the supplier is able to encourage the client to return within 24 hours of their departure the supplier
may consider the client’s stay uninterrupted. If the supplier is unable to return the client to the facility
then the last day funded is the last day the client was in the bed at midnight. (Part A Clause 3 Table 1
Note)
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Leaving Rehabilitation - Discharge
The supplier is expected to work closely with the client, family/whānau and ACC to plan and
coordinate the client’s successful long-term transition out the rehabilitation.
Process Map 3 - Discharge
Client Ready
to Discharge
Complete transition
needs assessments
Agree final discharge
plan arrangements with
- Client, family/Whanau
- Service suppliers
- ACC
Submit
to ACC
Create purchase
order for
community
services
Trial the arrangements
(If required)
Invite services suppliers
to meet Client, family/
Whanau
Finalise
discharge
arrangements
Draft Discharge
Report
ReviewACC
Transition
Plan & make funding
decision
Submit
to ACC
Review
Discharge
Report and file
Client Transitions
to new place
Hub & spoke support
Provide support to
suppliers in the
community as
required
Process Table
It is important that the client, family/whānau find the transition of the client seamless, efficient and
effective.
(Part B Clause 8.9)
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The following is a description of the previous process map. (Part B Clause 8.9)
Step
Action
Complete transition
needs assessment
The supplier will determine the supports required to ensure a safe and
enduring discharge by


using the appropriate clinical assessment tools
visiting to the client’s home where feasible
The supplier should work with community based assessment services,
where these are in place, to ensure a coordinated discharge.
Agree final
arrangements
The supplier will work with the client, their family/whānau and with ACC to
finalise the discharge plan. This should consider what supports may be
required including but not limited to:
-
Natural supports
-
Equipment
-
Residential providers
-
Care providers in the home
-
Community rehabilitation providers
-
Social work
-
Support agencies etc
This should also highlight the requirement to trial of any of the above
options.
Submit the finalised
plan to ACC
The discharge plan will be submitted to ACC within the time fames
outlined in the service specification to allow sufficient time for the
arranging of the goods and services required.
ACC will consider the plan and approve as appropriate. ACC will arrange
for needs assessments once the client is settled in their own home.
Trial arrangements
Once the discharge plan is approved by ACC the TBIRR supplier will
liaise with the approved service suppliers to ensure the transition is
efficient, effective and seamless for the client, family/whānau. This may
include planned visits residential, care and community rehabilitation
suppliers prior to discharge.
Any on-going rehabilitation plan should be discussed between the TBIRR
supplier, any following services and ACC to ensure continuity of care.
Where appropriate the client may participate in trials to ensure the new
arrangements meet their needs and to make refinements to the discharge
plan. The trial/s will be approved by ACC prior to commencement.
Finalise discharge
arrangements
The finalised discharge arrangements can be finalised by submitting the
final discharge section of the rehabilitation plan.
Once everyone is in agreement the client will transition.
Submit Discharge
Report
This post-discharge report summarises the client’s
-
rehabilitation programme
Part B Clause 8.9.6
-
gains made during the stay
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Step
Hub & spoke support
Action
-
status at discharge
-
on-going issues that require management
The supplier will provide two levels of support in the hub and spoke
model.
The supplier will during the discharge process build the appropriate links
with service providers in the community including allied health, GP,
medical specialist or any other service provider the client may need. The
service specification outlines the hours available to provide specific
support.
Client level – The supplier will provide advice to community suppliers for
up to two hours per month for six months, as the need arises.
Interactions must be documented in the client records. The supplier can
invoice for this service using the service item code TRR20.
Centre of Excellence – The supplier will provide rehabilitation advice
and support on TBI to the sector.
Long Term Equipment
The supplier will develop equipment solutions to aid the client’s discharge home by identifying any
challenges, barriers and risks by:
 visiting the client’s home and other community locations such as employer
 talking with the client’s family/whanau
 working with ACC and community assessors (where appropriate)
 completing a full specialised assessment (where appropriately contracted) as requested. Only
where the client lives within a reasonable distance.
ACC retains the right to select an appropriate assessor.
Home Trials and Weekend Leave
In preparation for the client’s long term discharge there maybe a number of different trials such as
return home routines, natural support, equipment, service suppliers such as home & Community
Support or Training for Independence, transport and community integration.
The Rehabilitation/Discharge Plan should identify any home trials required. Home trials should be
planned, monitored, reviewed and should clearly outline the gains to be made. ACC needs to approve
the trials and be advised of the outcomes. (Part B Clause 8.8)
Regular weekend leave should be limited and considered very carefully as TBIRR is a high intensity
rehabilitation service that provides rehabilitation seven days a week. Regular weekend leave can slow
the rehabilitation process. ACC may choose not to fund regular planned absences where there is no
identified benefit to the client’s rehabilitation goals.
Supporting Transition
Where appropriate the residential rehabilitation supplier should invite community suppliers to visit the
client prior to discharge. This will allow the client, family/whānau to build rapport with the people they
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will have close relationships with when they return home. The supplier will seek ACC’s approval by
outlining the extent of this in the discharge plan. (Part B Clause 8.9.5)
Post Discharge Specialist Assessments
This service does not include a post discharge assessment by the Medical or Rehabilitation specialist.
Any request for a follow-up assessment should be outlined in the discharge plan. A full rationale
outlining the benefit to the client should be provided. The service will be purchased, if approved,
under the Clinical Services contract.
Service Administration
Rehabilitation Complexity Scale (Appendix B)
The TBIRR contract specifies the use of the Rehabilitation Complexity Scale to determine the client’s
service level and input requirements. While intended as a planning tool for workload management the
National Health Service in England and now the ACC in New Zealand are using it to fund high
intensity TBI residential rehabilitation services.
(Part B Clause 8.4.1.2)
PROCESS MAP
Prospectively assess
the client weekly
using the RCS scores
to assess the client’s
needs
(clause 8.4.1.1)
Review the client’s
documentation to
assess the services
delivered
(clause 8.4.1.2)
TBIRR Operational Guidelines v4
Update RCS results
on the client’s
quarterly discharge
report
(clause 14.2 Table 6)
Monday, 30 June 2014
Invoice ACC for
Services
(Part A Clause 3
Table 1,(Clause 17)
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PROCESS TABLE
Step
Action
Assess client Needs
Undertake prospective assessments an optional activity.
Using the Rehabilitation Complexity Scale assess the client’s care and
rehabilitation needs for the coming week.
Refer to the RCS description table below.
Review Client Records
Review the clinical and input records of services delivered for the client
over the previous week. Determine a service level based on the highest
average score where that level of inputs was maintained for four out of
seven days.
Client Quarterly RCS
Discharge Report
Update the client’s quarterly discharge report completing all necessary
fields.
Supplier invoices ACC
The supplier can invoice for services as described in the service
specification. (Part A Clause 3 Table 1 & Clause 17)
Service level expectation description
The use of the scale is to allow the supplier to adapt to the needs of the client with the appropriate
level of funding. Suppliers are empowered to assess the client and determine the funding but they are
fully accountable to ensure that the services are delivered as assessed.
The description of use outlined in the attached document (RCS v8 LST UK) does not reference a
specific time period of the assessment. In reading all the background research papers it has been
interpreted to be an ‘on the day’ assessment that is then applied for the intended period, for TBIRR
this is a period of one week. As stated elsewhere in this document it is expected that the client would
have required the assessed level of care for at least four out of seven days or, if less than seven days,
where the client is resident in the facility. A single very heavy day does not push the overall rating
higher, rather consistently greater need and delivery will mean a higher rehabilitation complexity
score.
The descriptions below have been extracted from Appendix B – Rehabilitation Complexity Scale
version 8. Where additional descriptions have been made these are presented in italics.
C ~ Care – Basic care and support needs
Provision of physical and social cares within a residential facility such as bathing, dressing, feeding.
Level
Describes the approximate level of intervention required for basic self-care
0
Largely independent in basic care activities.
1
Requires help from 1 person for most basic cares.
2
Requires help from 2 people for most basic cares.
3
Requires help from more than 2 people for most basic cares or requires constant 1:1
supervision.
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N ~ Nursing – Skilled nursing needs
Monitoring, oversight, active management of the client, community integration. Rehab focused,
encouragement and support.
Level
Describes the level of intervention required from qualified or skilled rehab nursing
staff
0
No skilled nursing needs.
1
Requires intervention from qualified nurse (e.g. for monitoring, medication, dressings etc)
2
Requires intervention from trained rehabilitation nursing staff.
3
Requires highly specialised nursing care (e.g. for trachostomy, behaviour management etc)
T-D ~Therapy Needs – Number of Disciplines
Allied health therapist as listed within the TBIRR service specification
Level
Describes the approximate level of input that is required from therapy disciplines
Number of different therapy disciplines required to be actively involved in treatment
0
No therapy disciplines are actively involved.
1
1 discipline only
2
2 – 3 disciplines
3
4 or more disciplines
 Physio
 Social work
 Music/art therapy*
 O/T
 Psychology
 Play therapy*
 SLT
 Counselling
 Dietetics
 Other:
*Must only be a small proportion
of therapy
T-I ~Therapy Needs - Intensity
The number of hours of therapy planned within the scope of practice of the therapist as determined by
the IDT and rehabilitation plan.
Level
0
Overall intensity of trained therapy intervention required
No therapy intervention
(or<1 hour total per week - Rehabilitation needs met by nursing/care staff or self-exercise
programme)
1
Low Level - Less than daily
(e.g. assessment / review / maintenance / supervision) or group therapy only.
2
Moderate
Daily intervention 1:1 (+/- assistant) or very intensive group programme of greater than 6
hours per day)
5 - 7 days @ 1 - 2 hours per day = greater than 5 – 14 hours per week
Not
cover
in RCS
v8
15 – 19 hours per week.
14.5 – 16.5 hours per week go down to level 2
17 – 19.5 hours per week go up to level 3
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T-I ~Therapy Needs - Intensity
The number of hours of therapy planned within the scope of practice of the therapist as determined by
the IDT and rehabilitation plan.
Level
3
Overall intensity of trained therapy intervention required
High level
Very intensive 1:1 Intervention (e.g. trained therapists to treat, or total 1:1 therapy greater
than 25 hours per week)
5 - 7 days @ 4 - 5 hours per day = 20 - 35 hours per week.
M ~ Medical Needs
Level
Describes the approximate level of medical care environment required for
medical/surgical management
0
No active medical intervention – Could be management by GP on a basis of occasional
visits
1
Basic investigation / monitoring / treatment
(Requiring non-acute hospital care, could be delivered by community hospital with day time
medical cover)
Oversight by the consultant. Medical management at registrar level only. Includes prior
RCS level. Review / change medication regime, review changes in medical condition, i.e.
uncomplicated UTI / chest infection (medical stability). Organise / manage abnormal blood
test results, x-rays at non-specialist level.
2
Specialise medical intervention – for diagnosis or management / procedures
(Requiring in-patient hospital care in DGH or specialist hospital setting)
Medical management by SMO.
1 - Rehab consultant involvement over and above ward rounds equal to or less than 3 time
per week in total.
2 - Specialist opinion of client by another sub speciality direct +/- indirect of equal to or less
than 3 times per week in total.
3 - Consultant attending FM - Specialist investigation
(MRI / CT / EEG / Other)
3
Acutely sick or potentially unstable medical condition
(Requiring 24 on-site acute medical cover)
1. Rehab consultant involvement over & above word rounds greater than 3 times per week
in total
2. Specialist opinion of client by another sub-speciality direct / indirect greater than 3 times
per week in total
- Specialist investigation / procedures / management
- Botox, tracheotomy weaning, autonomic storming, IV / Picc, antibiotics, seizure
management, other
Documentary Evidence - Recording Keeping
(Part B Clause 14.4.1)
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The supplier will ensure a comprehensive record is kept of all services provided to the client during
their stay. The records will provide evidence in support of the RCS retrospective assessment used to
determine service levels billed.
The data collected by the supplier will be used in the

development of case weight categories

mapping of the rehabilitation journey by AN-SNAP (RCS modelling)

verifying inputs and costs
ACC Documentation Audits
(Part B Clause 14.4.1)
ACC will undertake periodic reviews of client records to confirm that the service levels invoiced have
been delivered. ACC will expect robust evidence of all services delivered including (but not limited to)
personal cares, nursing, therapy and medical services.
Where the documentation does not provide sufficient evidence that the service inputs (RCS level)
have been provided as invoiced ACC may require the service item to be adjusted to reflect the level of
service reflected in the documentation.
Where the change is service level results in a change in funding level the supplier and ACC will agree
an acceptable repayment schedule.
Inclusive and Exclusive
(Part B Clauses 8.6 & 11)
Given the highly specialised nature of this service & the funding levels agreed to the supplier is
expected to have the appropriate resources to meet all the client’s TBI injury assessment and
rehabilitation needs.
The supplier will provide:
Consumables
All consumables that are required for the management of high needs client in a specialist facility
including but not limited to:
Category
Description
Fluids & irrigation
products
Gloves and
protective garments
Incontinence
Fluids, IV sets, needles & syringes, luers, sharps containers
Nutrition
Thickener and thickened fluids, nutritional supplements, fluids for enteral
feeding, drinking straws (including one way), vitamin and mineral
supplements, antacids
Skin care &
dressings
Stockings, bandages, cotton wool, swabs, dry dressings, film dressings,
tapes, skin cleaners, lotions, creams, antiseptics, wipes, eye pads,
toothbrushes, mouthwash, mouth swabs, lip balm, sterile dressing change
packs
Gloves, sterile gloves, aprons, bibs, gowns, masks
Pads, lubricants, nappies, urinal bottles, bowls, nappy wrappers, wipes,
deodorants, non prescription laxatives, glycerol suppositories, disposable &
non-disposable underpads, uridomes, strips for uridomes, catheter change
packs
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Category
Description
Hearing
Standard hearing aid Batteries
Rehabilitation
Ultrasound gel and electrodes, therapeutic putty, crutch tips, digi caps, digi
sleeves
Other
Rubbish and waste bags, scissors, specimen containers, litmus paper, swab
sticks, measuring containers, forceps
Enteral feeding
Feeding tubes, gastronomy products, bottles and containers
Ostomy
Pouches (closed and drainable), wafers and flanges, belts and support
garments
Incontinence
Intermittent and indwelling catheters, drainage bags, connector and leg bag
accessories, enemas, irrigation equipment, suspensory garments, stoppers
and plugs, disposable and non-disposable briefs, swimmers, pull ups,
fixation pants
Respiratory
Oxygen therapy tubing & masks, suction equipment, traches, trache
accessories, filters
Specialist dressings
& wound care
Hydrogel dressings, hydrofiber dressings, hydrocolloids dressings, alignates
dressings, foam dressings, antimicrobial dressings, negative pressure
wound therapy dressings
Other
Haberman bottles, cast covers
Equipment
All equipment that is required for the management of high needs client in a specialist facility including
but not limited to:
Category
Description (included but not limited to)
Bed
Bed specific to the clients needs
Pressure management
Shower beds, lifting equipment (hoists, slings etc)
Wheelchairs, walking frames, walking sticks etc
Gym and therapy equipment such as treadmills, ceiling hoists, etc
Computers, adapted computers and educational equipment
Game machines, board games, music stereo etc and other participation
equipment as appropriate.
Care aids
Physical Rehabilitation
Cognitive Rehabilitation
Activity Equipment
Other Types of Medical Assessments and Treatments
The supplier will fund the provision of all medical assessments and treatments that relate to the
client’s traumatic brain injury.
The supplier is not responsible for funding separate (non-supplier provided) assessments and
treatments that may be required for a clients non-TBI related injuries such as fractures, spinal, internal
organs etc.
The supplier can request that the service be purchased from the client’s case manager with the
accompanying rationale and clinical information.
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TREATMENTS
There may be times in which certain specialist treatment would significantly aid the client’s recovery.
The treatment may not be considered to be “usual” even within the specialist rehabilitation setting and
as such may be very expensive. The supplier can ask ACC to considered approving specific funding
for the treatment.
ACC will consider




the likely impact the treatment will have on the client’s outcome and length of stay
the expected cost benefit of the treatment
the cost of the treatment
whether the treatment funding can be considered “usual” under the specialist TBI rehabilitation
model
Quality Management
Internal Quality Checks
(Part B Clause 9.8)
To ensure the supplier meets the requirements of the TBIRR service specification the supplier will
conduct internal monitoring or checks. This monitoring will be done on a monthly basis (and will be
reported to the appropriate member of the supplier’s senior management team). The results will be
reported in the supplier’s annual report to ACC.
The staff members doing the checks will not be the people regularly completing the tasks. They will
be trained to maintain an independent attitude and focus on quality improvement. The checking role
should be rotated.
The monitoring will include
Check
Goal, Risk and Action
Accuracy of
retrospective
assessments
Goal: Ensure the assessment for funding is fully supported by documentary
evidence that shows service delivery.
Risk: ACC documentation checks could find a lack of evidence to support the
level billed. The resulting amendment of the service level and recovery of the
over-billing would cause financial hardship.
Action: Ensure there is evidence of the service delivery such as
- client level work logs
- clinical notes
- rosters and staff allocations, etc
Frequency: The checks should be completed with a high level of frequency for
the majority of clients during the first few months of operation of the service
until the correct process is in place and the expectation is regularly met. The
checks can then become less frequent.
Example: 50% of all clients every month checking 5 randomly selected days
within the month until all cases meet expectation then 20%, then no less than
10% of cases.
Reporting &
submission
Goal: Ensure that timeliness is met.
Risk: ACC may loose confidence in the supplier if processing targets are not
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Check
Goal, Risk and Action
timeliness
met. The loss of confidence may begin to extend to other areas.
Action: Review client documentation looking for decision dates, notification
dates etc to check timeliness.
Frequency: The checks should be completed regularly until fully compliant
then they can be less frequent.
Example: 50% of clients where a report had been submitted in the previous
month. Dropping to no less than 10%.
Rehabilitation
review and
refinement
Goal: Ensure that the rehabilitation process is being properly implemented to
ensure the very best client outcomes.
Risk: Failure to implement and refine the client’s rehabilitation (therapy) plan
could mean poorer client outcomes and would mean not meeting the
expectations outlined in the service specification.
Action: Review the client’s clinical notes and identify
-
the frequency of the review of the therapy plan and functional assessments
-
the frequency of the updating of the therapy plan
-
where the plans changes was there any impact on client discharge and
needs and was ACC informed promptly
Frequency: 50% of clients until full compliance then dropping progressively to
no less than 10%.
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Australasian Rehabilitation Outcomes Centre (AROC)
(Part B Clause 9.2)
The Australasian Rehabilitation Outcomes Centre AROC is a joint initiative of the Australian and New
Zealand rehabilitation sector (providers, funders, regulators and consumers).
The purpose and aims of AROC were established as, and continue to be:
 Develop a national benchmarking system to improve clinical rehabilitation outcomes in both the
public and private sectors.
 Produce information on the efficacy of interventions through the systematic collection of
outcomes information in both the inpatient and ambulatory settings.
 Develop clinical and management information reports based on functional outcomes,
impairment groupings and other relevant variables that meet the needs of providers, payers,
consumers, the States/Commonwealth and other stakeholders in both the public and private
rehabilitation sectors.
 Provide and coordinate on-going education, training and certification in the use of the FIM and
other outcome measures.
 Provide annual reports that summarise the Australasian data.
 Develop research proposals to refine the selected outcome measures over time.
The supplier will collect and submit client level episode data as outlined by AROC.
Quality Forums
(Part B Clause 9.5)
The goal of quality forums is to promote and encourage a philosophy of continuous improvement in
clinical practice and service provision.
All TBIRR suppliers will attend a quality forum held every six months. The meeting will focus on the
-
Outcome results provided by AROC
-
Review of the bench marking results to try an replicate top performance
-
Planned quality improvement initiatives undertaken by the suppliers
-
Any challenges, lesson or improvements made
The quality forums will be hosted on a rota system with each supplier and ACC having an opportunity
to host.
Research Participation
The supplier will participate in any ACC initiated research into any component of the TBIRR service.
Pricing
During the first year and periodically thereafter the supplier will participate in service input
information to assist in the costing of the service.
Clinical
Suppliers are encouraged to develop research programmes within their clinical area. This
research may be within their own organisation or across all three suppliers. ACC will
provide data within the constraints of client privacy and subject to the appropriate ethical
approvals.
Service Monitoring
(Part B Clause 13)
This service will be monitored according to performance measurements outlined in the service
specification. The supplier is responsible for reporting on all required measures.
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Quarterly Reporting
The supplier will submit a quarterly discharge report on an MS Excel spreadsheet. The field format is
outlined in Appendix A – Field List for the TBIRR Quarterly Discharge Report.
The quarterly periods are:
Period start
Period finish
Submitted by
1 July
30 September
31 October
1 October
31 December
31 January
1 January
31 March
30 April
1 April
30 June
31 July
Summarised by
ACC will produce
summarised reports and
data analysis
This will assist in ACC’s monitoring and reporting of supplier performance for this service. Once the
information has been compiled, data will be extracted from ACC’s systems, in conjunction with the
supplier’s data, analysed and reported on. ACC will utilise this data to produce reports that will be
available to assist in service improvement.
Service Level Agreement
The Supplier will, in conjunction with District Health Board acute settings and ACC, develop an annual
service level agreement that includes

The roles of the Supplier’s transition liaison representative, DHB staff and ACC

The responsibilities of the Supplier, DHB and ACC

The expectations timeliness of communication, site visits, etc

Business Reporting
Customer satisfaction survey
(Part B Clause 9.7)
The supplier works with many stakeholders. As part of a continuous improvement process the
supplier will survey those stakeholders to gain insight into where improvements can be made. The
surveys can be found




Client, Family/Whānau Satisfaction Survey
District Health Board Satisfaction Survey
ACC Case Owner Satisfaction Survey
Residential and Community Provider Satisfaction Survey
The results will be reported annually
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Annual Reporting
(Part B Clause 14.2)
The Supplier will provide an annual report that includes the following topics:
Summary of Admissions
Capacity,
Utilisation,
Occupancy
Example
Total beds in the facility available for admissions (beds)
Number of days open (days)
Available Days
28
x 365
10,220
Beds x days
Client
Composition by
Funder
Funded days
 Ministry of Health
 ACC
 Private / Other
Total funded days including bed retention
Timeliness
Rehabilitation plan within 10 days
Client Outcomes
Evaluation of client outcomes in terms of changes in function,
cost and participation based on case mix severity using the
most recent AROC data including by ANSAP & total




Stakeholder
Satisfaction
Surveys
Days
3,066
6,132
1,022
%
30%
60%
10%
100%
FIM Efficiency
Length of stay
Discharge destination
Supports at discharge
Survey results for the
 Client, family and whānau
 DHB DHB
 ACC Client Services staff
 Residential Support Services and Community suppliers
The information provided will include
 The number of surveys issued
 The response rate
Percentage of satisfaction of responders
 Very Satisfied
 Satisfied
 Dissatisfied
 Very dissatisfied
Quality
improvement
plans
An outline of any short, medium and long term actions planned
as part of a
Issues
Management
Outline of any issues that may have presented during the year,
a description of the process taken to resolve those issues and
the resulting outcome. These issues may include


response to the satisfaction survey results
continuous improvement process
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


Other
Sentinel events such as a serious injury or death
Communication or access issues
Implementation issues
The supplier is encouraged to provide background information
on their other services, linkages and long term development
plans that could provide insight into the supplier’s business.
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Appendices
Appendix A – Field List for the TBIRR Quarterly Discharge Report
Field Labels
Description
Supplier
As named on the contract
Supplier's Client Identifier
ACC Claim Number
The supplier’s patient management system’s individual identify,
if any.
11 numeric characters, unbroken – 12345678912,
Not the ACC45 form number
AN-SNAP Class
As defined by AROC
Impairment Code
As defined by AROC
GCS at ED
Glasgow Coma Scale as taken in the Emergency department
(or at its worst)
Length of PTA (days)
Length of post traumatic amnesia in days
Admission Point
DHB DHB or community services
WHIM on admission
Wessex Head Injury Matrix score at admission
WHIM on emergence
Wessex Head Injury Matrix score on emergence
Acute Admission Date
Date admitted to the DHB
Admission Date
Date admitted to the Supplier facility
Final Discharge Date
The last day the client was in a bed at midnight
Days at TBIRR
Total number of says the client was in the service (funded), i.e.
not absent.
Return to Hospital Days
The number of day in the DHB
Nights at Home
The number of days the client was absent from the supplier’s
facility due to being on home leave.
Other
FIM/FAM Measures on Admission & Discharge
1. Eating
2. Grooming
3. Bathing
4. Dressing Upper Body
5. Dressing Lower Body
6. Toileting
7. Swallowing
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8(i) Bladder - Level of assistance
8(ii) Bladder - Frequency of incontinence
9(i) Bowel - Level of assistance
9(ii) Bowel = Frequency of incontinence
10. Bed, Chair, Wheelchair transfer
11. Toilet transfer
12. Tub, Shower transfer
13. Car Transfer
14. Walking / Wheelchair (Score mode likely to be used on discharge)
Preferred mode of locomotion
15. Stairs
16. Community Mobility
Preferred mode of community mobility
17. Comprehension - Audio/Visual
18. Expression - Verbal/N-Verbal
19. Reading
20. Writing
21. Speech Intelligibility
22. Social Interaction
23. Emotional Status
24. Adjustment to Limitations
25. Employability
26. Problem Solving
27. Memory
28. Orientation
29. Attention
30. Safety Adjustment
31. Meal preparation
32. Laundry
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33. Housework
34. Shopping
35. Financial management
FIM Motor
FIM Cognitive
FIM Total
FAM Total
DOM Total
Rehabilitation Complexity Scale (RCS)
Wk # - First Date of Period
Wk # - Last Date of Period
Wk # - Care
Wk # - Nursing
For each week of stay
Wk # - Therapist
Wk # - Therapy Intensity
Wk # - Medical
Wk # - Total
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Appendix B – Rehabilitation Complexity Scale version 8
The North West London Hospitals
NHS Trust
The Rehabilitation Complexity Scale (RCS) Version 8
The RCS can be used and copied freely,
but please acknowledge the originators in all publications using the following citation:
Turner-Stokes L, Williams H, Siegert RJ. The Rehabilitation Complexity Scale: A clinimetric evaluation in
patients with severe complex Neurodisability. Journal of Neurology, Neurosurgery and Psychiatry. 2010;
81(2):146-53.
Further information and advice may be obtained from:
Professor Lynne Turner-Stokes DM FRCP
Herbert Dunhill Chair of Rehabilitation, King's College London.
Regional Rehabilitation Unit,
Northwick Park Hospital,
Watford Road,
Harrow, Middlesex.
HA1 3UJ
Tel: +44 (0) 208-869-2800;
Fax: +44 (0) 208-869-2803
Email: lynne.turner-stokes@dial.pipex.com
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About the Rehabilitation Complexity Scale (RCS)
The RCS is a simple measure of the complexity of rehabilitation needs.
It was designed originally by the Expert Working Group for Rehabilitation Healthcare Resource groups (HRGs)
to be applicable across a broad spectrum of rehabilitation services.
It has been tested in a variety of areas of rehabilitation (including neurological, orthopaedic, respiratory and
burns rehabilitation) and is expected to form the basis for cost-banding of tariffs for rehabilitation under Payment
by Results.
It includes 5 items:
Subscale
Domain
Score range
C
Basic care and support needs
0-3
N
Skilled nursing needs
0-3
T-D
Therapy needs – no of disciplines
0-3
T-I
Therapy needs – intensity
0-3
M
Medical needs
0-3
Total
0-15
It may be applied both prospectively (as a measure of rehabilitation needs) and retrospectively as a framework
for assessing rehabilitation inputs. It can therefore be used to provide a simple evaluation of the gap between
needs and provision.
The RCS has been shown to be psychometrically robust(1) and to distinguish between services with different
caseload complexity(2). Whilst is can reasonably be summed into a total, the individual items provide clinically
useful information so we recommend that it is reported in a manner analogous to the GCS eg RCS 10 (C1 N2 T5
M2).
The standard scale does have ceiling effects in patients with very complex needs and an extended version (the
RCS-E) has been developed and is currently undergoing evaluation.
References
1. Turner-Stokes L, Williams H, Siegert RJ. The Rehabilitation Complexity Scale: A clinimetric evaluation in
patients with severe complex Neurodisability. Journal of Neurology, Neurosurgery and Psychiatry. 2010;
81(2):146-53.
2. Turner-Stokes L, Disler R, Williams H. The Rehabilitation Complexity Scale: a simple, practical tool to identify
‘complex specialised’ services in neurological rehabilitation.
Clinical Medicine 2007;7(6): 593-9.
Copyright and further information:
The RCS and RCS-E can be used and copied freely,
but please acknowledge the originators in all publications
Further information and advice may be obtained from:
Professor Lynne Turner-Stokes DM FRCP
Director, Regional Rehabilitation Unit, Northwick Park Hospital,
Herbert Dunhill Chair of Rehabilitation, King's College London.
Watford Road,
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Harrow, Middlesex. HA1 3UJ
Tel: +44 (0) 208-869-2800;
Fax: +44 (0) 208-869-2803
Email: lynne.turner-stokes@dial.pipex.com
The Rehabilitation Complexity Scale
PATIENT IDENTIFICATION
Name:
Hospital No:
Date of score:…../…../…….
For each subscale, circle highest level applicable
BASIC CARE AND SUPPORT NEEDS
Describes the approximate level of intervention required for basic self-care
C0
Largely independent in basic care activities
C1
Requires help from 1 person for most basic care needs
C2
Requires help from 2 people for most basic care needs
C3
Requires help from >2 people for basic care needs
OR Requires constant 1:1 supervision
SKILLED NURSING NEEDS
Describes the level of intervention required from qualified or skilled rehab nursing staff
N0
No needs for skilled nursing
N1
Requires intervention from a qualified nurse (e.g. for monitoring, medication, dressings etc)
N2
Requires intervention from trained rehabilitation nursing staff
N3
Requires highly specialist nursing care (e.g. for tracheostomy, behavioural management etc)
THERAPY NEEDS
Describes the approximate level of input that is required from therapy disciplines
Disciplines: State number of different therapy disciplines required to be actively involved in treatment
TD 0
0
Tick therapy disciplines involved:
TD 1
1 disciplines only
 Physio
 Psychology
 Orthotics
TD 2
2-3 disciplines
 O/T
 Counselling
 Prosthetics
TD 3
≥4 disciplines
 SLT
 Music/art therapy
 Rehab Engineer
 Dietetics
 Play therapy
 Other:
 Social work
Intensity: State overall intensity of trained therapy intervention required
TI 0
No therapy intervention (or<1 hour total/week - Rehab needs met by nursing/care staff or selfexercise programme)
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TI 1
Low level – less than daily (eg assessment / review / maintenance / supervision) OR Group
therapy only
TI 2
Moderate – daily intervention 1:1 (+/- assistant) OR very intensive Group programme of ≥6
hours/day
TI 3
High level – very intensive 1:1 intervention (eg 2 trained therapists to treat, or total 1:1 therapy >25
hrs/week)
Total
Total T score (TD + TI) :………….
MEDICAL NEEDS
Describes the approximate level of medical care environment required for medical/surgical management
M0
No active medical intervention
(Could be managed by GP on basis of occasional visits)
M1
Basic investigation / monitoring / treatment
(Requiring non-acute hospital care,
Could be delivered in a community hospital with day time medical cover)
M2
Specialist medical intervention – for diagnosis or management/procedures
(Requiring in-patient hospital care in DGH or specialist hospital setting)
M3
Acutely sick or potentially unstable medical condition
(Requiring 24 hour on-site acute medical cover)
TOTAL
C:
N:
T:
M:
Summed score:
/15
Further instructions for application
For each subscale, circle highest level applicable
BASIC CARE AND SUPPORT NEEDS
Includes washing, dressing, hygiene, toileting, feeding and nutrition, maintaining safety etc.
C0
Largely independent. Maintains their own safety and manages basic self-care tasks largely by
themselves.
May have incidental help just to set up or to complete – e.g. application of orthoses, tying laces etc
C1
Requires help from 1 person for most basic care needs ie for washing, dressing, toileting etc.
May have incidental from a 2nd person – e.g. just for one task such as bathing
C2
Requires help from 2 people for the majority of their basic care needs
C3
Requires help from >2 people for basic care needs
OR Requires constant 1: 1 supervision e.g. to manage confusion and maintain their safety
SKILLED NURSING NEEDS
Describes the level of skilled nursing intervention
N0
No needs for skilled nursing – needs can be met by care assistants only
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N1
Requires intervention from a qualified nurse
(e.g. medication, wound/stoma care, nursing obs, tracheostomy management, enteral feeding, IV
infusion etc)
N2
Requires intervention from nursing staff who are trained and experienced in rehabilitation
(e.g. for maintaining positioning programme, walking / standing practice, splint application,
psychological support)
N3
Requires highly specialist nursing care e.g. for very complex needs such as
Management of tracheostomy or ventilation
Management of challenging behaviour / psychosis / complex psychological needs
Highly complex postural, cognitive or communication needs
Vegetative or minimally responsive states, locked-in syndromes
THERAPY NEEDS
Describes the a) number of different therapy disciplines required and b) intensity of treatment
Includes individual or group based session runs by therapists, but not rehab input from nursing staff which is
counted in N2.
(NB The Northwick Park Therapy Dependency Assessment (NPTDA) can be used to calculate total therapy
hours in more complex cases e.g. Total T4 and above, and provide more detailed information regarding time for
each discipline etc.)
T0
No formal therapy involvement (or <1 hr /wk) – Rehab needs met by nursing/care staff or selfexercise
TD 1
1 discipline
only
TD 2
2-3
disciplines
TD 3
≥4
disciplines
Each
discipline
must be
actively
involved (≥
1-2 hrs/wk)
 Physio
 Psychology
 Orthotics
 O/T
 Counselling
 Prosthetics
 SLT
 Music/art
therapy
 Rehab Engineer
 Dietetics
 Social work
 Other:
 Play therapy
Intensity
TI 1
Low level – less than daily (eg assessment / review / maintenance/ supervision of self-exercise
programme)
OR by therapy assistant only OR Group therapy only
TI 2
Moderate – daily intervention 1:1 (+/- assistant) – may include mixture of group and individual
therapy
OR very intensive Group-based programme of at least 6 hours/day.
TI 3
High level – very intensive 1:1 intervention ( eg two trained therapists to treat, or total 1:1
therapy>25 hrs/wk)
Total
Total T score (TD + TI):…………………
MEDICAL NEEDS
Describes the approximate level of medical care environment for medical/surgical management
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M0
No active medical intervention
(Could be managed by GP on basis of occasional visits)
M1
Basic investigation / monitoring / treatment
(Requiring non-acute hospital care, could be delivered in a community hospital with day time
medical cover)
i.e. requires only routine blood tests / imaging. Medical monitoring can be managed through review
by a junior medic x2-3 per week, with routine consultant ward-round + telephone advice if needed)
M2
Specialist medical intervention (Requiring in-patient hospital care in DGH or specialist hospital
setting)
i.e. requires more complex investigations, or specialist medical facilities e.g. dialysis, ventilatory
support. Frequent or unpredictable needs for consultant input or specialist medical advice,
surgical intervention
M3
Acutely sick or Potentially unstable medical condition (Requiring 24 hour on-site acute
medical cover)
i.e. requires acute medical/surgical care e.g. infection, acute complication, post surgical care
or potentially unstable requiring out-of hours intervention – e.g. for uncontrolled seizures, immunocompromised.
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Appendix C – Satisfaction Surveys
Client, Family/Whānau Satisfaction Survey
What is this survey about?
Recently you or your family member left rehabilitation with ABI Rehab in Auckland. This survey to get your
feedback on the service received. Your opinion is important to us.
Please circle your answers:
Very
Very
Dissatisfied Satisfied
Dissatisfied
Satisfied
1.
With regards to discharge planning:
1
2
3
4
How satisfied are you that we involved you in the
discharge planning process ?
2.
With regards to brain injury education:
How satisfied are you that we provided you with
enough knowledge about
Your (or your family members) brain injury
The impact of brain injuries in general
The rehabilitation journey
1
2
3
4
1
1
1
2
2
2
3
3
3
4
4
4
With regards to communication from our staff:
 How satisfied are you that you were kept well
informed throughout you or your family
members rehabilitation?
1
2
3
4
How satisfied are you that you were you
satisfied that you understood what you were
being told by our staff?
1
2
3
4
4.
With regards to your involvement:
How satisfied were you with the level of involvement
you had in your family member’s rehabilitation?
1
2
3
4
5.
With regards to your overall satisfaction:
How satisfied were you with the service we provided?
1
2
3
4
3.

Do you have any comments or suggestions for areas of improvement?
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District Health Board Satisfaction Survey
What is this survey about?
ACC’s TBI Residential Rehabilitation has 3 contracted suppliers who provide a national rehabilitation service for
clients with moderate to severe TBI. The service is early intervention, high intensity and highly specialized.
The purpose of this survey is to give you an opportunity to provide feedback on our TBI Rehabilitation
preadmission service. Results of this feedback help to guide our quality processes.
Please rate your satisfaction with the preadmission service
you received as part of the Traumatic Brain Injury Residential
Rehabilitation (TBIRR) ACC Service.
1.
Regarding patient screening:
How satisfied are you with the assistance we provide
in screening patients with moderate to severe
traumatic brain injury?
2.
Regarding referral response time:
How satisfied are you with the time it takes for us to
respond to a referral?
3.
Regarding patient transfers:
How satisfied are you with the way we facilitated your
patients transfer to residential rehabilitation?
 Planning of the transfer
 Timeliness of the information
 Content & accuracy of the information
Regarding patient centred focus:
How satisfied are you that our service is patient
centred?
4.
5.
Regarding your overall satisfaction:
How satisfied are you with the overall service we
provide?
Please circle your answers:
Very
Very
Dissatisfied Satisfied
Dissatisfied
Satisfied
1
2
3
4
1
2
3
4
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
1
2
3
4
Do you have any comments or suggestions for areas of improvement?
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ACC Case Owner Satisfaction Survey
Recently a case you managed entered the TBI Residential
Please circle your answers:
Rehabilitation provided by
ABI Rehabilitation in Auckland. To continuously improve our
Very
Very
Dissatisfied Satisfied
service we would like your feedback on the service you
Dissatisfied
Satisfied
received
1.
Regarding family/whanau meetings:
1
2
3
4
On a scale from 1 to 4 (1 being very dissatisfied and 4
being very satisfied), how satisfied were you with the
amount of notice you were given for participation in
the client family/whanau meetings?
2.
On a scale from 1 to 4 (1 being very dissatisfied and 4
1
2
3
4
being very satisfied), how satisfied were you with the
options available for participating in the client
family/whanau meetings (e.g. in person, telephone,
video link)?
3.
Regarding the rehabilitation plan:
1
2
3
4
On a scale from 1 to 4 (1 being very dissatisfied and 4
being very satisfied), how satisfied were you that the
rehabilitation plan clearly outlined the steps that
needed to be taken to achieve the proposed
outcomes?
4.
Now, regarding progress updates:
1
2
3
4
On a scale from 1 to 4 (1 being very dissatisfied and 4
being very satisfied), how satisfied were you with the
amount of information we provided on your client’s
progress?
5.
Regarding the discharge process:
1
2
3
4
On a scale from 1 to 4 (1 being very dissatisfied and 4
being very satisfied), how satisfied were you that our
discharge process identified the supports required for
transfer to the community?
6.
Regarding communication:
On a scale from 1 to 4 (1 being very dissatisfied and 4
being very satisfied) how satisfied are you with the
communication you receive from us in terms of:
Frequency
1
2
3
4
Content
1
2
3
4
Method (e.g. email, phone)
1
2
3
4
7.
Regarding decision making:
1
2
3
4
On a scale from 1 to 4 (1 being very dissatisfied and 4
being very satisfied) how satisfied were you that you
were included in the decisions that were made with
the client?
8.
Regarding your overall relationship with us:
1
2
3
4
On a scale from 1 to 4 (1 being very dissatisfied and 4
being very satisfied) how satisfied are you with the
relationship you have with us?
We would be interested in any other comments you would like to make, ie anything that might improve
our service. Please comment here:
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Residential and Community Provider Satisfaction Survey
Context: ACC’s TBI Residential Rehabilitation has 3 contracted suppliers who provide a national rehabilitation
service for clients with moderate to severe TBI. The service is early intervention, high intensity and highly
specialized. This survey is to gain feedback from suppliers who receive clients from these contracted suppliers
and is part of the continuous improvement of the service.
Recently a client was referred to you by ABI Rehabilitation in
Auckland.
To continuously improve our service we would like your
feedback on the service you received during the transition of
clients into your service:
1.
Regarding discharge planning:
How satisfied were you with the level of involvement
you had in the lead up to the patient’s discharge?
Please circle your answers:
Very
Dissatisfied
Dissatisfied
Satisfied
Very
Satisfied
1
2
3
4
2.
Regarding the information we provided:
How satisfied were you that you received the
information you needed prior to discharge?
1
2
3
4
3.
Regarding the quality of the information we provided:
How satisfied were you with the quality of information
that we provided?
1
2
3
4
4.
Regarding follow up support:
How satisfied are you with the post discharge support
we provided?
1
2
3
4
5.
Regarding your overall satisfaction:
How satisfied are you with the overall service we
provided?
1
2
3
4
Please comment here if you have any suggestions for areas of improvement:
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