International Journal of Integrated Care (Aug 2019)
Supporting Patients through the rehabilitation continuum of care: The NRH Pre-admission Coordinator
Abstract
The National Rehabilitation Hospital (NRH) is a tertiary provider of rehabilitation. The Brain Injury Programme (BIP) provides in-patient specialist rehabilitation to people following an acquired brain injury. The national demand for this service far exceeds the number of beds and resources available. Because of a lengthy waiting list of patients with diverse and complex rehabilitation needs, the waiting time for admission has been extensive, i.e. waiting longer than 12 months. Patients have been admitted to the incorrect stream of rehabilitation or admitted inappropriately and there has been poorly coordinated continuity of care throughout the entire rehabilitation process. The absence of service provision for those waiting for admission has resulted in distressed families and referrers and a high percentage of delayed discharges in both the acute sector and the rehabilitation setting due to late collaboration with community and primary care services. In 2016, it was identified that a solution to the fragmented arrangement of services to patients with acquired brain injury was required. As a result, the Preadmission Service at NRH was established to optimise the transition of care from acute through to community settings including rehabilitation and discharge. The service aims to meet the standards set out by the National Waiting List Management Protocol 2014. The preadmission service collaborates directly with the patient and their family when appropriate, plus a wide range of clinicians and agencies. The preadmission service is improving patient outcome across several domains that can be described qualitatively and quantitatively. The effect is a reduction in waiting times for admission, the provision of effective intervention while waiting for admission and reducing the numbers of delayed discharges plus returns to the acute setting.
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