Community Rehabilitation and Supported Discharge

Transcription

1 Community Rehabilitation and Supported Discharge North Cork Community Rehabilitation and Support Team (CRST)

2 The North Cork Community Rehabilitation and Support Team (CRST) was set up in late CRST see clients with acute neurological conditions or who have had falls with fractures or become deconditioned following prolonged hospital stay.

3 CRST Team

4 The team consists of a physiotherapist, an occupational therapist and a nurse (all 0.8 WTE), a speech and language therapist (0.5 WTE) and two rehabilitation assistants (both 1.0 WTE). Dr Ciara McGlade Consultant Geriatrician, provides input from Mallow General Hospital. She attends team meetings regularly and reviews clients in her clinic.

5 The Team are based in the Gilbert Centre in Mallow, a multipurpose, multi agency building.

6 CRST rehabilitation gym

7 WHO definition of neuro-rehab is a problem solving process in which the person who experiences a neurological impairment or loss of function acquires the knowledge, skills and supports needed for their optimal physical, psychological, social and economic function

8 Aims of CRST CRST aim to facilitate early supported discharge of clients from acute hospitals and continue rehabilitation in the community. CRST provide intensive rehabilitation in the home and in the Gilbert centre. CRST support the client to regain independence in functional activities. CRST also encourage clients to link into local services and/or community groups for social support.

9 National Rehabilitation Strategy Diagram taken from the national policy and strategy for the provision of neuro rehabilitation services in Ireland published by the Department of Health in 2011

10 Referral Criteria Client must be medically stable and over 18. Be willing and able to participate in a rehabilitation programme. Require input from two or more disciplines. Have insight into personal safety or be supervised by someone at home. Live in a safe environment. Be registered with a local GP. Live within a 15 mile radius of Mallow or be able travel to the rehab gym in the Gilbert Centre in Mallow.

11 Referring conditions 2012/13

12 Referral Sources Mallow General Hospital (MGH) Primary Continuing & Community Care (PCCC) Cork University Hospital (CUH) St. Finbarr s Hospital (SFH) South Infirmary Victoria University Hospital (SIVUH) National Rehabilitation Hospital (NRH) Mercy University Hospital (MUH) Bon Secours Hospital Croom Orthopaedic Hospital Kerry General Hospital (KGH)

13 Source of Referrals 2012/13

14 Referral pathway On receipt of referral, clients are assessed either in the referring hospital, their own homes or the rehabilitation gym. Goals are agreed with the person. A daily home rehabilitation programme is set up by the therapists and supervised by the rehab assistants. Neuro clients are also seen twice weekly in the rehab gym by physio,, OT, SALT, and PHN as required. The period of rehab varies from 3 weeks to 3 months depending on the client s s needs and individual goals.

15 Referral Pathway Many clients and their carers need a lot of support during the transition from acute care to home. CRST support the individual and their carer to problem solve difficulties which arise during the transition home. A team meeting is held weekly to discuss progress and review goals.

16 Community Integration CRST aim to link clients in with local community services to maintain social contact and reduce the risk of isolation. Many of the clients live in isolated rural areas with little or no public transport. CRST help clients explore options around returning to driving, work with clients and carers to improve car transfers and/or accessing community transport schemes The Irish Wheelchair Association (IWA), Headway and National Council for the Blind Ireland (NCBI) all provide services in the Gilbert Centre building where CRST are located.

17 There is also a wheelchair accessible gym in the building which can be used by former clients on an ongoing basis. Access to the Motomed exercise bike is also available by appointment once or twice weekly. CRST support the North Cork Stroke Support Group which has monthly meetings in the Gilbert Centre. A Social Communication Group is ongoing for clients with aphasia to practice their communication skills in a safe environment. On discharge clients are referred to their local primary care team for ongoing support and rehabilitation as required.

18 Case Study

19 Case study 45 year old female Mary Attended MGH with cardiac symptoms. Transferred to CUH for management of cardiomyopathy and atrial fibrillation Left MCA infarct managed with thrombolysis. Transferred to NRH for inpatient rehabilitation.

20 Referral Pathway Pre Discharge Referred to CRST on admission to NRH. OT home visit assessment completed to facilitate weekend leave from the NRH. Mary and her family made aware of the CRST service and support available on discharge. OT recommended minor home adaptations and applied for funding to provide adaptive equipment to optimise Mary s s independence and safety in her home.

21 Rehabilitation Pathway post Discharge Mary and her husband attended the rehabilitation gym in the Gilbert Centre. Mary assessed by SALT, Physio,, OT and PHN to identify rehab goals. Examples of goals identified: to improve verbal communication, independent outdoor mobility, to cook family meals, to access local shops, bank etc.

22 OT setup home programme to facilitate Mary s s return to independence with personal ADLs,, cooking and household tasks. SALT saw the client twice weekly to work on apraxia, receptive and expressive language skills. She also requires work on letter formation and spelling. (She is using her non-dominant hand) Mary attended the CRST gym twice weekly to work on balance, endurance, strengthening and mobility. PHN liaised with the IWA to organise a PA service to enable her to access shops, the bank, hairdresser etc.

23 Home support The MTA visited Mary 5 days per week to supervise home programme. Helped setup of cooking tasks and to support Mary to use her affected upper limb in functional tasks. Supervised home exercise programme and practised outdoor mobility in her local neighbourhood. Practised speech therapy homework.

24 Community Integration Mary has been linked in to Headway, the IWA and the North Cork Stroke Support Group and she attends the wheelchair accessible gym. Mary s s PA assists her in the community for example they complete the weekly grocery shop, visit the bank etc. Mary has been referred to her local primary care team for ongoing rehabilitation and support. Mary has been linked to the return to driving pathway through the IWA in Blackrock.

25 How to contact CRST CRST office The Gilbert Centre Fair Street Mallow Co.Cork Telephone: Fax: