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Canberra Hospital and Health ServicesOperational Guideline Rehabilitation Care Coordinator Guidelines (UCH/RACC)Contents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Alerts.........................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Rehabilitation Care Coordinator Role and Responsibilities....................................2

Section 2 – Referral to the Rehabilitation Care Coordinator.....................................................3

Section 3 –Coordinate transition of patients............................................................................3

Section 4 – Support throughout Admission..............................................................................4

Section 5 – Discharge Planning.................................................................................................4

Section 6 – Post Discharge Follow Up.......................................................................................4

Implementation........................................................................................................................ 5

Related Policies, Procedures, Guidelines and Legislation.........................................................5

Search Terms............................................................................................................................ 6

Attachments..............................................................................................................................6

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Purpose

The Rehabilitation Care Coordinator Guideline has been developed to promote consistent Care Coordination across the Rehabilitation, Aged and Community Care (RACC) inpatient units at the University of Canberra Hospital (UCH) and Canberra Hospital and Health Services (CHHS).

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Alerts

This guideline does not apply to the RACC Day Service Rehabilitation Coordinator.

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Scope

This document applies to patients: Waiting for admission to UCH Within the rehabilitation wards at UCH Recently discharged from UCH (within 3 months).

This document applies to the following staff working within their scope of practice: Registered Nurses Allied Health Rehabilitation Care Coordinators (RCC) Students under direct supervision.

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Section 1 – Rehabilitation Care Coordinator Role and Responsibilities

The Rehabilitation Care Coordinator (RCC) role encompasses the following core components to ensure safe and timely transition, care and discharge of patients with complex needs from the acute and sub acute care setting: Act as the communication link between the patient, their family and carers and the

relevant stakeholders Assessment of patients who have been accepted to rehabilitation in order to facilitate a

smooth transition for the patient and the accepting ward at UCH Assist in the discharge processes for rehabilitation patients by attending goal setting

meetings, case conferences, family meetings and discharge planning meetings to support the Multi-Disciplinary Team (MDT) to improve performance against the Expected Date of Discharge (EDD) and other Australasian Rehabilitation Outcomes Centre (AROC) benchmarks

Attend patient flow meetings to contribute to flow of patients within the rehabilitation wards

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Attend MDT meetings to contribute to patient care and facilitate discharge planning Work independently and in conjunction with other health professionals to lead and

coordinate safe, appropriate and timely care of patients to achieve expected rehabilitation goals

Work with the MDT to facilitate a safe and timely discharge from hospital Patient advocacy Referral and coordination of patient care to receiving healthcare and community

providers in consultation with the MDT Initial and ongoing communication with relevant community based health services for

existing clients who have experienced a rehabilitation episode of care. This is to better facilitate a planned and safe discharge of the patient back to the community setting

Provide support for patients, family and their carers recently discharged from UCH to follow up on recommendations by the rehabilitation team and link to appropriate community services in order to assist the patient’s recovery and prevent readmission.

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Section 2 – Referral to the Rehabilitation Care Coordinator

Referrals to RCC can be made by: The rehabilitation consultant via the Canberra Hospital Acute Subacute Early

Rehabilitation Service (CHASERS) team during the patient flow meetings By any member of the clinical team using the decision tree in Attachment 1.

Referrals should be made via an email to the RCC team.

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Section 3 –Coordinate transition of patients

Once patients have been accepted into the RACC rehabilitation service the RCC will coordinate the transition of these patients by:1. Completing the Rehabilitation Care Coordinator Assessment form (35483) found on the

clinical forms register2. Visiting the patient weekly/as required3. Keeping in toUCH with patient progress via the transferring ward clinical team4. Providing information to the patient and family about the rehabilitation process5. Coordinating admission requirements with admitting unit.

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Section 4 – Support throughout Admission

Throughout the patients’ admission the RCC will:1. Ensure appropriate referrals are made2. Follow up to ensure referrals are actioned

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3. Provide regular updates/support to patients regarding outcomes and plans from case conference including expected dates of discharge

4. Liaise with the MDT regarding patient progress and its impact on the estimated date of discharge

5. As required act as the key worker for the patient to arrange their goal setting meeting.

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Section 5 – Discharge Planning

The RCC plays an integral role in discharge planning by: Attending goal setting meetings Coordinating and chairing Case Conference meetings Attending Family meetings Attending Discharge Planning meetings to support the MDT to improve performance

against EDD and other AROC benchmarks Ensuring post discharge supports are in place prior to discharge Working with the Clinical Nurse Consultant (CNC) to facilitate transfer of patients to

other hospitals Working with the MDT, patient and their family to facilitate the 10am discharge time as

per key performance indicators for UCH.

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Section 6 – Post Discharge Follow Up

Once patients have been discharged from the RACC inpatient units: If patients are discharged or transferred to the RACC Day Service or

Ambulatory/Sessional services the RCC will: 1. Support the patient from time of discharge until commencement of Day program by:

a. Following up on recommendations made by the medical and rehabilitation teamb. Linking the patient into appropriate community services and the GPc. Providing support to navigate the health system.

2. Providing education on issues sUCH as mental health management, carer fatigue and stroke prevention to assist patients to live well in the community and prevent readmission to hospital.

3. Finalise care and discharge from the inpatient RCC service.4. Provide comprehensive handover to the Day Service Rehabilitation Coordinator or

appropriate clinician.

If patients are discharged home or to non RACC service the RCC will:1. Provide support to the patient, family and carers by:

a. Following up on recommendations made by the medical and rehabilitation teamb. Linking to appropriate community services and the GPc. Providing support to navigate the health system

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d. Providing education on issues sUCH as mental health management, carer fatigue and stroke prevention to assist patients to live well in the community and prevent readmission.

2. Support will be provided via phone or home visit for a maximum of three months. Any further follow up after this time would require discussion with the CNC and/or Assistant Director of Nursing (ADON).

3. One home visit during this three month period unless otherwise clinically indicated.

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Implementation

This operational guideline will be communicated to staff via team meetings. It will be sent to the MDT in RACC for acknowledgement.

The guideline will be available for all staff to access via the policy register.

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Related Policies, Procedures, Guidelines and Legislation

Policies Health Directorate Nursing and Midwifery Continuing Competence Policy CHHS Consent and Treatment Policy

Procedures CHHS Clinical Handover Procedure CHHS Goals of Care and Resuscitation Plan UCH Admission and Eligibility Operational Procedure CHHS Family Meetings and/or Goal Setting Meetings and Case Conferences for

Rehabilitation Services Procedure

Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004 Work Health and Safety Act 2011

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Search Terms

UCH, Rehab Care Coordinator, Discharge, rehabilitation, RCC, EDD

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Attachments

Attachment 1: Referrals to Rehabilitation Care Coordinators

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 13/12/2018 New Document Linda Kohlhagen, ED

RACCCHHS Policy Committee

This document supersedes the following: Document Number Document Name

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Attachment 1: Referrals to Rehabilitation Care Coordinators

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