Child & Adolescent Rehabilitation Services (CARS)

Transcription

1 Child & Adolescent Rehabilitation Services (CARS) Operational Guidelines To be read in conjunction with the CARS contract June 2013 This is a living document and will be updated as required

2 Contents Child & Adolescent Rehabilitation Services Operational Guidelines Introduction to Child and Adolescent Rehabilitation Services (CARS)... 3 Purpose of the services... 3 Relationship expectations... 3 Eligibility... 3 Determining the best services for young people... 4 Clinical criteria for transfer from acute services... 4 Service summary... 6 Inpatient rehabilitation services... 7 Moving between service levels... 7 Transport and accommodation for families... 7 Specialist equipment... 7 Service deferrals... 8 Transition services... 8 Service delivery... 8 Discharge to the community... 8 Home visits... 9 Transfer to adult services... 9 Follow-up and monitoring Service delivery Key transition points Ongoing monitoring Following up clients who do not have an active ACC case manager Assessment/complex case review Measuring progress Reporting requirements June 2013

3 Introduction to Child and Adolescent Rehabilitation Services (CARS) The Child and Adolescent Rehabilitation service (CARS) consists of specialist inpatient, community rehabilitation and follow-up services for children aged 0 to 16 years who have sustained a spinal cord injury, traumatic or acquired moderate-severe brain injury, multi-trauma, burns or a comparable injury or who require rehabilitation following a complex orthopaedic intervention, or who require pain management. Purpose of the services The services: enable children and young people to achieve and maintain their optimal levels of physical, sensory, intellectual, physiological and social functioning and to participate in developmentally appropriate activities prevent further injury provide specialist advice to ACC to inform appropriate rehabilitation planning. The services support children and young people and their families/whānau to: improve their functional abilities transition to and/or participate in the community understand and manage the impacts of their injury receive ongoing clinical management and follow up if needed transition to adult rehabilitation services if needed. Relationship expectations Ongoing communication and cooperation between ACC client service staff and the supplier is vital to ensure the best rehabilitation outcomes for people accessing these services. Eligibility To be eligible for CARS the client must either: have a spinal cord injury have a traumatic or acquired moderate-severe brain injury have a multi-trauma have burns have a comparable injury require rehabilitation following a complex orthopaedic intervention require pain management. They must also: have an accepted claim with ACC no longer need acute services, be deemed clinically stable, and ready to participate in rehabilitation have been assessed by an acute services specialist as needing inpatient rehabilitation, or June 2013 Page 3 of 13

4 have been identified in the surgical Assessment Report and Treatment Plan as needing inpatient rehabilitation following elective surgery. Determining the best services for young people Some clients aged between 14 and 18 may be better placed in adult services, depending on their level of maturity. Likewise, some clients aged between 16 and 18 may be better suited to receiving rehabilitation at the supplier s facility. Decisions about the most suitable services for these clients must be discussed and agreed between the client, their family/whānau, ACC, clinicians and suppliers. Clinical criteria for transfer from acute services There are three conditions that must be met before a patient can transfer from acute to non-acute ACC-funded services: The patient is clinically stable and likely to improve, as well as having no life threatening condition that would require emergency surgery or intensive monitoring The clinical team responsible for discharge from acute services and the rehabilitation team agree to the transfer The patient has been accepted, or is likely to be accepted, as an ACC Client. Clients covered under this agreement are those who have sustained a personal injury as a result of an accident for which they have cover under the Accident Compensation Act 2001 and who need non-acute inpatient rehabilitation in a specialised unit. Generic criteria A patient s condition is medically stable and likely to improve, and the injured person is medically stable when the following conditions are met: there are no life-threatening conditions that would require emergency surgery, e.g. to depressurise an intra-cranial haemorrhage, or to stop a potentially catastrophic haemorrhage from a ruptured aneurysm, ruptured spleen or liver there is no life-threatening condition requiring intensive monitoring, e.g. no significant infection no raised intra-cranial pressure no cerebro-spinal fluid leak no naso-gastric drainage the airway is secure and the patient can control respiration, or can only control respiration with routine assistance from machine/people where this assistance is subordinate to rehabilitation needs the airway is secure, excluding patients with an acute, short-term tracheostomy who have just come off a ventilator; the tracheostomy must be removed or be stable before medical stability is achieved fractures firmly fixed either internally or externally there are no issues requiring daily clinical input from the non-rehabilitation specialist clinical team or there are issues requiring daily medical input but that are subordinate to rehabilitation needs. If the above clinical conditions are met, transfer to non-acute care may be suitable for people with the following conditions: patients feeding by mouth, naso-gastric tube or percutaneous gastrostomy patients requiring intravenous (IV) antibiotics with or without central line June 2013 Page 4 of 13

5 patients requiring continuous ambulatory peritoneal dialysis (CAPD), or haemodialysis, and who are stable with this management. Specific clinical criteria In addition to the generic criteria, people in the following patient groups must also meet the following clinical criteria: People with severe brain-injury 1 The patient must have no uncontrolled or significantly unstable epilepsy, consciousness levels, psychiatric conditions etc. People with stabilised epilepsy, cognitive disturbance and/or psychiatric conditions may be suitable provided other criteria are met. Medically stable for a severely brain-injured person occurs when the patient meets the following conditions: no issues requiring daily input from the specialist medical team intra-cranial pressure not raised no intra-cranial haematoma requiring intensive monitoring no cerebro-spinal fluid leak no significant chest infection airway secure, excluding patients with acute, short-term tracheostomy who have just come off a ventilator; the tracheostomy must be removed before medical stability is achieved. Those who have a longer-term tracheostomy, such as for a fractured larynx, are regarded as medically stable fractures firmly fixed either internally or externally, although people with fractures can be nonweight bearing no significant infection feeding by mouth, naso-gastric tube or percutaneous gastrostomy but not on naso-gastric drainage. People with spinal cord injury The patient must have no pressure areas or ulcers requiring surgical intervention. Patients with pressure areas that require significant time on bed rest may be suitable provided other criteria are met. People with severe multiple injuries/burns The patient must have no actual or suspected disseminated intravascular coagulation (DIC), renal failure, internal haemorrhage or viscous disruption (anatomical or physiological) requiring intensive monitoring. Patients must have restored fluid balance with normal intake and output. Patients must have no suspect compromised limb/extremity circulation. Patients who are receiving specialised dressings and/or bandages or are awaiting further surgery may be suitable provided other criteria are met. Clinician agreement to transfer care The clinician responsible for acute care, who may be a discipline-specific specialist, agrees to discharge with reference to this framework and the clinician who is to continue non-acute care agrees to accept responsibility. 1 Severe brain injury is defined as: initial or worst Glasgow Coma Score (GCS) is less than or equal to 8 or initial or worst GCS is between 9 and 15 and post traumatic amnesia (PTA) has lasted more than 24 hours. June 2013 Page 5 of 13

6 Service summary CARS is divided into three key phases: Inpatient rehabilitation services Level 1 High clinical support needs Level 2 High intensity rehabilitation Level 3 Moderate intensity rehabilitation Transition services Follow-up and monitoring services. The supplier identifies which level each client receives based on their clinical needs. The service levels are not consecutive. Most clients may only require level 2 services for the duration of their stay. The client may enter the Child and Adolescent Rehabilitation Service at any point of service level. Service Description Service location(s) Referral sources Inpatient Rehabilitation Service Level 1 (High Clinical Support Needs) for children and young people who have high clinical support needs which may include post traumatic amnesia (PTA) supplier s facility, including access to the onsite school client and staff home visits specialist medical referral from an inpatient hospital or the community ACC, the client s GP and/or paediatrician need to be advised of the referral Inpatient Rehabilitation Service Level 2 (High Intensity Rehabilitation) for children and young people who require high intensity rehabilitation supplier s facility, including access to the onsite school and local school as appropriate client and staff home visits specialist medical referral from an inpatient hospital or the community ACC, the client s GP and/or paediatrician need to be advised of the referral Inpatient Rehabilitation Service Level 3 (Moderate Intensity Rehabilitation) for children and young people who require a lower intensity of rehabilitation supplier s facility, including access to the onsite school and local school as appropriate client and staff home visits specialist medical referral from an inpatient hospital or the community ACC, the client s GP and/or paediatrician need to be advised of the referral Transition Services (Residential and/or Non Residential Rehabilitation) residential and/or non residential rehabilitation focusing on developing routines to support transition back to school and the community supplier s facility, including access to the onsite school and local school as appropriate client s home requirement specified in client s discharge plan ACC prior approval/ agreement Follow up & Monitoring follow-up and/or monitoring and review by medical, neuropsychological, nursing and/or allied health staff. Includes outpatient supplier s facility client s home outreach clinics other appropriate ACC prior approval/ agreement specialist medical referral June 2013 Page 6 of 13

7 Service Description Service location(s) Referral sources appointments, visits to specialist interdisciplinary clinics. May include home or school visits locations Inpatient rehabilitation services A client can enter the CARS service when an acute service Paediatric Specialist and CARS Rehabilitation Physician identify that the client is medically stable and will require inpatient rehabilitation, or when the surgical Assessment Report and Treatment Plan identifies that the client needs inpatient rehabilitation following elective surgery. The provider contacts the supplier and they agree the client s requirement for inpatient rehabilitation. The provider will provide the supplier with: Admission notes GCS/PTA scores Functional status and specialist recommendation Discharge summary Medication notes ACC45. The supplier notifies ACC about the need for inpatient rehabilitation and to agree that this is the most appropriate option for the client and their family. The supplier identifies the likely level of inpatient rehabilitation that the client will enter the service at. The supplier must provide the local NSIS Manager with the following information to support admission to inpatient rehabilitation: GCS/PTA scores Functional status Specialist recommendation Service level at entry. Moving between service levels The clinical interdisciplinary team reviews each client s service level weekly and must notify ACC within three working days if there are any changes. The ACC case owner will update the purchase orders accordingly if the client is changing service level. Transport and accommodation for families Many clients and their families/whānau are likely to be travelling to the supplier s facility from outside Auckland. The Child Rehabilitation Service at the Wilson Centre has some onsite accommodation for families/whānau. ACC may be able to assist with the cost of this accommodation and transport to and from services under ancillary services. Specialist equipment Specialist equipment is specific to the client and used in specialist situations that the supplier could not reasonably be expected to supply. It is also expected that the client will keep the equipment when they return home, e.g. ventilators and power wheelchairs for long-term use. June 2013 Page 7 of 13

8 ACC will pay for specialist equipment for use by a client when a clinician indicates that it is necessary to support rehabilitation. The supplier will complete an ACC096 Equipment Order form and forward to ACC for prior approval. Service deferrals In the event of an unplanned acute admission, the supplier will: notify the family/whānau and/or caregiver immediately notify ACC within 24 hours of the event provide regular contact with the client, family/whānau and ACC until the client is able to reenter the service or be referred to a more appropriate service. ACC will pay a bed retention rate (as identified in the Service Schedule) for a period of up to 5 days per event. Transition services The supplier provides residential and non-residential rehabilitation services for clients who are transitioning back to their community and school if this is appropriate to the individual client s needs. The services focus on establishing routines, attending school and participating in the weekly rehabilitation programme delivered by the interdisciplinary team. Service delivery When deciding if transition services are appropriate for the client the supplier should consider the following: Does the client and family/whanau need to be onsite? How intense is the need for therapy, i.e. is the therapy able to be provided in the local community? How easy is it for the client and family/whanau to get to and from the Wilson Centre as a day visitor? The supplier should determine whether this is a suitable service to meet the client s needs in consultation with the family/whanau and ACC. On admission to this service the supplier will provide ACC with a discharge plan that includes: Measurement of functional abilities Updated goals Supports required Transition plan Follow-up plan. The supplier must report monthly to ACC on the client s progress against the rehabilitation plan and any improvement in functional ability. The report should also include information about family/whanau meetings, planned home visits, and an updated discharge plan advising ACC of projected support needs for home and in the community. Discharge to the community Discharge planning begins from the date the client is admitted to the Wilson Centre and is updated prior to the discharge date to reflect any change in the client s functional ability. The supplier will organise a case conference prior to discharge and provide ACC with at least 2 June 2013 Page 8 of 13

9 weeks notice of this happening. The supplier will provide ACC with a finalised discharge plan at least 10 working days prior to planned discharge date. The Discharge plan will include: Measurement of functional abilities Updated goals Supports required Transition plan Follow-up plan. The supplier will provide ACC with a completed Support Needs Assessment within 5 working days of discharge. ACC will initiate any services required to ensure a safe discharge, e.g. housing modifications, equipment, attendant care, education, transport, rehabilitation etc. Home visits Client home visits Home visits are an important part of a client s transition from inpatient rehabilitation back to their home and community. Home visits may be for up to one week s duration, especially if the client s home is out of Auckland. ACC pays a bed retention rate for the full period of the home visit. There is no limit on the number of home visits. The supplier should advise ACC at least two working days before a home visit so that purchase orders can be arranged for the bed retention rate Home visits will be planned and notified in the monthly report prior to visit including any requirement for Attendant Care The supplier must document the goals for all home visits in the client s rehabilitation plan The Wilson Centre will advise ACC if attendant care is needed while the client is at home. There may be times when the client and/or their family/whānau do not cope with being at home or the client becomes unsafe. The client may return to the supplier s facility earlier than planned. ACC will provide support to facilitate this if required. Staff home visits Members of the interdisciplinary team may visit the client s home while they are an inpatient. These visits help the team identify any skills and equipment the client will need to return home safely. ACC must approve staff home visits Payment for the interdisciplinary team s home visit time is included in the inpatient bed day rate Standard travel costs are paid in addition to the bed day rate. Transfer to adult services When a client reaches the age of 16 or when leaves school and still needs long-term clinical management, the supplier will work with the client, their family/whānau, ACC and other suppliers to help the client transition to adult rehabilitation services. The supplier must send a discharge report outlining the predicted needs for the client to ACC. This report should include any need to transition to an adult physician for medical/clinical oversight, especially in the case of spinal cord injury, and ensure inclusion in specialised spinal cord outreach services or any interdisciplinary rehabilitation or support. June 2013 Page 9 of 13

10 ACC will facilitate any referral to the appropriate rehabilitation service. Follow-up and monitoring The supplier provides a range of community-based services, eg outpatient appointments and specialist interdisciplinary clinics. The CARS contract is designed to allow the supplier flexibility to provide the most appropriate services for each client and reduce administration. All services are purchased using an hourly rate for each of the professionals involved in the service delivery. If the client returns to the facility for multiple appointments on the same day the supplier may invoice for a day rate, or a day/night rate if the client sleeps over. These rates include rehabilitation, so this may not be invoiced for separately. Follow-up and monitoring can be delivered at the supplier s facility or in another setting if appropriate for the client. ACC funds travel when the services are provided away from the supplier s facility. The supplier must consider the client s key transition and developmental requirements and notify ACC of any follow-up appointments and potential travel arrangements. Early notification will help ACC organise participation at this appointment by other relevant providers. Service delivery The supplier reviews the client s current functional status and the effectiveness of the current and planned rehabilitation programme. The supplier must provide a follow-up report to ACC no later than 10 days after the appointment that includes: the client s current functional status the effectiveness of their rehabilitation programme strategies and rehabilitation opportunities that would benefit the client the next follow-up appointment. Key transition points Programme Brain injury follow-up programme Under 5 s brain injury clinic (Early injury pathway) Transition time points 1. Before the start of primary school 2. Before the start of intermediate school 3. Before the start of high school 4. NCEA years, towards transition to adult services. Start discussions when child is 13 years old The majority of the children would be seen annually focusing on the key transition points. Some clients may need to be seen six monthly, e.g. if they are in Botulinum Toxin A programme. Time points relevant to development: 1. 6 months of age 2. 1 year of age months of age 4. 2 years of age Then yearly after this, depending on the impairments that have June 2013 Page 10 of 13

11 Programme Spinal cord injury followup programme Transition time points resulted from their brain injury. 1. Before the start of primary school 2. Before the start of intermediate school 3. Before the start of high school 4. NCEA years, towards transition to adult services. Start discussions when child is 13 years old Then yearly after this, although may need to see more frequently depending on issues, e.g. establish self catherisation, Botulinum Toxin A programme. Children who also have a brain injury as well may come under the Brain injury follow-up programme. Follow-up visits include a visit with a paediatric rehabilitation physician and/or members of the interdisciplinary team to review progress. Referrals to this service can come directly from a scheduled follow-up following a period of inpatient rehab, a referral from ACC for a client who has never entered the service (but meets eligibility criteria) or a referral received by ACC (where another health professional has identified a need for review by the CARS team). Ongoing monitoring The supplier will monitor and follow-up children and adolescents living in the community where clinically appropriate. This will minimise the risk of them not achieving planned outcomes and ensure ACC-funded supports and interventions are appropriate. The supplier s clinical staff will determine the frequency of follow-up based on the client s individual needs. It is likely to happen at key transition points and milestones and, where possible, co-ordinated with an outreach clinic to best meet the needs of the client and their family/whanau ACC staff can also contact the supplier to request follow-up appointments The supplier will maintain a database of clients for follow-up and will arrange the appointments The supplier will contact ACC at least 10 working days prior to the appointment to confirm the appointment and to request any information that may inform the review. Following up clients who do not have an active ACC case manager Many of the clients who will be followed up in the community are managed by the National Serious Injury Service (NSIS) and will have support coordinators. The remainder will be managed by the branch. Often the timeframe between follow-ups means that the case is no longer being actively managed by the branch. In these situations, the Wilson Centre should contact the provider helpline to find out whether the case is currently allocated to an ACC Case Manager. If the client does not have an active Case Manager, the service manager should contact the local NSIS Manager as the primary initial point of contact. Assessment/complex case review ACC can use Follow-up & Monitoring to refer children and young people who may not have June 2013 Page 11 of 13

12 previously entered any of the CARS services for a medical/interdisciplinary assessments/review and complex case reviews. The ACC Case Owner will contact the supplier s service manager to discuss referrals. Measuring progress The supplier will measure the client s progress using an agreed standardised scale, e.g. Paediatric Evaluation of Disability Inventory (PEDI) PEDI-CAT Functional Independence Measure for Children (WeeFIM) Canadian Occupational Performance Measure (COPM). The supplier will select the most appropriate measure/s to use with each client. The admission and discharge scores for these assessments must be included in the client s admission and discharge report. Reporting requirements The supplier must provide the following reports to ACC within the indicated timeframes. Report Information required Timeframe ACC6201 CARS Preadmission report GCS/PTA scores Functional status Specialist recommendation At least 5 working days before client is admitted to Inpatient Rehabilitation Services Service level at entry to the Wilson Centre ACC6202 CARS Admission report FIM/WeeFIM or other admission assessment Goals Within 10 working days of admission to Inpatient Rehabilitation Services Rehabilitation plan Discharge plan ACC 6203 CARS progress report Progress against rehabilitation plan Functional improvement achieved Each month from date of admission to service Description of family/whanau meetings, planned home visits Updated discharge plan Notification of scheduled case conference ACC6203 CARS progress report - to notify any change in service level Rationale for request Supporting evidence Within 3 working days of change in service level ACC6204 CARS Transition report for discharge to transition phase services Measurement of functional abilities Updated goals Supports required Transition plan Follow-up plan At least 10 working days before planned discharge date June 2013 Page 12 of 13

13 Report Information required Timeframe ACC6204 CARS Transition report for discharge to community Measurement of functional abilities Updated goals Supports required Transition plan Follow-up plan Completed Support Needs Assessment within 5 working days of discharge Finalised discharge plan at least 10 working days before planned discharge date Follow-up report Current functional status Review of rehabilitation programme Strategies and rehabilitation opportunities that will benefit the client Next follow-up appointment Within 10 working days of the appointment June 2013 Page 13 of 13