Community rehabilitation enablement support team
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Community Rehabilitation, Enablement & Support Team. An example of working smarter. Community lead Different services working together to improve patient outcomes to reduce length of stay avoid hospital admissions Working across sites and across traditional boundaries

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Community Rehabilitation, Enablement & Support Team

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Community Rehabilitation, Enablement & Support Team

An example of working smarter

  • Community lead

  • Different services working together

    • to improve patient outcomes

    • to reduce length of stay

    • avoid hospital admissions

  • Working across sites and across traditional boundaries

  • Working with older people in the Christchurch region


  • Reduced length of stay in hospital

  • Increased time spent at home over a year

  • Reduction in residential care placement

  • Reduction in the need for long term home care

  • Improvement in function

Key points

  • Responsive to patients needs

  • Provides support in patient own home to facilitate functional gains (rehabilitation)

  • Multidisciplinary approach to goal setting that includes the patient. Goals are set after an assessment in the patients own home.

  • Culturally appropriate

  • Provides supported discharge

  • Ability to see and assess patient outside the 4 walls of the hospital

  • Ideal patient needs 2 to 6 weeks of rehabilitation

Patient Flow

Joint visit

  • Joint assessment by coordinator and case manager look at

    • Confirmation of safety (environment, medication etc)

    • Full assessment using varies tools

    • Identification of any additional equipment that may be required

  • Leads to development of goal ladder and organisation of key workers to support rehabilitation activities

Case Study

Agnes has three sons and a daughter. Her sons live in Canterbury where one of them works on the family farm. Agnes and Bill moved up to live near their daughter Liz six years ago when they retired from the farm due to Bills ill health. Liz is married with three grown up children and four grandchildren. She works fulltime at a local pharmacy. Liz visits Agnes every day and brings her dinner each night.

Since Bill’s death Agnes has become a lot less active. She never had a drivers licence as Bill would drive them both around. Liz tries to take Agnes out in the car when she can but they both find this difficult now. Three months ago Liz took Agnes for dinner at a local restaurant to celebrate Liz’s 60th birthday. Agnes needed the help of one of Liz’s sons to get her in and out of the car.

After Bill’s death Agnes feels she gave up for a while. She got weaker and weaker and lost her appetite. She lost a considerable amount of weight. One night she got up to go to the toilet and fell in the bathroom. She was taken by ambulance to the local hospital where she spent three weeks recovering from a broken hip.

On her discharge from the hospital Liz wanted Agnes to come and live with her; however Agnes refused to go anywhere but back to her own home. Liz has noticed that since that time Agnes has become more and more frail. She has had four falls in the last six months. The last fall was while she was walking to the toilet, she fell and was not able to get up until Liz arrived that evening. Liz had to call her grandson to help get Agnes back into her chair. When she fell Agnes cut her shin badly.

The district nurses had to come to dress the wound. Now she still has the dressing changed weekly. Liz also has noticed that her mum is constipated and this causes her pain and discomfort. She cooks her mum a meal each day and brings it round. However Agnes’ appetite is so poor nowadays that she never finishes the meals.

Liz thinks that the time is coming where her mum will need to come to live with her. Agnes has always been extremely house proud but now Liz finds that she is having to do all the housework which is becoming more and more difficult. Liz does not know how she will cope as she has a bad back. She is scared she will hurt herself and then her mother would be in a worse situation.

  • One morning, Agnes’ 6 month old great grandchild visits and sneezes all over Agnes,

  • Within 2 days, she is in bed with a cold which quickly deteriorates into a pneumonia. Liz contacts the GP who starts on ABs but a day later, Liz visits and finds Agnes delirious and the GP advises visit to ED, upon which she is admitted to AMAU and 1 day later assessed by Jay (Liaison worker)

  • Given her past deterioration, CREST is considered and Jay informs Agnes’ GP, the CREST case manager and Agnes chooses Nurse Maude as the provider.

  • Agnes’ daughter collects her that afternoon and the team commences immediately.

CREST discharge

Commenced HBSS x 2hrs week

Grocery shopping (& coffee) with Liz by x

Attending church with friend by x

Preparing breakfast and snacks by x

Walking to dairy (450 metres) by x

One 2 hour visit x3 week

Walking to car and getting in with help by x

For pain to be 3/10 - getting in/out bed by x

To be able to defrost and heat MoW by xxx

Withdraw weekend visits

Walking to letter box independently by xxx

Dressing independently at home by xxx

Withdraw AM visits

Washing independently at home by xxx

CREST x3 a day x7

Dressing independently within 5 days

Withdraw night visits

Drawing curtains independently by x

Getting in / out of bed independently by x

Hosp. discharge

Washing independently within 3 days

Walking to toilet independently day or night by 3 days

Walking to ward doors within 2 days

Point of discharge from CREST

  • GP updated

  • NASC have become involved if long term supports required

  • Referral sent to falls prevention programs

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