Background paper 9: Rehabilitation services

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1 Background paper 9: Rehabilitation services Current services Townsville Health Service District (HSD) provides all rehabilitation services for the District. Within the District, a number of Institutes contribute services including the Institute of Medicine (inpatient rehabilitation), and the Institute of Primary Health and Ambulatory Care (through community services). There are no private service providers. The rehabilitation unit provides a range of services including: inpatient rehabilitation day rehabilitation spinal, amputee and general rehabilitation clinics North Queensland Spinal Service Transition Care Program. Allied health services provided for rehabilitation services are currently managed by the Institute of Support Services operating under a service agreement. This paper is focussed on services delivered at The Townsville Hospital. Rehabilitation services delivered at other facilities and in community health settings are essential to the successful delivery of rehabilitation across the continuum of care. The development of these services should be addressed in other planning processes. Current and future demand Current supply of services The supply of designated adult overnight rehabilitation has increased over the last four years from 5,245 bed days in 2004/05, an equivalent of 16 beds (calculated at 90% occupancy), to 7,446 designated rehabilitation bed days in 2007/08, equivalent to 23 beds (at 90% occupancy). Table 1: Supply of designated adult (15 years+) overnight rehabilitation, 2004/05 to 2007/08. Year Bed days Beds 2004/ / / / Source: Queensland Health Admitted Patient Data Collection. Note: Beds calculated at 90% occupancy. Information from the service providers suggests that almost half (46%) of these patients were recovering from a stroke, 15 per cent from a neurological condition (primarily acquired brain injury), 14 per cent from spinal injuries, and 10 per cent from amputations. Orthopaedic rehabilitation services are currently restricted to those with complex multi-trauma. Patients aged between 15 and 64 years accounted for 69 per cent of designated rehabilitation bed days in 2007/08. In addition to the 23 identifiable beds of activity in 2007/08, there were a substantial number of non designated rehabilitation bed days in acute medical and surgical separations (Table 2). This activity is defined as all bed days over 10 days in rehabilitation sensitive Diagnostic Related Groups, as detailed in the methodology section of this paper. Page 1 of 6

2 Table 2: Estimated adult rehabilitation bed days (at 90% occupancy) in acute medical and surgical Service Related Groups, 2007/08. Service Related Group Bed days Orthopaedics 2914 Neurology 2970 Neurosurgery 1053 Endocrinology 850 Vascular Surgery 504 Immunology & Infections 488 Non Subspecialty Surgery 293 Non Subspecialty Medicine 370 Other medical and surgical 716 Total Sum of Days >10 10,158 Note: Based on analysis of Queensland Health Admitted Patient Data Collection, see Appendix 1 for details. The majority of non designated rehabilitation was on the orthopaedic and neurology wards, and reflect a lack of access to the rehabilitation unit. Projection methodology Queensland Health has nominated occupancy rates and planning benchmarks for the service planning of inpatient beds, chairs and spaces to facilitate a consistent approach to determining bed numbers. In moving towards a more consistent service planning methodology Queensland Health is going through the process of formally endorsing these benchmarks. Occupancy rates are a measure of bed utilisation in relation to the total bed capacity of a service, facility or ward. In order to future proof services (allowing for high and low seasonal activity, and for future increases in activity) no unit is ever planned to be occupied at 100 per cent (all beds occupied at all times). Projected sub acute services are planned at 90 per cent occupancy. Planning rehabilitation beds at these occupancy rates means that the expected activity is accommodated, whilst allowing extra capacity to accommodate peaks in demand. For example, a service with a projected requirement for 36,500 bed days in 2016/17 would require 100 beds if all beds were occupied all the time (100% occupancy). The same service would require 111 beds to achieve 90 per cent occupancy. It is important to note that the bed numbers are based on actual or projected activity, and do not represent the physical number of beds available. Further details of the projection methodology, data sources and assumptions are included in Appendix 1. Future demand and supply and projected bed requirements Based on the population based planning benchmark, the Townsville HSD will require 79 rehabilitation beds by 2016/17. Projections of demand by patient diagnostic group indicate that 19 stroke, 12 orthopaedic and 12 neurological rehabilitation beds will be required (Table 3). Further details of the assumptions and methods for estimating the clinical stream activity are provided in the methodology Appendix 1. Table 3: Projected rehabilitation beds by rehabilitation service stream, 2016/17 Page 2 of 6

3 Diagnostic group Beds Stroke 19 Amputees 5 Orthopedic 12 Neurology (acquired brain injury) 12 Spinal 6 TTH total 54 Extended rehabilitation (Parklands) 13 Other (off site) 6 HSD total 73 Note: See Appendix 1 for details of analysis. Note that the projected 13 beds required for extended rehabilitation will be established at the Parklands Facility. The remaining six beds (from the total of 79 projected) should be developed at other District facilities. Service issues The rehabilitation service cannot meet the current demand for rehabilitation at The Townsville Hospital, resulting in delayed commencement of therapy and longer lengths of stay for patients on acute wards. A lack of capacity in community services to provide top up rehabilitation for patients whose condition has deteriorated places additional pressure on the day rehabilitation program at The Townsville Hospital. Substantial demand is projected for stroke and orthopaedic rehabilitation services, with 19 stroke rehabilitation beds and 12 orthopaedic rehabilitation beds required by 2016/17. Organised stroke care has been demonstrated to significantly improve patient outcome and reduce hospital length of stay, but this model of care has not been implemented at The Townsville Hospital. There is a need for culturally appropriate acquired brain injury rehabilitation services for Townsville HSD residents. There is limited rehabilitation capacity in other District facilities, increasing the demand for services at The Townsville Hospital. A proportion of rehabilitation patients would benefit from extended rehabilitation. Government have also committed to enhancing rehabilitation and sub-acute capacity in the District by establishing 30 extended rehabilitation beds at Parklands, Townsville to open in This development is contingent on the residential aged care beds currently held at Parklands being transferred offsite. Strategies Increase the number of designated rehabilitation beds at The Townsville Hospital by up to 37 by 2016/17 to improve access to the service and meet the projected demand. Re-designate acute orthopaedic and neurological beds to rehabilitation services to fast track rehabilitation. o Transfer up to nine orthopaedic beds to the rehabilitation service to establish a 12 bed ortho-rehabilitation service by 2016/17. Page 3 of 6

4 o Transfer up to five neurological beds (primarily for patients with acquired brain injury) to the rehabilitation service to establish a 12 bed service by 2016/17. Increase the capacity of multi-disciplinary rehabilitation services (including facilities such as gyms) to meet the projected demand for this service. Integrate acute and rehabilitative services for the treatment of stroke patients. Designate up to nine acute stroke beds and up to 19 stroke rehabilitation beds to this service by 2016/17. Support and promote early initiation of rehabilitation in acute wards. Develop greater linkages with statewide services for patients with spinal and acquired brain injury to; better support initial management of patients locally, facilitate greater access to Brisbane based services and investigate options for step down services locally. Review the requirement for developing of spinal and acquired brain injury units at The Townsville Hospital post delegation of spinal and acquired brain injury as a statewide service. Work with other facilities to increase the rehabilitation capacity across the District. Work with private sector to transfer residential aged care services from Parklands and commence refurbishment of facility for an extended rehabilitation service. Continue the planning and development of rehabilitation across the continuum of care to ensure the integration of services. Page 4 of 6

5 Appendix 1 Projection methodology and assumptions Data sources Current rehabilitation activity was sourced from the Queensland Health Admitted Patients Data Collection (QHAPDC). Planning benchmarks were applied to the Population Projections, Queensland, 2008 Edition, Medium Series by age and sex, produced by the Planning Information and Forecasting Unit, Department of Infrastructure and Planning (PIFU). Information on the proportion of diagnostic groups receiving rehabilitation was sourced from the Townsville Health Service District. Planning benchmarks The Queensland Statewide Rehabilitation Medicine Services Plan recommends a planning benchmark of 19 public and 11 private rehabilitation beds per 100,000 population. In the absence of a private service provider in Townsville, a benchmark of 30 rehabilitation beds per 100,000 projected population was applied. A substantial proportion of rehabilitation activity occurs in acute separations and is not identifiable in QHAPDC. Rehabilitation occurring in acute separations was estimated using the method set out in the Queensland Statewide Rehabilitation Medicine Services Plan This method assigns all bed days beyond day 10 in acute rehab sensitive separations as rehabilitation activity. This approach provides a proxy measure of patients requiring rehabilitation focussed care and identifies those patients who are more likely to be requiring sub acute care in a designated rehabilitation unit who are still located in an acute bed. Rehabilitation beds are calculated at 90 per cent occupancy (bed days/328.5) for consistency across reporting periods. For projected activity, this creates a notional 10 per cent buffer in bed capacity to allow for peaks and troughs in activity over the year. Assumptions The future supply of rehabilitation in Townsville was assumed to be 100 per cent public. Patient diagnostic groups were assumed to continue to account for the same proportion of designated rehabilitation bed days in 2016/17 as they did in 2006/07, as detailed in the following table. Table 4: Per cent of rehabilitation bed days by patient diagnostic group, 2006/07. Per Diagnostic group cent Stroke 46 Neurology (acquired brain injury) 15 Spinal 14 Amputees 10 Orthopaedic (multi-trauma) 7 Other 9 Source: Townsville Health Service District, Page 5 of 6

6 To project the future supply of acute rehabilitation activity, the per cent of acute neurology (50%) and orthopaedic (32%) rehabilitation bed days in 2007/08 was assumed to apply to projections for those services in 2016/17. As 66 per cent of the projected orthopaedic rehabilitation bed days are for patients aged 70 years and older, the number of orthopaedic rehabilitation beds was discounted from 18 to 12 to avoid duplication of activity with the orthogeriatric service. The overall benchmark number of beds for 1016 was discounted to account for the development of six beds in other facilities in the District. Extended rehabilitation was defined as rehabilitation activity over 90 days, however it is understood that patients requiring this service may be identified prior to 90 days. The demand for this service should be reviewed as additional data becomes available. Well organised stroke care has been shown to reduce hospital length of stay by up to 27 per cent, 1 with the greatest reductions in length of stay observed for units combining acute and rehabilitative care. 2 The projection of non designated stroke rehabilitation activity on The Townsville Hospital neurology ward indicated that up to four beds could be re-assigned for rehabilitation by 2016/17, representing a potential saving of four beds with the integration of the acute and rehabilitation stroke services. Given that reductions in length of stay are influenced by a wide range of factors, a more conservative saving of two beds has been factored into projections. This should be reviewed once the service is well established. The two beds have been allocated to the rehabilitation service to meet the projected demand from other diagnostic groups. 1 Schouten L, Hulscher M, Akkermans R, van Everdingen J et al Factors that influence the stroke care team s effectiveness in reducing the length of hospital stay. Stroke; 39: Foley N, Salter K, Teasell R Specialised stroke services: a meta-analysis comparing three models of care. Cerebrovascular diseases; 23(2-3): Page 6 of 6

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