Community Rehab Team

Kate Bradfield (Physiotherapist)Sarah McFarlane (Occupational therapist)

Team Purpose

To optimise a patient’s mobility and independence with their activities of daily living by providing a specialist short-term

rehabilitation service to patients in bedded units or in their own homes

CRISIS Consists of:

•Bed based Intermediate Care

•Intermediate Care at Home – High Priority

- Medium priority

•CPAT (Community Prevention of Admission Team)

•Currently based at The Wilson, Mitcham

•Accept adults with a Merton GP

•Age > 18 years old

•Bed based units >55 years old

Community Rehab Team• Supported Discharges and POA’s

• Bed-based Rehabilitation Units (24 beds in total)

• Home-based rehabilitation (up to three calls a day 8am- 6pm).

Woodlands House (17beds)

Carter House (7 beds)

Colliers Wood Raynes Park

Referral Sources

• GP’s (via CPAT)• Hospital Therapists• Discharge co-ordinators• Community Liaison Nurses• CPAT

• Do not accept self referrals

Types of referrals

Supported discharges

•From Acute Trust

•Referrals screened by a therapist and then placed on waiting list

Prevention of Admission (POA)

•Referred by CPAT via direct referral from GP (telephone) or Rapid Response or STAR team

•Take priority over SD referrals

Conditions not accepted

• Patients presenting with symptoms primarily due to neurological diagnoses

Need to be referred to: The Community Neuro Therapy Team The unidisciplinary Neuro

Physiotherapy Team New strokes to the Early Supported

Discharge Team

• Patients with respiratory diagnoses who require only chest physiotherapy Need to be referred to:

The Community Respiratory Therapy Team

Who is appropriate?

oMust have potential to transfer with carers/ therapy staff without use of a hoist, but could be with Molift / Re-turn / Rotastand/ Sara Stedy

oDischarge destination must be known at time of referral for bed based

oMust be medically fit for rehaboMust have rehab potential

Bed-Based Therapy

Occupational Therapists, Physiotherapists & Rehabilitation Assistants

Nurses and Carers

Monday-Friday and RA weekend cover when capacity allows

Length of stay dependant on therapists’ assessment and goal achievement – usually 2-4 weeks

Weekly MDT meetings with temporary GP & nursing staff

Home Based Rehab (high board)

• Must have both Occupational Therapy (OT) and Physiotherapy (PT) goals

• Assessed by therapist on day of discharge if home by lunchtime.

• 1-3 therapy visits daily by a rehabilitation assistant• Regular reviews by Occupational Therapist and

Physiotherapist• Increase independence in personal care, meal prep,

transfers, mobility, stairs within patients own home.

Home Based Rehab (medium board)

• Require multidisciplinary input from OT &PT

• Can be supported with up to 2 - 3 calls in a week

• Contact within 3 working days of discharge from hospital to prioritize

• Increase and progress mobility, outdoor mobility, public transport and accessing the community.

Patient journey

• Mrs H is a 78 year old female living alone with no formal care services but family support.

• Background of diabetes, OA, osteoporosis, fibromyalgia, pseudo gout, cataracts

• Referred to CPAT by her GP with reduced mobility (unable to weight bear), pain in her lower limbs and not eating and drinking for 2 days

• Diagnosed with UTI.

Assessment at Home

• Assessed by CPAT at home who referred her to bed based rehab as no hospital admission needed but not safe to stay at home.

• Admitted to bedded unit the same day • Needing assistance with personal care and

meals

On admission• Assessed by therapists, required assistance of 2

people and rollator frame to transfer. Not able to mobilise

• Barthel 8/20• Developed pressure area on heel due to

prolonged period in bed, seen by tissue viability nurse

• Liaised with temporary GP to manage pt’s pain and started antibiotics for UTI

• Rehab plan agreed with pt and daily exercise sessions commenced

Treatment

• Encouraged pt to complete personal care as independently as able

• Practiced meal preparation in breakfast group• Daily exercises• Mobility practice• Stair practice• Home visit after 3 weeks input needs identified for

discharge• Wound care

On discharge• Pt able to transfer and mobilise independently

with equipment• Managing personal care and meals

independently• Managing stairs with supervision from family• Barthel 19/20• UTI resolved, pain under control and pressure

sore had healed• Referred on to HARI for further rehab and district

nursing to monitor pressure areas• Total length of stay – 4 weeks

Contact detailsCommunity Rehabilitation TeamWilson HospitalCranmer RoadMitchamCR4 4TP

Screener’s phone: 0208 687 4593Fax: 0208 646 6408

Sutton and Merton CommunityServices Administration CentreSMCS Administration TeamPO Box 70926LondonSW19 9FS

T 0845 567 2000E rmh-tr.smcsadmin@nhs.netF 020 345 85 888

Sutton and Merton CommunityServices Administration CentreSMCS Administration TeamPO Box 70926LondonSW19 9FS

T 0845 567 2000E rmh-tr.smcsadmin@nhs.netF 020 345 85 888

CPATTel: 02082510152

Thank you