INTRODUCTION
The RMP Model of Care shares a common purpose with the framework outlined in the 2011 Neurorehabilitation Strategy. The model and terminology is adopted from other published rehabilitation models of care and adapted to the Irish context. The model outlines specialist rehabilitation services allowing service users access to appropriate services in a fully integrated manner and includes all the components of the continuum of services delivered in a comprehensive coordinated system of care.
Fundamental to the development of specialist rehabilitation services is the
appreciation that different service users need different input and different levels of expertise and specialisation at different stages in their rehabilitation journey. The critical point of this model is that, although service users may need to access different services as they progress, the transition between services should be facilitated by appropriate communication and sharing of information between services so that they progress in a seamless continuum of care.
FIGURE 6: REHABILITATION MEDICINE MODEL OF CARE
*Rehabilitation phase
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KEY COMPONENTS OF THE RMP MODEL OF CARE
Key aspects that are integral to the delivery of specialist rehabilitation services are summarized below:
Patient / service user Clinicians Infrastructure Health Promotion and
Prevention
Self-Management Information Provision Vocational Rehabilitation
Key worker & case manager models
Education and training Research
Appropriate workforce planning
Rehabilitation Database Use of Technology National, regional and community units with
• in-patient
• out-patient
• informal meeting (families and voluntary organisations)
• staff development facilities
1. *Interdisciplinary approach with standardised assessment procedures
2. **Managed Clinical Rehabilitation Networks
In this chapter the concept of managed clinical networks is explicated along with a presentation of referral and intervention key performance indicators.
ASSESSMENT AND INTERVENTION RECOMMENDATIONS
REFERRAL
• Early referral, after initial medical stability, is required to minimise complications of neurological injury and immobility79.
• For example, in a major trauma unit, it is recommended that the patient is referred to the Rehabilitation Consultant within 48 hours.
• Within regional hospitals the longest wait to assessment is extended to 7 days. This is based on the understanding that most patients with more complex needs are treated in tertiary centres after initial triage.
• Rehabilitation teams will be required to establish strong links with acute hospitals within their regions and develop responsive referral protocols.
REHABILITATION ASSESSMENT
79 Early referral is recommended in all instances on the basis of evidence already presented, and international best practice related to improved patient outcomes.
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• Standardized assessment by senior rehabilitation IDT members will be carried out using a rehabilitation prescription template and within agreed timescales
• The assessment will be holistic covering physical, cognitive, psychological &
social domains of function
• Goal setting will be patient centred
• The assessment will generate a plan of care – REHABILITATION PRESCRIPTION (chapter 2)
• Assessing clinicians will continuously collaborate and communicate with the patient and those who care for them
STANDARDS / PARAMETERS FOR CLINICAL DECISION-MAKING DURING REHABILITATION ASSESSMENT
Guidelines are required for clinicians who are not rehabilitation specialists, and patients, to explain what it means to be ‘ready for rehabilitation’. These guidelines may differ somewhat dependent on the care setting and individual patients but should reflect or establish:
• The benefit of continuing review by the specialist rehabilitation team, particularly in relation to prevention of complications
• The characteristics of medical stability (for post-acute rehabilitation)
• Patient’s ability to participate in rehabilitation (daily duration / intensity and nature)
• Triage/preadmission assessment by Rehabilitation Clinician to determine whether patients needs’ can be best met in setting. This will ensure patients receive rehabilitation services in the most appropriate setting
• Active waiting list management systems that ensure equitable, transparent access to rehabilitation facilities/services. In this regard, the RMP refers readers to the National Waiting List Management Policy8081
• Standards for effective communication with all relevant stakeholders i.e.
patient/family/referrer
SERVICE DELIVERY
• Health professions deliver interventions that align with current best practice, guidelines and standards
80 National Waiting List Management Policy 2013: A standardised approach to managing scheduled care for in-patient, day case and planned procedures’ developed by the National Treatment Purchase Fund (NTPF) and the Department of Health; accessed 23rd November 2014
http://www.ntpf.ie/home/PDF/NTPF%20WL%20Final%20Print%20version.pdf
81 NRH waiting list project http://www.rcpi.ie/content/docs/000001/1336_5_media.pdf
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• Patients receive appropriate intensity of treatment
• Care plans / goals / rehabilitation prescription are reviewed at regular intervals by the interdisciplinary team and with patient/family.
TRANSFER OF CARE, FOLLOW-UP AND RE-ENTRY
• There should be clearly defined criteria for transfer, communicated to patient and family.
• A list of agreed global and impairment specific outcome measures should be used to communicate patients’ functional achievements and ongoing goals
• The team receiving the patient should be given comprehensive discharge / transition information at the time of transfer
• Post-intervention review over a period of 1-2 years with access to requisite therapies through the tertiary centre, regional unit or community services
• Re-entry can be planned or unplanned; both should be monitored for trends/patterns that will inform future service delivery.
MANAGED CLINICAL REHABILITATION NETW ORKS (MCRN)
Managed clinical networks facilitate re-design, quality improvement, strategy and planning across pathways. Teams work across department boundaries, teams, units and divisions. They achieve their results through consensus and collaboration by enabling clinicians, patients and service managers to work together to deliver safe, effective and person-centred care.
A managed clinical network provides a template for enhancement of service provision to patients requiring neurological and limb absence rehabilitation. The following are the essential components of a MCRN:
• The acknowledgement of three distinct levels of complexity in specialist rehabilitation service in a variety of rehabilitation settings (chapter 2)
• Clear referral protocols and pathways at the interface between specialist and non-specialist rehabilitation, and disability services
• Collaborative working between statutory and non-statutory agencies to improve services for service users
It is intended to promote the following key aspects of service design and delivery:
• Responsive services at appropriate levels
• Development of integrated quality services with continuity
• The needs of patients will be met wherever they enter the service continuum.
• Access to a wide range of support services
• A clear focus on clinical governance and quality assurance82.
• Specialised staff with competencies in appropriate areas
82 This will be achieved through integrated teamwork, development and sharing of agreed protocols benchmarking against agreed standards, identification of good practice and supporting innovation and clear measurement of efficiency, effectiveness and value for money.
MCNs for a wide range of medical conditions
England, and consist of linked groups of health professionals and organisations from primary, secondary and tertiary care working
MCNs can encourage all service providers that when more than the individual parts
STRUCTURE OF
A national steering committee will support and guide the work of each regional network. Membership of the steering group will include representatives from all relevant stakeholders. Supporting the role of the steering committee are subgroups, including public and patient involvement, quality assurance, education/training.
The leadership and management function of the MCN will be delivered through the sessional commitment of an appointed MCN clinical lead and MCN Manager. The capacity of the management team will need to be flexible dependent on the stage of development of the regional network.
FIGURE 12 : LEADERSHIP W ITHIN
The structure of a network derives from definition of points of entry to care, points of care delivery and their connections
principles governing the relations between points of care, as care pathways and guidelines. All professionals involved with care delivery are de
network.
MCRNS
Clinical Strategy & Programmes Division
National
for a wide range of medical conditions have been established in Scotland and consist of linked groups of health professionals and organisations from primary, secondary and tertiary care working in a coordinated manner.
MCNs can encourage all service providers that when they work together they idual parts when working in isolation.
STRUCTURE OF A MANAGED CLINICAL NETWORK
A national steering committee will support and guide the work of each regional network. Membership of the steering group will include representatives from all
nt stakeholders. Supporting the role of the steering committee are subgroups, including public and patient involvement, quality assurance, education/training.
The leadership and management function of the MCN will be delivered through the ment of an appointed MCN clinical lead and MCN Manager. The capacity of the management team will need to be flexible dependent on the stage of development of the regional network.
: LEADERSHIP W ITHIN THE MANAGED CLINICAL REHABILITATION NETW
The structure of a network derives from definition of points of entry to care, points of and their connections. A key task is to set out the mechanisms and principles governing the relations between points of care, as care pathways and
idelines. All professionals involved with care delivery are de facto members of the
MCRNS - BENEFITS FOR PATIENTS
Clinical Strategy & Programmes Division
National Rehabilitation Medicine
have been established in Scotland and consist of linked groups of health professionals and organisations from
in a coordinated manner. At best the work together they deliver
WORK
A national steering committee will support and guide the work of each regional network. Membership of the steering group will include representatives from all
nt stakeholders. Supporting the role of the steering committee are subgroups, including public and patient involvement, quality assurance, education/training.
The leadership and management function of the MCN will be delivered through the ment of an appointed MCN clinical lead and MCN Manager. The capacity of the management team will need to be flexible dependent on the stage of
REHABILITATION NETW ORK
The structure of a network derives from definition of points of entry to care, points of . A key task is to set out the mechanisms and principles governing the relations between points of care, as care pathways and
facto members of the
Clinical Strategy & Programmes Division
National Rehabilitation Medicine
Regional MCRN
Community based Specialist Rehabilitation
services
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• More efficient joined up care, delivered as close to home as their complexity of needs allows
• Consistent care regardless of location
• Improved access to appropriate services, in the appropriate setting
• Clarity exists about how to re-engage with services as the condition requires
BENEFITS FOR STAFF
• Consistent approach to the local implementation of the national standards, guidelines and care pathways
• Service designed in line with national guidance
• Skills, knowledge and expertise of a range of staff are used in new ways
• There is improved understanding of the roles required to deliver comprehensive service in the regions and locally
BENEFITS FOR MANAGERS / ALL SERVICES
• Cost-effective and accessible services
• Reduced unnecessary delays in hospital
• Partnership working to reduce delays in the system
• Improved understanding of the type of care needed, appropriate activities, service complexity and dependency.
Complex Specialised
NRH
Regional HSE-RRU Acute
Hospital
Community CBT
Primary Care
Managed Clinical Rehabilitation Network
FIGURE 13 MANAGED CLINICAL REHABILITATION NETW ORK
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MCRN GOVERNANCE
LINKS WITH HEALTH SERVICE
MCRNs will be fully integrated and embedded within HSE planning, operational service delivery and governance structures. MCRNs will be involved in discussions on the prioritization of services and resource re-allocation in their region.
Annual service and quality improvement plans will be agreed with the appropriate HSE division. Further clarity is needed on the reporting and governance
arrangements for MCRNs within the HSE.
Integration of primary and secondary care is critical to the realisation of the managed clinical network model.
LEADERSHIP
MCRN Lead Clinicians will be drawn from the ranks of senior, experienced
rehabilitation clinicians within the network and must exhibit clinical authority, ability to inspire the interdisciplinary team and to work in partnership across professional boundaries and with colleagues from other sectors.
The job plan for the Lead Clinician will allocate time away from clinical work to lead the network with a supporting team. Appropriate remuneration will be required to fund backfill of the lead clinician’s post. The supporting team will include a network manager who will ensure the network functions effectively and achieves tangible progress in developing equitable, high quality, safe and effective person-centred services. The Lead Clinician and network manager should have access to leadership training.
MCRNs will, where possible, cover relatively related conditions. Network managers and Lead Clinicians require a great deal of knowledge and experience of services in a particular clinical area. Their remit should not be spread too thinly across several disease areas as this could reduce the efficiency of the MCRN’s concerned.
ACCREDITATION
Every MCRN should be subject to a process of endorsement/quality assurance by the HSE, in particular the national quality standards, Safer Better healthcare, and/or other quality standards deemed appropriate.
CORE PRINCIPLES AND ELEMENTS OF MANAGED CLINICAL NETWORKS ACCOUNTABILITY
Service providers co-ordinated by the MCRN should have clear accountability arrangements to deliver quality, safe and reliable healthcare in line with HSE QPSD and HIQA standards. Targets will be agreed with each site to ensure that the
maximum benefits outlined in the business case / benefits plan are achieved.
Reporting will be captured on a continuous basis and reviewed regularly in the early stages of network operation.
CLARITY
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Each MCRN will have clarity about its management arrangements including the appointment of a Lead Clinician who is recognised as having joint responsibility for network clinical governance. Each network will produce an annual report to the HSE (to which it is accountable) and that annual report will be publically available.
GOVERNANCE PROTOCOLS
Policies and protocols derived from national guidance documents, and compliant with Irish and European legislation, will be developed. These procedures will ensure services users receive coordinated, consistent integrated care along the
rehabilitation continuum. They will be monitored and audited at intervals.
MONITORING AND REVIEW
Key performance indicators (KPIs) will be developed jointly by the MCRN lead clinician and local clinicians. Clinical and process outcomes will be monitored, measured and review. Service providers will have in-house systems relating to service, clinical or workforce underperformance and the MCRN steering committee will develop joint governance mechanisms with those service providers.
MULTIPROFESSIONAL / INTERDISCIPLINARY
Each MCRN will be interdisciplinary and multi-professional. Rehabilitation team members will have clearly defined roles and responsibilities.
CAPACITY AND CAPACITY PLANNING
MCRNs will have systems to define and make recommendations on clinical priorities, and identify and implement cost savings initiatives. The MCRN will plan and manage resources to deliver high quality, safe and reliable rehabilitation services.
COMMUNICATION AND CONSULTATION
MCRNs will have systems to ensure there is clear communication and consultation with all stakeholders in the planning, design and delivery of services.
CLINICAL EFFECTIVENESS AND AUDIT
MCRNs will develop systems to ensure gathering and reporting of high quality information on clinical effectiveness and outcomes. MCRNs will develop and implement an annual clinical audit plan. Services within the network should reflect contemporary evidence of what is known to achieve best patient outcomes.
PATIENT/SERVICE USER INVOLVEMENT
Patient and carers / family involvement, formal and informal, will be facilitated at all points on the continuum of care and feedback will inform service development.
Systems will be in place to facilitate information delivery to patients and families as well as feedback, complaints procedures and self-management.
RISK MANAGEMENT AND PATIENT SAFETY
Specialist rehabilitation services in the provider organisations within the MCRNs will take heed of the HSE’s Risk Management Policy, specifically through the Quality and Patient Safety Division. The MCRN will ensure that there are mechanisms in place to
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develop, implement and monitor patient safety initiatives around critical areas including essential mechanisms such as robust incident management, effective risk registers and complaints and ensure they are managed effectively and in line with relevant policies
STAFFING AND STAFF MANAGEMENT
The MCRNs will ensure their service providers will have robust recruitment and workforce planning procedures allowing them to recruit staff with the relevant competencies and registration to treat particular levels of complexity. All service providers within the network will have adequate supervision, support, reporting arrangements and clinical accountability systems for their staff. Interdisciplinary audits will be encouraged to nurture team learning.
EDUCATION / TRAINING
MCRNs will ensure that all professionals involved in the network are participating in appropriate appraisal systems that assess competence to carry out roles. Systems will be developed to ensure consistent policies on training, competencies and CPD.
MCRNs educational and training potential will be exploited in particular through exchanges among clinicians working across the rehabilitation continuum in community and primary care, and in hospitals or specialist centres.
COST EFFECTIVENESS
Each MCRN will monitor opportunities for achieving value for money through the delivery of optimal, evidenced based care that improves patient experience, optimizes productivity and reduces service variation.
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