Guidelines. for. Allied Health - Resources required. for the provision of. Quality Rehabilitation Services. Version 10 July 2007

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2 Guidelines for Allied Health - Resources required for the provision of Quality Rehabilitation Services Version 10 July 2007 Prepared by the Allied Health in Rehabilitation Consultative Committee This is a WORKING DOCUMENT. Please ensure that you have the most current version. Contact list for verification appears Page 2. 1

3 Preamble The following guidelines have been developed with the co-operation of eight Allied Health Professional Associations under the auspices of the Allied Health in Rehabilitation Consultative Committee. The Allied Health Professional Associations involved, and the contacts for verification of this version are: Australian Association of Occupational Therapists Liz Howard Austin Health Royal Talbot Rehab Centre Eddie Taalman Southern Health Continuing Care Sector Kingston Centre Australian Association of Social Workers Jill Feltham Barbara Wier Australian Orthotic Prosthetic Association Joanne Pugh Australian Physiotherapy Association Janne Williams Sousan Radwan Australian Podiatry Association Stephen Tucker Australian Psychological Society Gloria Smith-Tappe Austin Health Royal Talbot Rehab Centre Southern Health Rehab and Aged Services Program Royal Childrens Hospital Southern Health Continuing Care Sector Kingston Centre Southern Health Continuing Care Sector Kingston Centre St Vincent s Hospital stephen.tucker@svhm.org.au Austin Health Royal Talbot Rehab Centre gloria.smith-tappe@austin.org.au Dietitians Association of Australia Pauline Cooper Southern Health Continuing Care Sector Kingston Centre pauline.cooper@southernhealth.org.au Claire Martin Royal Melbourne Hospital Royal Park Campus claire.martin@mh.org.au Speech Pathology Australia Cathy Naismith Caulfield General Medical Centre c.naismith@cgmc.org.au Ruth Townsend Austin Health Royal Talbot Rehab Centre ruth.townsend@austin.org.au Chairman Wendy Hubbard Ballarat Health Services wendyh@bhs.org.au This is a WORKING DOCUMENT. Please ensure that you have the most current version. Contact list for verification appears Page 2. 2

4 These professional bodies and their representatives have undertaken a major consultative process within their members to prepare this document, which provides guidelines for staffing requirements by each of the represented disciplines in each of the specialties appearing in the rehabilitation patient group. They are considered by the Allied Health Rehabilitation Consultative Group as consensus practice statements of the resource requirement to carry out quality, team-based, time limited and goal directed treatment to maximise functional outcomes for rehabilitation clients. For ease of application of the guidelines, the recommended EFT appear as the second part of the document in table form. Within the table rehabilitation is divided into Specialist rehabilitation programs for diagnostic categories which are high complexity, high cost, low frequency (eg. Spinal, Burns etc), and rehabilitation programs which incorporate the broad range of services for higher frequency diagnostic groups. Within the body of the table is the suggested EFT per 10 patients for each of the allied health disciplines - on the left column, on the right. When using the table, it is suggested that the average annual number of beds allocated to a specific diagnostic group be multiplied by the EFT/10 to provide the recommended EFT. For example a 30 bed ward with an average of 7 amputees, 14 orthopaedic and 9 neurological patients requires (7 x 1.5/10) + (14 x 1.0/10) + (9 x 1.5/10) or 3.8 EFT physiotherapists. Diagnoses included in the broad categories appear in Appendix 1. It should be noted that when considering the notional 10 patients, their varying status should be acknowledged in the EFT estimate (ie. Not all 10 patients should be considered to be requiring highest intensity therapy) Grading of EFT It should be noted that in general when Grade 1 staff are specified but actual positions in an organisation are sole positions, they should be allocated at Grade 2. Please liaise with the discipline representative if unsure. The introduction of Grade 4 therapists in Victoria has not been taken into account when devising the EFT table. Consideration of substitution of Grade 3 to Grade 4 should be made in the context of the complexity and specialisation of the anticipated caseload Validation of the recommended EFT through comparison with current practice was undertaken through consultation with rehabilitation providers across the state of Victoria including the specialised rehabilitation areas within: Austin Health Royal Talbot Rehabilitation Centre Ballarat Health Sevices Barwon Health Bendigo Health Care Group Bethesda Rehabilitation Service (now Epworth Healthcare) Bundoora Extended Care Centre Caulfield General Medical Centre Cedar Court Healthsouth (now Epworth Healthcare) Donvale Centre Hampton Rehabilitation Hospital (now Southern Health Continuing Care Sector Kingston Centre) Kingston Centre (now Southern Health Continuing Care Sector Kingston Centre) Melbourne Extended Care and Rehabilitation Service (now Royal Melbourne Hospital, Royal Park Campus) These consultations continue, with review planned annually. This is a WORKING DOCUMENT. Please ensure that you have the most current version. Contact list for verification appears Page 2. 3

5 ALLIED HEALTH DISCIPLINE ROLE STATEMENTS FOR REHABILITATI What follows are rehabilitation role statements for each of the Allied Health disciplines represented on the Consultative Committee. Although some Centres provide interventions by disciplines not represented on the committee, it is not within the scope of this document to cover the roles and EFT levels of those disciplines. Dietetics In the rehabilitation setting, there is a wide range of co-morbidities which require dietetic intervention in addition to the primary reason for admission. These co-morbidities include: malnutrition and malnutrition risk, swallowing and feeding difficulties, cardiovascular disease, newly diagnosed or unstable diabetes, renal disease, pressure wounds, gastrointestinal diseases/disorders and obesity. Dietary management of co-morbidities is often required before other therapies can optimise improvement of functional and psychological status. Dietitians provide specialised assessment and individualised nutrition care plans for rehabilitation patients. Nutrition care plans involve consultation with other rehabilitation team members, liaison with Food Services, provision of therapeutic diets, oral and enteral nutrition support and individualised dietetic counselling. Dietitians are also specialists in nutrition education and goal setting for clients and their families/carers. The Australasian Faculty of Rehabilitation Medicine recognises that the majority of patients in a Rehabilitation Medicine Service will require input from dietitians (AFRM Standards 2005). Occupational Therapy Occupational therapy works in the context of a client s stage of life and environment to promote health and wellbeing, independence and productivity. Occupational Therapy is indicated where the person s health condition, possibly in association with physical, social or attitudinal barriers within the environment limits the ability to carry out activities of everyday life and/or restricts the ability to participate in social, vocational or recreational activities. The aim of intervention is to increase the person s engagement in self-care, productivity and leisure activities within the context of their social and physical environment, and to maximise their physical, cognitive, affective and spiritual function. Therapy may be provided individually or in group settings. Intervention includes assessment and program planning, education and training / retraining, remedial techniques, compensatory strategies and environmental adaptation and discharge planning. Potential outcomes are that the person s self management, occupational skills, range of involvement, and motivation are maximised, occupational dysfunction is minimised, the person is reintegrated safely and effectively into his / her environment and the person has adapted optimally to the level of performances achieved. Physiotherapy Physiotherapy is a key component of multidisciplinary rehabilitation services. Physiotherapy intervention plays a significant role in the treatment of a wide range of diagnostic groups including neurological, musculoskeletal, cardiovascular, mental health, falls and balance, continence, pain management, amputees and chronic diseases. Rehabilitative Physiotherapy is provided in different settings including in patient, subacute ambulatory and home based. This is a WORKING DOCUMENT. Please ensure that you have the most current version. Contact list for verification appears Page 2. 4

6 Physiotherapy programs are based on functional goals designed to facilitate the patient s physical recovery, minimise length of hospital stay and maximise the patient s ability to reach optimal levels of function and independence. The physiotherapist is involved with the education of clients, carers and other health professionals. Podiatry In a rehabilitation setting, podiatrists are involved in care planning, clinical interventions and education for patients with issues relating to the status of their feet. Foot health can impact on the overall health status of a client in terms of mobility, comfort, the ability to participate in weight-bearing rehabilitation activities and the likelihood of new complications arising like pressure areas and ulceration. Podiatrists consult to specialist clinics or to clients with special needs like those with diabetes, vascular disease or arthropathy. They are generally involved in primary care and assessment including vascular, neurological, musculoskeletal, biomechanical, balance and mobility, footwear assessment and education, prescription and provision of insoles both palliative and functional, wound management and pressure relief for ulceration, foot care education and discharge planning. Prosthetics/Orthotics In the rehabilitation setting the Orthotist Prosthetist is predominantly involved with service provision to those patients with musculoskeletal issues. Appropriate planning and timely intervention assist with the provision of other Allied Health treatments and ultimately discharge. Education of patients / families / other staff involved in treatment / management regarding donning, doffing, effective use, wearing regimes, care and maintenance of the orthosis / prosthesis and problem solving is inclusive in the Orthotic / Prosthetic treatment. Psychologists in rehabilitation settings assess, monitor, treat and assist in the management of a range of cognitive, behavioural and adjustment difficulties. Interventions may be offered to individual patients, patient groups or family groups as appropriate. Psychologists working in rehabilitation usually specialise in either Clinical or Clinical Neuropsychology. Clinical/Health Psychologists specialise in the prevention, diagnosis or treatment of serious psychological difficulties with the aim of helping rehabilitation patients, carers and rehabilitation teams to address their situation effectively and adaptively. Assessments and interventions may focus on adjustment difficulties, affective disorder, anxiety, challenging behaviours, poor self-care, substance abuse, eating disorders, sleep disorders or other problems involving significant psychological disturbance. Where psychopathology cannot be managed in the rehabilitation setting, the clinical psychologist will assist in the identification of and referral to appropriate alternative service providers. Clinical Neuropsychologists provide specialist assessment and intervention for rehabilitation patients with known or suspected neurological disorders or acquired brain injury Assessments may focus on diagnostic issues, cognitive strengths and weaknesses or competency issues. Clinical neuropsychologists document and provide feedback about their assessments to patients, families and treating teams as appropriate to assist the understanding and management of cognitive difficulties. Clinical neuropsychologists also assist in the design and implementation of cognitive behavioural management programs, in designing compensatory strategies for this group of patients, providing psychotherapeutic interventions to facilitate emotional adjustment, assist with return to work or study, and patient reintegration into the community. This is a WORKING DOCUMENT. Please ensure that you have the most current version. Contact list for verification appears Page 2. 5

7 Social Work In rehabilitation, a patient s need for social work service and the extent of service is not a simple correlate of the patient s diagnosis. Rather, social work service need and resource requirements are influenced by multiple key factors. These key factors are: The degree and extent of long term/permanent disability/high dependency and lifestyle change, especially where the diagnosis/disability is unexpected and age/lifestyle atypical The degree and extent of personal/family/significant other crisis reactions in response to the diagnosis/disability/lifestyle changes and/or other non health related problems The existence of non health related personal, social or environmental problems/issues which negatively impact upon the patient or their family/significant others The availability of and ease of access to required resources to support the patient/family/significant others and establish ongoing adequate coping strategies In general, the greater the presence of the above-mentioned factors the higher the need for and extent of social work services which will be required. Social Work interventions in rehabilitation include psychosocial assessment, counseling, crisis intervention, bereavement intervention, education and information, case management/discharge planning, service co-ordination, liaison, referral, resourcing, advocacy, and critical incident stress debriefing. They are provided to maximise patient psychosocial functioning, and family/significant other psychosocial functioning, and to ensure patient/family/significant other awareness and access to required support services. Further, they work with the other disciplines to maximise patient/family/significant other participation in their rehabilitation and future plans, and to maximise patient/family/significant other adjustment to disability and lifestyle change. Speech Pathology The role of the Speech Pathologist in the Rehabilitation setting is concerned with provision of services to patients presenting with disorders affecting speech, oro-motor function, language, cognition and swallowing. These disorders may result from a wide range of underlying aetiologies, including stroke, traumatic brain injury, and degenerative diseases. The Speech Pathologist is responsible for the specialised assessment, diagnosis and management of these disorders. The primary focus of therapy is restoration of function, or the establishment of effective compensatory strategies and techniques. Such clinical decision making is guided by the nature and severity of the presenting deficits and services may be delivered in an individual and/or group context. In Rehabilitation, the Speech Pathologist is concerned with re-establishment of effective speech, language, cognitive and/or swallowing skills and considers the social, educational and vocational needs of the patient in setting these goals. They are also responsible for the education and training of families, carers and others staff in understanding the nature of an individual s communication, cognitive or swallowing deficit(s) and their role in the optimal management of these disorders. Exercise Physiology An Exercise Physiologist in a rehabilitation setting provides services in the area of exercise as a treatment strategy in physical rehabilitation, as a preventative strategy for disease prevention, and work hardening as part of establishing and sustaining functional independence. Treatment regimen include strength and conditioning training, functional capacity conditioning, community based gym program design and transition in to the community ongoing programs (long term lifestyle education and management). This is a WORKING DOCUMENT. Please ensure that you have the most current version. Contact list for verification appears Page 2. 6

8 Allied Health Assistant The role of an allied health assistant within a rehabilitation setting is to work under the supervision of any one or more of the allied health professionals outlined above to enhance the health outcomes of their mutual patients and clients. As part of the multi-disciplinary team, the keys areas of responsibility typically lie with physiotherapy, occupational therapy, and speech pathology. The particular tasks performed will vary according to the therapy area and will be determined by the supervising therapist. Work may include individual treatment (supervision and reinforcement of therapeutic strategies), group treatment (leading or participating), health promotion, management of equipment (eg. stock control, ordering, maintenance), administration, and environmental duties (linen changes, tidying of therapy areas). Orthotic/Prosthetic Technician The Orthotic/Prosthetic technician fabricates and adjusts orthoses and/or prostheses under the direction of a Prosthetist/Orthotist. This is a WORKING DOCUMENT. Please ensure that you have the most current version. Contact list for verification appears Page 2. 7

9 Spinal Injury (specialist) Inpatients Grade 3 Grade 2 Grade 1 Supervised Total Occupational Therapy Physiotherapy Speech Pathology (neuropsych) Podiatry Dietetics Social Work Prosthetics/Orthotics P/O technician AHA Exercise Physiology Spinal Injury Occupational Therapy Physiotherapy Speech Pathology *consult (neuropsych) *consult Podiatry Dietetics Social Work Prosthetics/Orthotics P/O technician AHA Exercise Physiology This is a WORKING DOCUMENT. Please ensure that you have the most current version. Contact list for verification appears Page 2. 8

10 Head Injury (specialist) Grade 3 Grade 2 Grade 1 Supervised Total Occupational Therapy Physiotherapy Speech Pathology (neuropsych) Podiatry *consult Dietetics Social Work Prosthetics/Orthotics *consult P/O technician 0 AHA Exercise Physiology Head Injury Occupational Therapy Physiotherapy Speech Pathology (neuropsych) Podiatry *consult *consult Dietetics Social Work Prosthetics/Orthotics *consult *consult P/O technician 0 0 Exercise Physiology This is a WORKING DOCUMENT. Please ensure that you have the most current version. Contact list for verification appears Page 2. 9

11 Amputee (specialist) Grade 3 Grade 2 Grade 1 Supervised Total Occupational Therapy Physiotherapy Speech Pathology *consult (neuropsych) *consult Podiatry Dietetics Social Work Prosthetics/Orthotics P/O technician AHA Exercise Physiology Amputee Occupational Therapy Physiotherapy Speech Pathology *consult *consult (neuropsych) *consult Podiatry Dietetics Social Work Prosthetics/Orthotics P/O technician Exercise Physiology This is a WORKING DOCUMENT. Please ensure that you have the most current version. Contact list for verification appears Page 2. 10

12 Burns (specialist) Grade 3 Grade 2 Grade 1 Supervised Total Occupational Therapy Physiotherapy Speech Pathology Podiatry *consult Dietetics Social Work Prosthetics/Orthotics P/O technician AHA Exercise Physiology 0.0 Burns Occupational Therapy Physiotherapy Speech Pathology *consult *consult Podiatry *consult *consult Dietetics Social Work Prosthetics/Orthotics P/O technician Exercise Physiology This is a WORKING DOCUMENT. Please ensure that you have the most current version. Contact list for verification appears Page 2. 11

13 Neurology Occupational Therapy Physiotherapy Speech Pathology (neuropsych) Podiatry Dietetics Social Work Prosthetics/Orthotics P/O technician AHA Exercise Physiology Orthopaedics Occupational Therapy Physiotherapy Speech Pathology *consult Podiatry Dietetics Social Work Prosthetics/Orthotics P/O technician Exercise Physiology This is a WORKING DOCUMENT. Please ensure that you have the most current version. Contact list for verification appears Page 2. 12

14 Arthritis Occupational Therapy Physiotherapy Speech Pathology *consult *consult *consult *consult Podiatry Dietetics Social Work Prosthetics/Orthotics P/O technician Exercise Physiology Pain Occupational Therapy Physiotherapy Speech Pathology *consult *consult Podiatry *consult *consult Dietetics Social Work Prosthetics/Orthotics *consult *consult P/O technician Exercise Physiology This is a WORKING DOCUMENT. Please ensure that you have the most current version. Contact list for verification appears Page 2. 13

15 Cardiac Occupational Therapy Physiotherapy Speech Pathology *consult *consult *consult *consult Podiatry Dietetics Social Work Prosthetics/Orthotics *consult *consult P/O technician Exercise Physiology Pulmonary Occupational Therapy Physiotherapy Speech Pathology *consult *consult *consult Podiatry Dietetics Social Work Prosthetics/Orthotics *consult *consult P/O technician Exercise Physiology This is a WORKING DOCUMENT. Please ensure that you have the most current version. Contact list for verification appears Page 2. 14

16 Major Multiple trauma Occupational Therapy Physiotherapy Speech Pathology *consult *consult *consult (neuropsych) *consult Podiatry *consult *consult Dietetics Social Work Prosthetics/Orthotics 0 0 P/O technician Exercise Physiology Multiple Comorbidities Occupational Therapy Physiotherapy Speech Pathology *consult (neuropsych) *consult Podiatry Dietetics Social Work Prosthetics/Orthotics *consult *consult P/O technician AHA Exercise Physiology *consult = EFT Nb. Although Allied Health Assistants maybe represented here under AHA they have no committee representation and figures are indicative only. This is a WORKING DOCUMENT. Please ensure that you have the most current version. Contact list for verification appears Page 2. 15

17 Appendix 1 Diagnostic Groups used in the table Spinal Injury Includes paraplegia and quadriplegia, both complete and incomplete Head Injury Includes acquired brain injury, particularly post-trauma Amputee Includes upper and lower extremity amputation and one or both limbs Burns Includes all patients where burns are the major reason for rehabilitation Neurology Includes stroke and degenerative neurological disorders such as Multiple Sclerosis and Parkinsons disease. Also includes polyneuropathy and Guillian-Barre and other miscellaneous neurological disorders Orthopaedics Includes fractures, joint replacements, sprains and strains. Arthritis Includes rheumatoid and osteoarthritis Pain Includes neck, back, extremity and other pain Cardiac Includes any heart condition or cardiac surgery Pulmonary Includes Chronic Obstructive Pulmonary Disease (COPD) and any other pulmonary conditions including post-pulmonary surgery Major Multiple Trauma Includes multiple trauma incorporating a number of combinations of conditions post-trauma Multiple Co-Morbidities Includes multiple complex medical and/or psychosocial issues. Often categorised as Other Disabling Impairment in the rehabilitation setting This is a WORKING DOCUMENT. Please ensure that you have the most current version. Contact list for verification appears Page 2. 16