Clinical Strategy and Programmes Division. Rehabilitation Medicine Programme. Model of Care

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Clinical Strategy and Programmes Di Rehabilitation Medicine Programme

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DOCUMENT MANAGEMENT

Document Info

Document Number: RMP001

Created By: National Clinical Programme in Rehabilitation Medicine

Version Number: 0.18

Last Saved On: 24th November 2014

Document Status 2nd substantive draft

Date Effective: To be confirmed

Approval Date:

Approved By: RMP Working Group

RMP Consultants’ Clinical Advisory Group Responsible for

Implementation:

Responsible for Audit and Monitoring:

Revision Date:

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VERSION CONTROL

Version 0.01 16th November 2011: first draft by AC, VT and DD for first

MOC work-stream meeting 11.4.12

Version 0.02 9th May 2012: MOC work stream

Version 0.03 13th June 2012: MOC work stream

Version 0.04 11th July 2012: MOC work steam for review by AC

Version 0.05 31st July 2012: Additions by AC

Version 0.06 10th January 2013: additions / changes made by VT, DD

and WG members

Version 0.1 5th April 2013: 1st substantive draft- incorporating additions

from DD and working group. For review by RM CAG

Version 0.12 1st May 2014: alterations by EO’D

Version 0.13 4th May 2014: alterations by EOD after WG meeting

Version 0.14 June 2014: alterations by EO’D after WG feedback

Version 0.15 July and August 2014: redraft by JM and EO’D

Version 0.16 22nd August 2014: amendments after WG meeting

Version 0.17 15th October 2014: beginning of final edit for second

substantive draft by JM and EO’D

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GLOSSARY

Acronyms

ABI Acquired Brain Injury

ANP Advanced Nurse Practitioner CRT Community Rehabilitation Team

CSPD Clinical Strategy and Programmes Division (HSE) CSRS Complex Specialist Rehabilitation Service

CNM Clinical Nurse Manager CNS Clinical Nurse Specialist DRS Disability Rating Scale DML Dublin Mid-Leinster DNE Dublin North-East DoH Department of Health

GCS Glasgow Coma Scale

HSCPs Health and Social Care Professionals HIQA Health Information and Quality Authority HSE Health Service Executive

ICF International Classification of Function ISA Integrated Service Area

LHO Local Health Office

MCRN Managed Clinical Rehabilitation Network NCPOP National Clinical Programme for Older People NDA National Disability Authority

NHO National Hospitals Office

NRH National Rehabilitation Hospital

PCT Primary Care Team

POLAR Prosthetic, Orthotic & Limb Absence Rehabilitation PTA Post Traumatic Amnesia

RCS Rehabilitation Complexity Scale RMP Rehabilitation Medicine Programme RTA Road Traffic Accident

SRS Specialist Rehabilitation Service

VFM Value for Money

VFMPR Value for Money and Policy Review WHO World Health Organisation

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8 Terms

ABI: An Acquired Brain Injury (ABI) is a term given to any injury to the brain sustained during a person’s lifetime occurring as a result of traumatic brain injury, stroke, brain haemorrhage, brain tumour or infection. Crucially, each person who suffers an injury will have his or her own unique characteristics, difficulties or symptoms that can vary in severity from mild to severe.

Health & Social Care Professions (H&SCPs) The HSCP Act 2005 has given statutory basis to the regulation of 12 professions listed below. Any other health and social care profession deemed appropriate by the Minister for Health may be added in the future.

Clinical Biochemists Dietitians Medical Scientists Occupational Therapists Orthoptists Podiatrists

Physiotherapists Psychologists Radiographers

Social Care Workers Social Workers Speech and Language Therapists

Managed Clinical Networks are linked groups of health professionals and

organisations from primary, secondary and tertiary care, working in a coordinated manner, unconstrained by professional and health board boundaries, to ensure equitable provision of high-quality, clinically effective services.

National Policy: The National Policy and Strategy for the Provision of

Neurorehabilitation Services in Ireland is an overarching Government policy for people with specialist neurorehabilitation needs.

Performance Indicators are data points used to measure inputs, activities, outputs or outcomes, and are used to monitor the progress of the programme being

reviewed.

Voluntary Agency is an autonomous non-profit and non-statutory organisation providing a social or community service. In the context of the Programme, a voluntary agency is a specialist non-profit provider of neurological or disability services or supports.

Voluntary Sector is the collective name for organisations with social, charitable or philanthropic function that are not established by statute and who do not generate profits or distribute dividends.

Team-working

• Interdisciplinary: The interdisciplinary model uses a holistic, collaborative and patient focused approach. Effective joint goal-setting and review is the cornerstone of the IDT’s process

• Multidisciplinary: Traditional multidisciplinary team (MDT) approaches involve professionals working independently in order to achieve discipline specific goals. Individual team members may not communicate directly with all other team members in care planning

Whole-Time Equivalent is the equivalent number of combined part-time and full-time staff resources operating on a full-full-time basis, e.g. two staff members both working half-time are equivalent to one whole-time post.

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1.

EXECUTIVE SUMMARY

Since its establishment in 2010 the Rehabilitation Medicine Programme (RMP) has been concerned with shaping current and future specialist rehabilitation services for adults with disability resulting from neurological injury and limb absence across acute, post-acute and primary care settings.

There is a significant body of international evidence to support the benefit and cost effectiveness of specialist rehabilitation services within a modern health service. In Ireland there are significant gaps identified within current services for neurological and limb absence specialist rehabilitation. This has resulted from chronic

underinvestment in such services and the lack, until recently, of a coherent national strategy to guide the development of these services1.i

The programme’s overall objective is to extend access to specialist rehabilitation services for people with acquired disability so that their ability can be maximized, dependency reduced and societal participation increased. The RMP has aligned its objectives with several other HSE Clinical Strategy and Programmes Division (CSPD) programmes including Neurology, Stroke, Older Peoples’, Psychiatry and Rheumatology. Liaison with the Paediatric Programme is also underway to enable the continuance and development of specialist rehabilitation services for children.

There is an overwhelming demand for specialist rehabilitation services particularly for people who have sustained severe brain injuries. Emergency trauma and medical care is now more responsive and protocolised, and more people are surviving

catastrophic injuries with complex, life-changing neurological, vascular and orthopaedic sequelae. Fortunately those who are developing the framework for managing trauma in Ireland2 have recognised the crucial role of rehabilitation services in ensuring the best functional outcome for all severely injured patient.

It is vital to ensure rapid access to specialist rehabilitation in all hospitals admitting patients after major trauma and neurological injury. This involves patients having access to a centre equipped to treat patients with complex rehabilitation needs, developing regional specialist inpatient and outpatient rehabilitation units, and reconfiguring community based rehabilitation services. The desired outcomes are reduced length of stay, prevention of unnecessary re-admissions and successful, sustained discharge to home.

The rehabilitation medicine programme proposes a model of care which is based primarily on national strategy and policy3. The proposed model defines this

framework and outlines how specialist rehabilitation services should be designed for the evolving care needs, across three levels of complexity, of those patients who

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National Policy and Strategy for the Provision of Neuro-Rehabilitation Services in Ireland 2011 – 2015 (DoHC 2011) http://health.gov.ie/blog/publications/national-policy-and-strategy-for-the-provision-of-neuro-rehabilitation-services-in-ireland-2011-2015-2/ accessed 20th November 2014

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NOCA Major Trauma Audit and Governance Committee http://www.noca.ie/major-trauma-audit

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present with residual disability after significant injury4.ii A hub and spoke model consisting of a national centre (National Rehabilitation Hospital) with six regional in-patient units that will be coterminous with the catchment area of the new hospital groups will provide coordinated care for patients across the levels of complexity. These units will in turn work with voluntary agencies and community rehabilitation clinicians in their recently-described ‘local’ Community Health Organisations5. The RMP is advocating a model of care where patients are managed by specialist rehabilitation clinicians who are connected and supported by the governance structures of a managed clinical rehabilitation network (MCRN). The National Rehabilitation Hospital has been the national hub for specialist rehabilitation for many years and will link formally with new rehabilitation teams in regional centres within each hospital group area. The boundaries of the new community healthcare organisations (CHOs) require further scrutiny to determine how rehabilitation

voluntary agencies can continue to deliver and expand their existing services within those new structures.

This model of care delivers, in line with the National Policy and Strategy for the Provision of Neuro-Rehabilitation Services in Ireland 2011 – 2015 (DoHC 2012)6, a blueprint for future provision of specialist rehabilitation services in Ireland. The illness management models and pathways contained within the document have been

developed taking note of existing best practice within Ireland and beyond after an extensive collaborative process involving interdisciplinary working groups.

It is hoped that uniform standards of service delivery can be realised in due course across the national, regional and community components of the network.

Development of clear referral protocols and pathways at the interface between specialist and non-specialist rehabilitation services, and community disability services will ensue. It is important that statutory and non-statutory services should work collaboratively to improve outcomes and experience for service users.

Many community residential options for severely disabled people under the age of 65 do not meet their unique needs where continuing slow functional recovery is possible over several years after their injury. In this context the RMP supports development of more structured community based rehabilitation teams that could support people during gradual step-down from tertiary centres and regional units so that they can be supported in reintegrating within their local communities.

The Programme is engaged in a number of important workstreams including (i) the publication of Standards and Guidelines for the Procurement of Prosthetics,

Orthotics and Specialist Footwear (2012), (ii) liaison with the National Disability Unit in developing an implementation plan for the 2011 Neurorehabilitation Strategy and

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http://www.lenus.ie/hse/bitstream/10147/141055/1/Future%20for%20neurological%20conditions %20in%20Ireland.pdf p.33, accessed 19th November 2014

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http://www.hse.ie/eng/services/publications/corporate/CHOReport.htmlaccessed 19th November 2014

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(iii) development of standards of care for specialist in-patient and community rehabilitation services.

Effective and realistic goal setting, with patient and family engagement, and across the continuum of recovery and service delivery, is the cornerstone of the

rehabilitation process. Ongoing education of healthcare professionals within the rehabilitation clinical community is important and, more broadly, among clinicians and voluntary agencies who interface with those specialist services. This MoC describes the generic and specialist competencies for staff working in rehabilitative care spanning acute, post-acute and community settings.

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2. INTRODUCTION

WHAT IS REHABILITATION?

Rehabilitation is a dynamic and critical component of the therapeutic continuum and one that is essential if patients are to regain their life roles, status and quality of life after serious illness or injury. Rehabilitation can improve health outcomes, reduce costs by shortening hospital stays, reduce disability and improve quality of life7.iii Families and carers are a vital part of the rehabilitation team and require support and services in their own right.

The process is a goal directed one and involves assessment and treatment by which the individual is supported in achieving their maximum potential in all functional domains. Therefore rehabilitation resources should be provided along a continuum of care ranging from acute hospital care to rehabilitation in the community.

The process of rehabilitation is defined in a number of ways. This person-centred definition is synthesised from several sources:

Rehabilitation is an iterative, problem-solving process in which the person who experiences loss of function acquires the knowledge, skills and supports needed to achieve their optimal physical, psychological, social and economic status.

The World Health Organisation (WHO) recommends that priority is given to ensure access, for those in need, to appropriate, timely, affordable and high-quality

rehabilitation interventions consistent with the Article 26 of the UN Convention on the Rights of Persons with Disabilities8. The service-based WHO definition can be

viewed on its website9.

INTERNATIONAL CLASSIFICATION OF FUNCTIONING (ICF)

The World Health Organisation (WHO) model of illness has evolved over the past thirty years (WHO-ICF 2001)10 and charts the transmission of the impact of the disease pathology through to its effect on the person’s ability to perform day to day activities and consequently their ability to participate in their societal roles. ICF belongs to the WHO family of classifications and presents taxonomies of functioning and disability associated with health conditions.

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Cheville AJ, Basford JR. Post-acute care: reasons for its growth and a proposal for its control through the early detection, treatment and prevention of hospital-acquired disability. APMR, Vol 95, Issue 11, pp 1997-1999, Nov 2014

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http://www.un.org/disabilities/default.asp?id=286 accessed 19th November 2014

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WHO definition http://www.who.int/topics/rehabilitation/en/accessed 18th November 2014

10

World Health Organisation International Classification of Functioning (WHO-ICF) 2001, is a more complex version of the first edition published in 1981 http://www.who.int/classifications/icf/en/.

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FIGURE 1 PROVIDES A VISUAL REPRESENTATION OF THE MODEL OF DISABILITY THAT IS THE BASIS FOR ICF

ICF is so named because of its emphasis on health and functioning, rather than disability. Previously, disability began where health ended. Diagnosis alone does not predict service needs, length of hospitalization, care requirements or functional outcomes. Nor is the presence of a specific disease or disorder an accurate predictor of level of impairment or activity limitations.

The ICF provides a more comprehensive model of disability than medical or social models in isolation. It recognizes that disability is an interaction between the features of the person and elements of the overall context in which the person lives.As the diagram indicates disability and functioning are viewed as outcomes of interactions between health conditions and contextual factors in the ICF framework.

WHAT IS SPECIALIST REHABILITATION?

Specialist rehabilitation services are required for people with more complex disabilities. A BSRM position paper in 2010 defines specialist rehabilitation (SR):

…SR is the total active care of patients with a disabling condition, and their families, by a multi-professional team who have undergone recognised specialist training in rehabilitation, led /supported by a consultant trained and accredited in rehabilitation medicine (RM)11.iv

Patients with complex needs typically present with a combination of medical, physical, sensory, cognitive, communicative, behavioural and social problems that

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Turner-Stokes, L. Specialist neuro-rehabilitation services: providing for patients with complex rehabilitation needs. In: Levels of specialisation in rehabilitation services, BSRM website 2010 http://www.bsrm.co.uk/publications/Levels_of_specialisation_in_rehabilitation_services5.pdf accessed 20th December 2014 Health Condition (Disorder or disease) Body Functions & Structure Environmental factors Personal factors Activity Participation

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require specialist input from a wide range of rehabilitation disciplines12 as well as specialist medical input from consultants trained in rehabilitation medicine. The three-tier model of complexity-of-need has formed the basis for the

commissioning of specialist rehabilitation services in the UK since the designation of Brain Injury and Complex Rehabilitation as definition number 7 of the Specialised Services National Definition Set (SSNDS)13. The model is derived from the Kaiser Permanente illness triangle14 and was used extensively in the UK in the early years of implementation of the NHS Plan (2000) to convey the conceptual basis for the paradigm shift required to move chronic disease management from hospitals into primary care.15v

FIGURE 2: LEVELS OF LONG TERM CONDITIONS MANAGEMENT (DEPARTMENT OF HEALTH ENGLAND & W ALES 2002)

It is a model that translates well to the Irish rehabilitation context.

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Rehabilitation nurses, physiotherapists, occupational therapists, speech and language therapists, psychologists, dietetics, orthotics and social work

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Archived web content on the 3rd edition of the SSNDS 2010; accessed 20th November 2014 http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Managingyourorganisation/Commi ssioning/Commissioningspecialisedservices/Specialisedservicesdefinition/index.htm

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http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Healthcare/Longtermconditions/ DH_4130652 Archived NHS reference to the KP Triangle accessed 21st November 2014

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Wilson T, Buck D, Ham C. Rising to the challenge: will the NHS support people with long-term conditions? BMJ Mar 19, 2005; 330(7492): 657–661

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FIGURE 3: COMPLEXITY LEVELS IN IRISH REHABILITATION SERVICES

Tertiary, complex specialist rehabilitation services (Level 1):

These are high cost / low volume services that provide for a high proportion of patients with highly complex rehabilitation needs whose needs are not fully met by their local and regional specialist services. Level 1 services provide a higher level of specialist expertise, facilities and programme intensity to meet the needs of these patients. Patients attending tertiary specialist rehabilitation services typically require intensive, coordinated interdisciplinary intervention from four or more therapy

disciplines.

In the ICF context, rehabilitation services provided in Level 1 facilities may focus on addressing impairment by ameliorating the symptoms of the health condition where possible and reduce their impact on activity limitations.

Regional specialist rehabilitation services (Level 2):

These services serve a regional-level population and are led or supported by a consultant trained and accredited in Rehabilitation Medicine working in hospital and community settings. The specialist interdisciplinary team provides advice and support for local non-specialist rehabilitation teams. Patients treated in regional rehabilitation units will typically have moderate to severe physical, cognitive and/or communication difficulties. In the ICF context rehabilitation provided by Level 2 facilities will focus on reducing the impact of impairment, with significant focus on addressing activity limitations.

Community specialist rehabilitation services (Level 3):

Local specialist (community based) rehabilitation teams provide general multi-professional rehabilitation and therapy support. The type of patients who require these services (community rehabilitation teams) would typically present with more

Level 1

Tertiary, complex specialist rehabilitation services Level 2 Regional specialist rehabilitation services Level 3 Community specialist rehabilitation services

Complexity

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complex needs such as cognitive, communicative, perceptual, behavioural and social difficulties requiring coordinated input of an interdisciplinary team in order to manage and treat symptoms and to coordinate multi-agency referral and on-going care. Level 3 rehabilitation programmes focus generally on addressing activity limitations and likely participation restrictions.

ICF AND SPECIALIST REHABILITATION

Use of the ICF paradigm allows a deeper understanding of the horizontal effects of disease on patients and their family. Factors related to the person’s life and living conditions, and contextual factors related to their environment, moderate the effects of the disease to a greater or lesser extent. This complex interplay is illustrated in figure 1. Figure 2 represents the sum of clinical manifestations, interventions and outcome measures employed by clinicians in each facet of an illness. Treatment of disability, in the case of the RMP – neurological, traumatic and limb absence, encompasses a wide range of interventions, at all levels of disease.

Different clinicians tend to concentrate their efforts in quite specific areas of the disease process, while working in clinical interdisciplinary teams. For instance, doctors are concerned primarily, by virtue of their training and experience, with body structure and function and rarely stray into activity and participation unless

specifically trained to do so. Clearly, accurate diagnosis of a condition is an absolutely crucial component of management in terms of directing appropriate therapies, elucidating the disease prognosis and informing the timelines of those interventions, for the patient, their families and their treating professionals. As regards other clinicians and their roles, nurses use their expertise across the disease process whereas many allied health professionals focus their assessments and treatments on body function and activity. This is withthe notable exception of occupational therapists, who are specifically concerned with the participative consequences of their interventions. Medical social workers concentrate on

modifying environmental factors that affect the person’s participation in their societal roles.

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THE REHABILITATION PRESCRIPTION

**TO BE COMPLETED**

LINKS W ITH OTHER NATIONAL CLINICAL PROGRAMMES

Cross Programme collaboration with related clinical programmes16 within the CSPD and with Primary and Social Care Divisions is central to the design and delivery of a service which delivers patient focused, evidenced based rehabilitation.

NEUROLOGY

The RMP has liaised formally with the Neurology Clinical Programme particularly with reference to scope and synergies between the two programmes. The role of rehabilitation medicine in the management of patients with neurological conditions is wide ranging. Both programmes are advocating for managed clinical networks with national complex specialist services, regional specialist services and community or local services.

Implementation of the models of care for both programme will be reliant on the development of adequately resourced local primary care teams to support service users who may not require complex specialist services.

OLDER PERSONS’

There are many synergies between the RMP and National Clinical Programme for Older Persons (NCPOP) which published its model of care in 2012. The NCPOP has kindly shared its template for in-hospital data collection with the RMP for adaptation and this is presented in detail in chapter 16.

PAEDIATRICS

While paediatric specialist rehabilitation services are outside the scope of the RMP acknowledges that an equivalent hub and spoke model is required to address the needs of disabled children. To this end, the RMP continues to engage with the development board for the new National Paediatric Hospital, the National Rehabilitation Hospital which will continue to be the tertiary centre for complex specialist paediatric rehabilitation, and the Paediatric Clinical Programme.

STROKE

Patients with stroke who have complex specialist rehabilitation needs are considered within scope of the RMP. Links are being forged with the national Stroke

Programme, particularly in relation to their TRASNA programme (Telemedicine rapid access for Stroke and Neurological Assessment). If expanded to include

rehabilitation medicine facilities this would afford patients and treating clinicians the opportunity to conduct remote OPD clinics, offer clinical opinions on acute and complex cases and conduct interdisciplinary meetings across hospital sites. The use

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of TRASNA could also enhance links, both clinical and educational, between hospitals within each clinical network.

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3. BACKGROUND AND MODEL OF CARE CONTEXT

EPIDEMIOLOGY OF DISABILITY

Accurate information on incidence17 and prevalence18 of a disease, and the numbers disabled by it, is essential in planning services particularly around workforce skill mix and numbers, and the geographical location of those services. For instance, there are more than 30,000 people living in Ireland with the effects of an acquired brain injury whereas there are fewer than 250 individuals with Motor Neurone Disease19. In addition, not all patients are disabled by their condition at all times and accurate information indicating the numbers that are, can be difficult to ascertain. Good estimates of the numbers of individuals living with and disabled by a neurological illness are presented in the same paper extrapolated from the UK Neuro Numbers report from 2003, also from the UK Neurological Alliance20. At any one time, 17% of the Irish population (726,000) is living with a neurological illness and 85,000 (2%) are disabled by the condition defined as needing the help of another person to perform most of their activities of daily living, including personal care, meal preparation, housework and shopping.

Many factors have contributed to this substantial and enlarging number of disabled individuals: certainly, diagnostic accuracy and disease registration systems have improved however imperfect they may still appear to be. In addition, over the past 20 years, sustained improvements in retrieval and intensive care management of those who have sustained severe brain injuries have yielded a group of patients, mostly of working age, who demonstrate slow and incomplete recoveries. Improved

immunological therapies and other high-cost and sophisticated remedies have ensured the survival of many patients who would in the past have succumbed to their diseases.

Potentially the process of rehabilitation after such injuries and illnesses, given the degree of nervous system damage, can be of indefinite duration. In many cases, recovery results in limited functional gains both for the injured individuals and wider society, in terms of the patients’ ability to re-engage in their former life roles. In addition, their care needs impact hugely on the lives of their carers and families, many of whom are forced to abandon their own educational and work activities. Assessing the level of need for specialist rehabilitation services is constrained by absence of epidemiological research and the lack of a single comprehensive data source for recording and monitoring this information within the health services. This section outlines an estimate of the need based on consideration of the data sources

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Incidence refers to the number of new cases of a disease occurring annually in a given population.

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Prevalence refers to the total number of individuals living with a disease in a given population, at a given time.

19

Hardiman O (2010). Neurological conditions: a challenge for the Irish Health system, in Neurological Alliance of Ireland position document 2010.

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that are available. The need for a single comprehensive database is outlined in the Model of Care in Section four of this document.

It is estimated that over 700,000 people in Ireland live with a neurological condition, representing approximately 17 per cent of the total popul

include acquired brain injury, epilepsy, multiple sclerosis, stroke, Parkinson’s

disease, dementia, and other progressive, intermittent or disabling conditions of the brain or spinal cord. Neurological conditions can impact the phys

emotional, social and economic life of the person and their family

FIGURE 3: DEMAND, CAPACITY AND GAPS IN T

LEVEL 1 = COMPLEX SPECIALIST; LEVEL 2= R

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The Future for Neurological Conditions in Ireland http://www.nai.ie/go/resources/nai_documents/the accessed 18th November 2014

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e need for a single comprehensive database is outlined in the Model of Care in Section four of this document.

It is estimated that over 700,000 people in Ireland live with a neurological condition, representing approximately 17 per cent of the total population. These conditions include acquired brain injury, epilepsy, multiple sclerosis, stroke, Parkinson’s

disease, dementia, and other progressive, intermittent or disabling conditions of the brain or spinal cord. Neurological conditions can impact the physical, intellectual, emotional, social and economic life of the person and their family21.

PACITY AND GAPS IN THE DELIVERY OF IN-PATIENT REHABILITATI

ECIALIST; LEVEL 2= REGIONAL SPECIALIST; LEVEL 3= COMMUNITY S

The Future for Neurological Conditions in Ireland – Neurological Alliance of Ireland (2010) http://www.nai.ie/go/resources/nai_documents/the-future-for-neurological-conditions

e need for a single comprehensive database is outlined in the

It is estimated that over 700,000 people in Ireland live with a neurological condition, ation. These conditions include acquired brain injury, epilepsy, multiple sclerosis, stroke, Parkinson’s

disease, dementia, and other progressive, intermittent or disabling conditions of the ical, intellectual,

.

PATIENT REHABILITATION

LEVEL 3= COMMUNITY SPECIALIST

Neurological Alliance of Ireland (2010) conditions-in-ireland

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Figure 3 above presents a visual summary of the estimated demand, capacity and gaps in the provision of specialist rehabilitation services in Ireland, based on consideration of the information sources outlined in this chapter.

There is an approximate prevalence of 4,000 people with limb absence and prosthetic requirements in Ireland, and an incidence of 500 people with primary major limb loss.

The incidence of new SCI (traumatic and non-traumatic) is estimated to be approximately 120 per annum22.vi

According to Hospital Inpatient Enquiry Scheme (HIPE) data from 2010 more than 30,000 individuals were discharged from an acute hospital in Ireland with a

neurological condition or amputation. Based on international comparisons about 50% will require access to specialist rehabilitation services to reduce complications. They require assessment and triage towards appropriate services in hospital or community settings. There are significant gaps in provision of specialist rehabilitation across all levels of complexity (1-3).

The estimated gap in level three services has been identified through service mapping performed for the 2011 Neurorehabilitation Strategy. With an ageing population and increased survival from acute illness and trauma the demand for specialist rehabilitation is steadily increasing.

GUIDING POLICY DOCUMENTS IN IRELAND

The RMP recognizes the need for a collaborative approach to service enhancement and delivery across agencies, programmes and sectors.

The development of the RM model of care draws from key policy developments and reforms within the Irish health services with detailed consideration of the following:

• National Policy and Strategy for the Provision of Neuro-rehabilitation Services in Ireland 2011-2015 published in 201123. This strategy outlined the significant issues in relation to services in Ireland including resource issues, fragmented service delivery and overall lack of access to specialist neurological

rehabilitation for the majority of those needing it. Implementation is being led by HSE disability services

• Department of Health and Children’s Value for Money Review of Disability Services, 201224vii has resulted in significant restructuring of disability services following the recommendations of the review. There are also recommendations for further restructuring and policy development in the areas of reconfiguration of therapy services (recommendation 5.10), formal

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BSRM Standards for Rehabilitation Services mapped on to the National Service Framework for Long-term Conditions, BSRM, 2009

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2011 Neurorehabilitation Strategy

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Value for Money Review of Disability Services, Department of Health and Children, 2012

http://www.publicaffairsireland.com/news/1120-report-of-the-value-for-money-and-policy-review-of-the-disability-services-programme accessed 12th November 2014

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outcome measurement based on the assessment of person-centred plans (recommendation 6.6); establishment of a primary care network

(recommendation 7.12) and cross-sectoral working (recommendation 7.17).

• Health (Amendment) Act 200525; Disability act 200526

• HSE Procurement Policy27: this policy refers to the purchasing of supplies, works and services and is governed by core values which include; patient focus, dealing with quality suppliers who comply with all relevant legislation and government guidelines and managing risk. Considering the needs of patients requiring specialist rehabilitation and their requirements for

aids/appliances/prosthetics, this policy will guide development of any national guidelines with respect to aids & appliances.

• National Standards for Safer Better Healthcare 201228: by incorporating national and international best available evidence, these standards from the Health and Information Quality Agency (HIQA) promote healthcare that is up to date, effective and consistent. The standards provide a sound basis for anyone planning, funding or providing healthcare services to work towards achieving and maintaining high quality, safe and reliable care. They also determine the characteristics of high quality and safe healthcare and what patients and clinicians should expect from a well-run service.

• National Healthcare Charter, National Advocacy Unit, Quality and Patient Safety Directorate29, HSE 201230.This charter, developed by service users, patient advocacy organisations and the HSE QPSD31, is designed to involve service users in influencing the quality of healthcare in Ireland. It is used to support the implementation of the National Standards for Safer Better Healthcare.

• Key policies on prevention and public awareness campaigns e.g. Road safety Authority (RSA) and smoking cessation

• The Establishment of Hospital Groups as a transition to Independent Hospital trusts - in November 2012 the Department of Health launched the policy document Future Health: A Strategic Framework for Reform of the Health Service 2012-201532 providing the overarching policy framework for the establishment of hospital groups. At the time of writing the six hospital Group CEOs had just been appointed.

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http://www.irishstatutebook.ie/2005/en/act/pub/0003/index.htmlaccessed 19th November 2014

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http://www.oireachtas.ie/documents/bills28/acts/2005/a1405.pdf accessed 20th November ‘14

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http://www.hse.ie/eng/about/Who/Procurement/ accessed 20th November 2014

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http://www.hiqa.ie/standards/health/safer-better-healthcare accessed 20th November 20 2014

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Now the Quality and Patient Safety Division

30

http://www.nmh.ie/_fileupload/Patient%20Services/HSE%20It's%20Safer%20to%20Ask.pdf accessed 20th November 2014

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HSE Quality and Patient Safety Division

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http://health.gov.ie/blog/publications/future-health-a-strategic-framework-for-reform-of-the-health-service-2012-2015/ accessed 20th November 2014

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• HSE Chronic illness framework 2008:33 the goal of this framework is to provide individuals, groups and carers with early diagnosis, education, optimum clinical and social care in the most appropriate setting and achieve stable control of their condition. Self-management support, avoidance of complications and improved outcomes are also addressed.

• HSE review of Neurology and Clinical Neurophysiology Services (Laffoy

report, submitted December 2007 to the National Hospitals’ Office):34 Dr Marie Laffoy carried out a strategic review of these services in 2007 and her

recommendations were revisited at the request of the HSE in March 2009 by external experts Professors Charles Warlow and Jan Van Gijn. The report recommended that more resources be allocated to specialist personnel and facilities to improve access to diagnostic facilities for patients with neurological conditions. 33 http://www.lenus.ie/hse/bitstream/10147/65295/1/Chronicillness08.pdf accessed 20th November 2014 34

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4. RATIONALE FOR THE RMP

EFFECTIVENESS AND COST BENEFIT OF REHABILITATION

The RMP model of care will take into consideration the problems associated with current service provision and to outline solutions in line with wider reform and changes within the Irish health services. The cost saving that can be achieved requires attention when planning service development

• in terms of lessening the burden of need in the more highly dependent patients and

• Return to work/productivity for those with lower dependency.

There are many difficulties in demonstrating the effectiveness of a series of

interventions as diverse and all-inclusive as rehabilitation and until relatively recently, that body of evidence did not exist. There is now substantial proof that intensive rehabilitation in specialised environments, delivered by trained and committed staff, is both effective and cost-effective, in terms of reducing the burden and cost of onward care35viii. This has been demonstrated in a variety of settings, such as in-patient units and community teams, and in different diagnostic groups (traumatic brain injury36ix, stroke37x and multiple sclerosis38xi).

A recent study39,xii examined spending in health services across Europe during recessionary times to determine its affordability. The study evaluated the economic effects of alternative types of government spending by estimating ‘fiscal multipliers’ (the return on investment for each $1 dollar of government spending). A multiplier greater than 1 corresponds to a positive growth stimulus (returning more than $1 for each dollar invested). The fiscal multiplier for investment in health was determined as being 4.3 (2.5-6.1). These findings could have important implications for policy as they suggest that investment in health, and this case, rehabilitation contribute to economic health in the long term by creating a healthier labour force.

In the RCP / BSRM document Medical Rehabilitation in 2011 and beyond40, xiii evidence is presented from randomised and unrandomised intervention trials for sudden onset neurological conditions, progressive or intermittent neurological

conditions, and limb absence. The balance between benefits and risks, judged at the level of the individual and society, is assessed and recommendations are formulated

35

Turner-Stokes L (2004). The evidence for the cost-effectiveness of rehabilitation following acquired brain injury Clinical Medicine; 4[1]: 10-12

36

Powell J, Heslin J, Greenwood R (2002) Community based rehabilitation after severe traumatic brain injury: a randomised controlled trial. JNNP 72:193-202

37

Patel A, Knapp M, Perez et al (2004). Cost-effectiveness and cost-utility analyses from a prospective randomized controlled trial Stroke 35: 196-203.

38

Thompson AJ (2000). The effectiveness of neurological rehabilitation in multiple sclerosis J

Rehabil Res Devel; 37[4]: 455 – 461 39

Reeves A, Basu S et al; Does investment in the health sector promote or inhibit economic growth? Globalization and health 2013, 9:43 doi:10.1186/1744-8603-9-43

http://www.globalizationandhealth.com/content/9/1/43 accessed 15th October 2014

40

Medical Rehabilitation in 2011 and beyond; Report of a joint working party of the Royal College of Physicians and the British Society of Rehabilitation Medicine, 2010 www.bsrm.co.uk

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for clinical practice based on the balance between desirable and undesirable effects of an intervention.

The economic benefits and cost-effectiveness of rehabilitation are evident from a small group of studies from the UK and US. One such example is a 6 year cohort study of patients with acquired brain injury admitted to a tertiary referral centre.41 xiv All patients in each of the 3 graded categories of dependency (using the RCS)42 showed significant reduction in dependency and on-going care costs. The main reduction in weekly cost of care was greatest in the high dependency group (at £639 per week); reduced mean costs for the medium-dependency group was about half this amount (£323 per week), and about £111 per week for the low dependency group. Despite their longer length of stay and higher treatment costs the time taken to offset the initial cost of rehabilitation was only 16.3 months in the higher

dependency group.

Rehabilitation services have the opportunity to reshape service delivery and work more collaboratively with health care providers across the continuum. Through the development and implementation of this model of care, founded on good practice and innovation, rehabilitation services have the opportunity to improve service efficiencies and patient outcomes.

OVERVIEW OF CURRENT SERVICE GAPS

The key gaps and problems in relation to the provision of supports have been described in detail, most recently in the 2011 Neurorehabilitation Strategy. Similar deficits have been highlighted in POLAR services in the 2012 HSE Prosthetics and Orthotics review, considered in chapter 9. They can be summarized as:

I. An extensive shortage of key specialists involved in the provision of neurological rehabilitation services including:

• Consultants in Rehabilitation Medicine

• Medical social workers, occupational therapists, speech and language therapists and physiotherapists,

• Neuropsychologists

• Specialist nursing staff i.e. clinical nurse specialists and advanced nurse practitioners

II. Lack of

• appropriate community rehabilitation

• inpatient rehabilitation beds which means inappropriate use of acute hospital beds

• appropriate post-acute rehabilitation facilities for people discharged from hospital based specialist rehabilitation services

• sufficient data to facilitate adequate planning of needs and services

• rehabilitation services in many residential facilities and nursing homes

41

Turner-Stokes L, Paul S, Williams H. Efficiency of specialist rehabilitation in reducing dependency and costs of continuing care for adults with complex acquired brain injuries 2006 JNNP; 77(5):634-9

42

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Currently there are no pathways that signpost appropriate services, and referral and transition processes. Rehabilitation services within the community are often offered to patients with specific conditions rather than on the basis of need.

Mapping and gapping in the 2011 Neurorehabilitation Strategy documented patchy access for patients to certain services determined by historical availability of that service in their area rather than the patients’ clinical need for that service.

Lengthy delays in effecting necessary house adaptations and inadequate provision of essential aids, appliances and assistive technology present challenges to the effective provision of rehabilitation services. Solutions for these areas of need are outside of the scope of the RMP.

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5. AIMS AND OBJECTIVES OF THE RMP

INTRODUCTION

The overarching aim of the RMP is to maximize ability and reduce disability by increasing access to specialist rehabilitation services.

The RMP’s objectives have been developed over the past 4 years and reflect the expressed aspirations and needs of current and former service users, and

rehabilitation clinicians.

QUALITY

• Reduction of inappropriate patient discharges to nursing homes

• Ensure provision of rehabilitation in the most appropriate care setting to meet patient needs

• Ensure provision of specialist rehabilitation provided by interdisciplinary teams

• Monitor and work towards reduction in adverse events such as transfer to the acute hospital, and falls

• Enable earlier transfer of care between rehabilitation settings i.e. acute to tertiary, tertiary to regional, regional to community

• Ensure equitable access to specialist rehabilitation services regardless of geography

• Work towards introduction of nationally agreed, defined and tracked outcome measures for specialist rehabilitation services

ACCESS

• 80% access to early Specialist Rehabilitation assessment within 2 weeks of referral

• 80% access to admission to specialist inpatient rehabilitation beds within 60 days

• Reduction in the number of patients waiting to access complex specialist rehabilitation by 20% (through the introduction of appropriately resources regional rehabilitation units

• Reduction in delayed discharges from complex specialist rehabilitation to 8%

COST

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• Reduced length of stay (LOS) in complex specialist rehabilitation hospital beds by 5 days

• Reduction in the days lost to delayed discharge in specialist rehabilitation services

• 10% reduction in readmission and attendance at ED rate (readmission based on primary condition for which specialist rehabilitation services were required)

• Reduction in inappropriate discharge destinations

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6. THE SCOPE OF THE RMP

The RMP is concerned with the development of a framework for the delivery of specialist rehabilitation services for adult service users (over the age of 18) based on need rather than diagnosis.

When considering patient and service needs it is helpful to consider disease characteristics in several dimensions. The longitudinal effect of disease over time, also referred to as the disease trajectory, varies considerably among injuries. Serious single injuries or illnesses and progressive neurological diseases will affect the individual, or their family, in one way or another for the rest of their life43.

Musculoskeletal conditions are not included within the scope of the RMP as the rehabilitation needs of this cohort of patients is managed through the

musculoskeletal physiotherapy initiative which is a joint initiative of the Orthopaedic and Rheumatology National Clinical Programmes.

SUDDEN ONSET NEUROLOGICAL CONDITIONS

Under the remit of rehabilitation medicine four categories of conditions, adapted from UK NSF classification of long-term conditions44 and excluding musculoskeletal

conditions, are summarised in Table 1.

Conditions Example

Sudden onset conditions Brain injury, spinal cord injury, limb absence

Intermittent conditions Relapsing remitting Multiple sclerosis (MS)

Progressive conditions Parkinson’s disease, secondary progressive MS

Stable conditions Cerebral palsy, post-polio syndrome

TABLE 1: TAXONOMY OF NEUROLOGICAL CONDITIONS

The majority of the studies examining sudden onset conditions have been conducted in patients with acquired brain injury (ABI), predominantly stroke, and spinal cord injury (SCI). The strongest recommendations are for:

• Early intensive rehabilitation starting soon after onset of the medical condition

• Specialist programmes for all those with complex needs

• Specialist vocational programmes for those with potential to return to work As an example, recently in the NRH, an Early Access Rehabilitation Unit (EARU) was developed with monies from the 2012 DoH Frail Elderly Initiative (FEI). The aim of is unit is to offer early access to rehabilitation for patients with recent onset

neurological injury of low to moderate dependency. 45

43

National Service Framework for Long Term Conditions, March 2005, chapter 1, para 16

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4105361 44

National Service Framework for long term conditions 2005

http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Healthcare/Longtermconditions/Lo ng-termNeurologicalConditionsNSF/DH_4128647 accessed 20th November 2014

45

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The average length of stay in 2012 for patients admitted to the NRH’s Brain Injury Programme was 68 days. The average LOS for patients in the EARU in 2013 was 34 days. 90% of patients were admitted to the EARU from acute hospitals, and 97% were discharged home. The average waiting time from referral to admission to this unit for 2013 was 13 days.

(…would benefit from presentation in tabular form)

This initiative has demonstrated efficiencies in use of bed days both at acute hospital level and indeed rehabilitation hospital without compromising quality or patient

outcomes46.

PROGRESSIVE OR INTERMITTENT CONDITIONS

The largest body of evidence for rehabilitation in progressive or intermittent conditions is observed in multiple sclerosis patients47. The strongest

recommendations are for

• Short term intensive inpatient rehabilitation programmes and

• Lower-intensity community-based programmes conducted over a longer period.

Treatment by community based multidisciplinary teams can be cost saving. A review of effectiveness of one such community team48 demonstrated that savings arising from reduced hospital bed usage and reduced out-patient visits with MDT

involvement was equivalent to the cost of the team itself thereby rendering the team’s work cost neutral. There is strong evidence from Cochrane and other

systematic reviews that multidisciplinary rehabilitation can improve the experience of living with a long term neurological condition, both at the level of functional activity and societal participation49 xv.

LIMB ABSENCE CONDITIONS

Patients with lower limb amputation account for 92% of those who undergo

amputation. Those with upper limb amputations are a much smaller population and account for 5% of those with limb loss. People with congenital limb absence are the smallest group representing just over 2%.

46

Commentary required on process changes that have led to this reduction in LOS

47

Thompson AJ (2000). The effectiveness of neurological rehabilitation in multiple sclerosis J

Rehabil Res Devel; 37[4]: 455 – 461 48

Ward et al, 2009

49

Khan F, Turner Stokes L, Ng L, Kilpatrick T, Multidisciplinary rehabilitation for adults with multiple sclerosis Cochrane Database of Systemic reviews Apr 18 (2):CD006036

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FIG 1 AMPUTEE AND PROSTHETIC NUMBERS FROM BSRM50xvi

It is recommended that Rehabilitation Services for those with limb loss should remain a specialist rehabilitation service (defined as interdisciplinary service having input from a consultant in rehabilitation medicine).

While there is limited supporting evidence with respect to best practice in the area of limb absence rehabilitation expert opinion recommends:

…the development of hub and spoke models of service delivery, where groups of services (centres) establish formal affiliations with focused clinical leadership and further specialism coming from one tertiary referral centre.51 Tertiary centre referral is indicated for upper limb, congenital and multiple limb loss conditions. Regional specialist centres can assess and treat lower limb amputees, non-complex upper limb amputees and some patients with congenital limb loss depending on local team expertise. Patients with complex presentations whose conditions are stable can also be treated in regional specialist rehabilitation centres. Specialist rehabilitation teams should include: (Table 2)

Consultant in Rehabilitation Medicine Clinical Nurse Specialist and RGN

Prosthetist Clinical psychologist

Physiotherapist Counselling services

Occupational therapist Medical Social Worker

Podiatrist Dietitian

50

BSRM Amputee Rehabilitation: Recommended Standards & Guidelines, October 2003

51

http://www.bsrm.co.uk/publications/StdsAmpProsRehab.pdf from 2003; accessed 19th November 2014

Epidemiology

Lower limb amputation Upper limb amputation Congenital limb absence

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Prosthetic Rehabilitation enables patients to achieve maximum functional

independence, taking into account their pre-amputation lifestyle, expectations and limitations. Amputee rehabilitation is multi-professional and interdisciplinary involving surgeons, rehabilitation staff as in table 2 and clinicians in community services. Units providing prosthetic rehabilitation should have access to a prosthetic workshop with facilities for the adjustment, repair and assembly of prostheses. Manufacture of prostheses can be located elsewhere assuming providers meet national standards. Three large studies to date that describe consistent patterns of improved survival, function and use of prosthesis, discharge to home, reduced redo or additional amputations and a reduction in co-morbidities. Chronological age appears not to be a barrier to using prostheses. The BSRM conclude that there is an active need for research into both high-tech developments as well as low-tech service changes, which apply to POLAR services. (refs required)

The model of care is not prescriptive in terms of work practices but allows for guiding principles and standards of care to be developed nationally in a coordinated and consistent way. The model also allows flexibility in designing practices that meet local needs leaving room for innovation in service delivery.

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7. CORE VALUES AND PRIN

SERVICE DELIVERY

FIGURE 1: CORE VALUES UNDERPIN

EMPOW ER AND INFORM P

Many specialties within healthcare are organised to respond and treat acute illnes and are facing challenges in

manage chronic disease. Chronic diseases are now the biggest cause of de disability worldwide causing

and, as a consequence, in roles and responsibilities of patients.

The practice of rehabilitation is innately patient centred. The International Association Patient Organisations (IAPO) Declaration on Patient

Healthcare53 outlines five key principles against wh

measured to determine the degree to which they are patient

culture accepts that rehabilitation services and individual rehabilitative interventions are built on these principles.

52

Patient Empowerment – Living with Chronic Disease; the European Network on Patient Empowerment; Website accessed 1

http://www.enope.eu/media/14615/a_series_of_short_discussion_topics_on_different.pdf 53 www.patientsorganizations.org

Empower &

Inform

Patients

34

CORE VALUES AND PRINCIPLES UNDERPINNING

ELIVERY

CORE VALUES UNDERPINNING SERVICE DELIVERY FOR THE RMP

EMPOW ER AND INFORM PATIENTS

INTRODUCTION

ties within healthcare are organised to respond and treat acute illnes hallenges in accommodating the care and treatment required to manage chronic disease. Chronic diseases are now the biggest cause of de disability worldwide causing a fundamental shift in health systems and health care

nsequence, in roles and responsibilities of patients.52

ehabilitation is innately patient centred. The International Association Patient Organisations (IAPO) Declaration on Patient-Centred

outlines five key principles against which models of care can be the degree to which they are patient-centred

culture accepts that rehabilitation services and individual rehabilitative interventions are built on these principles. These are:

Living with Chronic Disease; the European Network on Patient ; Website accessed 1st November 2014

http://www.enope.eu/media/14615/a_series_of_short_discussion_topics_on_different.pdf www.patientsorganizations.org accessed 15th October 2014

Core

Values

Develop &

Streamline

Infrastructure

Support

Development

of Expert Staff

NDERPINNING

Y FOR THE RMP

ties within healthcare are organised to respond and treat acute illness, accommodating the care and treatment required to manage chronic disease. Chronic diseases are now the biggest cause of death and

health systems and health care

ehabilitation is innately patient centred. The International Centred ich models of care can be

centred. The RMP’s culture accepts that rehabilitation services and individual rehabilitative interventions

Living with Chronic Disease; the European Network on Patient http://www.enope.eu/media/14615/a_series_of_short_discussion_topics_on_different.pdf

Support

Development

of Expert Staff

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FIGURE 2:

In clinical practice, the rehabilitation cycle guides clinicians in this regard i.e.

• Initial assessment

• Goal setting in collaboration with the patient

• Treatment plan

• Intervention

• Regular review of goals (evaluation

Incorporating the International Classification of Fun

requires consideration of the patients’ health and wellbeing and limits scope for clinicians to look only at impairment/disease in isolation.

The RMP acknowledges the impo providers and patients. Patient most relevant and up-to-date their own health care management

The 2011 Neurorehabilitation

reference to the need for clear information for patients and families at each stage of the rehabilitation process in a

and cognitive issues among patients mean that information provided at one stage of the rehabilitation process will need to be repeated at further stages.

The programme’s information strateg Access and

Support Information

35

FIVE PRINCIPLES OF ‘PATIENT-CENTREDNESS’

e, the rehabilitation cycle guides clinicians in this regard i.e.

Goal setting in collaboration with the patient

Regular review of goals (evaluation)

rporating the International Classification of Functioning guides interventions as it requires consideration of the patients’ health and wellbeing and limits scope for clinicians to look only at impairment/disease in isolation.

acknowledges the importance of communication between service ents. Patients need to have easy and customized access to the

date information to allow them to be active participants in own health care management.

INFORMATION PROVISION

The 2011 Neurorehabilitation Strategy’s consultation exercise made frequent

reference to the need for clear information for patients and families at each stage of in a clear format. Levels of anxiety among family members d cognitive issues among patients mean that information provided at one stage of the rehabilitation process will need to be repeated at further stages.

information strategy across all care settings will focus on:

Person-centred

care

Respect Choice and Empowerment Patient Involvement in Health Policy Access and Support CENTREDNESS’

e, the rehabilitation cycle guides clinicians in this regard i.e.

guides interventions as it requires consideration of the patients’ health and wellbeing and limits scope for

rtance of communication between service need to have easy and customized access to the

active participants in

made frequent

reference to the need for clear information for patients and families at each stage of . Levels of anxiety among family members d cognitive issues among patients mean that information provided at one stage of the rehabilitation process will need to be repeated at further stages.

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• Provision of accurate and accessible quality information to patients and families across each care setting

• Provision of information in a manner in which the patient and family are given the time to ask any questions and request any clarity

• Provision of information on the relevant patient support group or organization at the earliest stages

• Provision of information at frequent periods during the rehabilitation process

DEVELOP AND STREAMLINE INFRASTRUCTURE

The RMP wishes to propose development of a flexible service that facilitates

seamless transitions across all levels of specialism and encourages joint working as a core value.

Rehabilitation services should consist of an interdisciplinary team of people who:

• Work together towards common goals for each patient

• Involve and educate the patient and family

• Have relevant knowledge and skills

• Have competencies required to support their patients in terms of their rehabilitation goals

There are a number of key principles that should underpin infrastructure development. Specialist services should:

• Be person and carer-centred

• Allow direct access where appropriate

• Be close to the individual’s home environment when appropriate

• Develop interdisciplinary, multi-agency teams working together

• Have clear, transparent and mutually understood indicators for determining appropriate transition between levels of specialism

• Provide equitable access for all patients in need of those services

• Measure effectiveness and efficiency, in terms of cost and patient outcomes

• Demonstrate evidence of continuous quality improvement

• Record and monitor patient / service user satisfaction which is used in the generation of their quality improvement plans (QIPs)

SUPPORT DEVELOPMENT OF EXPERT STAFF

The expertise of staff delivering specialist rehabilitation service is central to the provision of effective rehabilitation services and education of patients and family. Maintaining and developing the expertise of staff across all sectors delivering rehabilitation services is essential to achieving the aims and objectives of the RMP. The RMP places emphasis on education and support of expert staff, and sub groups in the proposed managed clinical networks that focus on both education and clinical standards will play an integral role in developing rehabilitation specific competencies.

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The National Rehabilitation Hospital, the identified national tertiary centre, has

specific responsibilities related to education and training and will be supported by the RMP in fulfilling its role as the

The RMP also acknowledges the scope for further development of clinical specialist roles with respect to nursing and HSCPs.

Maintenance of CPD, membership of national discipline bodies as appropriate and further development of interdisciplinary team working across organisations is also considered essential in ensuring an expert workforce in rehabilitation. Not only will it support the seamless transition of patients between services, it will ensure that interventions are based on current evidence/research based practice.

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8. BEST PRACTICE IN SPECIALIST REHABILITATION

GUIDELINES AND CARE PATHW AYS

The RMP has a role in identifying and supporting best practice in the development and execution of the rehabilitation process. The programme is undertaking the

development of national standards for the provision of rehabilitation services in which the patient is central to the rehabilitation process including:

• Service provision

• Referral management

• Assessment of patient need

• Goal setting • Treatment programmes • Family/carer liaison • Discharge planning • Service Improvement • Staffing

Consensus standards for the provision of in-patient and community rehabilitation54, rehabilitation after traumatic brain injury55 xvii and organisation of stroke services and clinical management of stroke56xviii have been in routine use across all areas of the UK (Scotland57xix, Northern Ireland58xx) for much of the last decade. They contain evidenced-based recommendations regarding the organization of the services, minimum staffing levels and skill mix, process of clinical interdisciplinary work such as referral and discharge processes, and minimum weekly therapy interventions. More recently, health departments in the devolved territories of Wales and Northern Ireland have commissioned external reviews of their neurosciences59 xxi and brain injury rehabilitation60xxii services respectively.

Clinical guidance is becoming more specific and explicit with clear and all-inclusive algorithms available at the touch of a mouse to ensure logical and comprehensive management of patients throughout the course of their illness. Examples include the

54

BSRM (2002) http://www.bsrm.co.uk/ClinicalGuidance/BSRMStandardsforRMServices2002.pdf

55

RCP (2003) Rehabilitation after traumatic brain injury: National Clinical Guidelines. Royal College of Physicians

56

RCP National Clinical Guidelines for Stroke, 4th Ed. (2012); accessed 18th November 2014 https://www.rcplondon.ac.uk/sites/default/files/national-clinical-guidelines-for-stroke-fourth-edition.pdf

57

SIGN Management of patients with stroke. Health Improvement Scotland, October 2014 http://www.sign.ac.uk/guidelines/fulltext/118/index.html accessed 18th November 2014

58

Improving stroke services in Northern Ireland, July 2008; accessed 18th November 2014 http://www.dhsspsni.gov.uk/recommendations-stroke-services-in-ni.pdf

59

Report of the Welsh Neuroscience External Expert Review Group; September 2008 http://wales.gov.uk/about/cabinet/cabinetstatements/2008/indexprev/?lang=en

60

Review of services for people with acquired traumatic brain injury in Northern Ireland http://www.dhsspsni.gov.uk/showconsultations?txtid=34865 accessed 19th Nov 2014

Clinical Strategy and Programmes Division. Rehabilitation Medicine Programme. Model of Care

DOCUMENT MANAGEMENT

VERSION CONTROL

TABLE OF CONTENTS

GLOSSARY

EXECUTIVE SUMMARY

2. INTRODUCTION

Complexity

3. BACKGROUND AND MODEL OF CARE CONTEXT

4. RATIONALE FOR THE RMP

5. AIMS AND OBJECTIVES OF THE RMP

6. THE SCOPE OF THE RMP

Epidemiology

7. CORE VALUES AND PRIN

SERVICE DELIVERY

Empower &

Inform

Patients

CORE VALUES AND PRINCIPLES UNDERPINNING

ELIVERY

Core

Values

Develop &

Streamline

Infrastructure

Support

Development

of Expert Staff

NDERPINNING

Support

Development

of Expert Staff

Person-centred

care

8. BEST PRACTICE IN SPECIALIST REHABILITATION