The Rehab Process

• Admission
• Assessment
• Goal Setting
• Timetable
• Discharge Planning

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Admission

Where possible, patients are admitted Monday to Friday between the hours of 9am and 5 pm

Teams
As far as possible, staff work in 2 teams - red or blue.
On admission patients are allocated into either red or blue team.

Orientation
As soon as is practical, patients and carers are offered the opportunity to look around the unit with a member of staff to help orientate themselves.

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Assessment

Within 24 hours, all patients will be assessed by:

• Doctor
• Nurse
• Occupational Therapist
• Physiotherapist

 Based on this assessment:

• Appropriate equipment will be ordered / provided
• Risk assessments will be completed for manual handling and falls in addition to anything highlighted by the assessment
• Referrals to other professionals can be made (if required) e.g. Speech and Language Therapist, Social Worker.
   

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Goal Setting

Admission Meeting
Within 7 days of admission, each patient has an admission meeting.

This is an opportunity for the whole team to meet. The patient is also given an opportunity to invite someone to the meeting for example a carer, relative or friend. The rest of the team is made up of staff involved in their care this can include: Doctors, Nurses, Occupational Therapists, Physiotherapists, Speech & Language Therapists or Rehabilitation Assistants.

At this point we can discuss assessment findings, progress so far and patient / carer expectations. Using this information, the patient can then be supported to set realistic goals for the future.

Rehabilitation Folder
Each patient will have a folder including:

• Information to help orientate the patient to their environment
• Their individual timetable of activity for the week
• Their overall goals for example "to return home" or "to go back to work"
• Smaller goals which will help them achieve overall goal for example "to walk 10m without assistance" or "to dress themselves independently"
• Activities to support their rehabilitation for example "exercises to do in gym" or "a dressing routine to follow"

  

A Rehabilitation Assistant & patient using a rehabilitation file

Weekly Goal Review Meeting
All goals are reviewed throughout the week with the patient and this information is fed back by the team in a weekly Goal Review Meeting.

Patients are not present, however a ward round takes place prior to, or following if patients wish to discuss anything specific with their Doctor.

Case Conference
A case conference is meeting between the team working with the patient and the patient themselves.

Case conferences are arranged at regular intervals during an admission to support communication between patient, staff, carers and family as well as to aid discharge planning. These are ideal opportunities to ask questions however; staff are always available to speak with patients, carers or family members throughout the working week.

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Timetable

Patients are involved with formulating an individual timetable based on their needs. This is dependant on available staff on the unit and the other demands on the service.

Therapeutic washing and dressing
Patients will have allocated staff in the morning, they may be Nurses, Occupational Therapists, Rehabilitation Assistants or Physiotherapists, depending on an individual patients needs.

Meal times
All patients, where possible, are encouraged to make their own way to the dining room for meals. Visitors are requested to avoid meal times.

Routine
Some patients may have specific daily routines. For example they may become more fatigued in the afternoon, in which case they should make staff aware so that their timetable can be modified where possible.

Practice
Patients participating in Physiotherapy, Occupational Therapy and Speech and Language Therapy will have specific activities to practice. These can be found in patients individual Rehabilitation Folders. The specific activities are done with the patients Rehabilitation Assistants, carers, family members or independently. Clear instructions on how each activity should be done will be provided by the patients therapists.

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Discharge Planning

Discharge planning begins shortly after a patient is admitted, it may include:

An access visit
By an Occupational Therapist. This is to assess the access to, and layout of the property a patient is to be discharged to. This helps to decide is any specialist equipment or adaptations are required.

Ordering of equipment
For example

• Hoist
• Chair raises
• Grab rails
• Stair rails

Home visits
With the patient are undertaken by an Occupational Therapist and (where appropriate) a Physiotherapist. This is not a test, but an opportunity for the patient to "dry run" their daily routine at home. This might include: 

• Ensuring a patient can access the property
• Getting on & off chairs / toilet / bed
• Practicing the stairs
• Meal / hot drink preparation
• Allowing patients and their carers to highlight any areas of concern
• Identifying any adaptations / equipment that may be required
• Practice in the use of any special equipment e.g. hoist
   

An Occupational Therapist assessing access to property and kitchen tasks on a home visit
 

Referral to other professionals
For example Social Services for support at home or advice about benefits

Carer training
This can be provided across a range of areas:

• Safe manual handling
• Use of specific equipment. For example a hoist
• Maintenance programs. For example cognitive strategies or stretching regimes

Day leave
Once the patient is ready for time away from the unit, day leave can be arranged for a Saturday or a Sunday. This can only happen once the team are satisfied that there is suitable access to the property the patient is being released to.

Weekend leave
This allows patients to spend time at home over a weekend, returning to the unit for rehabilitation during the week.

This usually occurs after successful day leave and can only be put in place when it is clear that the patient can be transferred safely, any equipment or adaptations are in place and carers have been adequately trained.

Weekend leave is an opportunity to put newly acquired skills into practice at home. It is also an opportunity to identify any possible difficulties to allow for a safe and trouble free discharge.