university of canberra public hospital · university of canberra public hospital - model of service...

University of Canberra Public Hospital

Dear Member, As members will be aware, a new Public Hospital is opening in July 2018. This hospital has been a long time in the planning and now ACT Health are in the process of consultation in relation to impact on employees. As part of these processes the attached documents have been provided to the HSU: - Rehabilitation, Aged and Community Care, Model of Care - Service Delivery Framework - Staff FAQ If you have any questions or concerns about the establishment of this new hospital in Canberra please email HSU Industrial Officer, Julie Gordon, on [email protected] by Friday 2 March 2018. If you would like a workplace meeting organised to discuss the impact of the new hospital on you and your colleagues then please contact HSU Organiser, Sarah Gleeson on [email protected]. After receiving your feedback, the HSU will seek the establishment of a consultative forum with ACT Health in order to have the questions/concerns of members addressed.

In unity,

Gerard Hayes Secretary, HSU NSW/ACT

Newsletter: 91/2018 Date: 20 February 2018

Distribution: ACT Health Contact: Your Local Organiser

mailto:[email protected]

mailto:[email protected]

University of Canberra Public Hospital Model of Service Delivery Plan

Service Delivery Framework

August 2017

University of Canberra Public Hospital - Model of Service Delivery Plan Page i

Table of Contents

1 Purpose ........................................................................................................................................... 1

2 Introduction .................................................................................................................................... 1

3 General Services & Amenities ......................................................................................................... 1

3.1 Customer Service Reception ................................................................................................... 1

3.2 Access to the Facility ............................................................................................................... 2

3.2.1 Opening Hours ................................................................................................................ 2

3.2.2 After Hours ...................................................................................................................... 2

3.2.3 Equipment Loan Service .................................................................................................. 2

3.2.4 Loading Dock ................................................................................................................... 2

3.3 Car Parking .............................................................................................................................. 2

3.4 Patient Scheduling .................................................................................................................. 2

3.5 Room Booking System ............................................................................................................ 3

3.6 Video-Conferencing Facilities.................................................................................................. 3

3.7 Tele-Health .............................................................................................................................. 3

4 ACT Health Corporate Services ....................................................................................................... 4

4.1 ACT Health Records Management .......................................................................................... 4

4.2 ACT Health Revenue and Financial Services ........................................................................... 4

4.3 Patient Transport .................................................................................................................... 4

4.4 Disaster Response ................................................................................................................... 4

5 Clinical Services ............................................................................................................................... 5

5.1 Rehabilitation Aged and Community Care .............................................................................. 5

5.1.2 Mental Health ................................................................................................................. 5

5.1.3 Management of the Deteriorating Patient ..................................................................... 6

6 Clinical Support Services ................................................................................................................. 7

6.1 Clinical Records ....................................................................................................................... 7

6.2 Courier Service ........................................................................................................................ 7

6.3 Medical Imaging ...................................................................................................................... 7

6.4 Tissue Viability Unit and Infection Prevention and Control .................................................... 7

6.5 Pathology ................................................................................................................................ 7

6.6 Pharmacy ................................................................................................................................ 7

6.7 Aboriginal Liaison Service ....................................................................................................... 8

6.8 Administration Services .......................................................................................................... 8

6.9 Facility Wide After Hours Management ................................................................................. 8

University of Canberra Public Hospital - Model of Service Delivery Plan Page ii

6.10 Demand Management ............................................................................................................ 9

6.11 Multi Faith Services ................................................................................................................. 9

6.12 Department of Veteran Affair’s Liaison Service ...................................................................... 9

6.13 Bio Medical Engineering ......................................................................................................... 9

6.14 Equipment Loan Service .......................................................................................................... 9

6.15 Central Equipment Store ......................................................................................................... 9

6.16 Body Holding ......................................................................................................................... 10

7 Business Support ........................................................................................................................... 11

7.1 Café ....................................................................................................................................... 11

7.2 Linen ...................................................................................................................................... 11

7.3 Waste Management ............................................................................................................. 11

7.4 Volunteers ............................................................................................................................. 11

8 Facility Management Services ...................................................................................................... 12

8.1 Contract Management and Administration Services ............................................................ 12

8.2 Facility Management (FM) Help Desk Services ..................................................................... 12

8.3 Building Engineering Maintenance (BEM) Services ............................................................. 12

8.4 Grounds and Gardens Maintenance Services ....................................................................... 12

8.5 Food Services ........................................................................................................................ 12

8.6 Distribution and Patient Support Services ............................................................................ 12

8.7 Cleaning Services................................................................................................................... 13

8.8 Materials Distribution Services ............................................................................................. 13

8.9 Pest Control Services............................................................................................................. 13

8.10 Security ................................................................................................................................. 13

9 University of Canberra .................................................................................................................. 14

9.1 Faculty of Health ................................................................................................................... 14

University of Canberra Public Hospital - Model of Service Delivery Plan Page 1

1 Purpose

The purpose of this document is to outline the Model of Service Delivery (MoSD) as a principle framework for the operational of services at the University of Canberra Public Hospital (UCPH).

A MoSD has been developed to describe the full range of services being delivered at UCPH, including existing services which are transferring to the new consolidated outpatient facility and those services which are new initiatives for the CHHS. UCPH will be a custom designed sub-acute outpatient facility which is focuses on innovative and efficient patient care in a tertiary education and teaching setting within the Health Precinct of the University of Canberra campus.

2 Introduction

The University of Canberra Public Hospital (UCPH) will be a purpose built rehabilitation hospital located on the University of Canberra campus on the corner of Aikman Drive and Ginninderra Drive, Belconnen. UCPH will form part of a planned network of ACT Health hospitals and facilities designed to meet the needs of our ageing and growing population, and Mental Health rehabilitation services.

Extensive planning has been undertaken to define the services to be provided at UCPH. This planning information is publicly available in the Service Delivery Plan and Functional Brief, both of which are available on the ACT Government ‘Time to Talk’ website. UCPH will deliver sub-acute adult care consisting of:

Mental Health inpatient rehabilitation;

Mental Health day services;

Geriatric inpatient rehabilitation; and

Day and Ambulatory services.

UCPH will not have an Emergency Department and will not deliver acute services. At full capacity UCPH will have 140 inpatient beds, 75 day places and additional ambulatory clinics and services. UCPH will open with capacity to meet the current demand in ACT and a have a staged approach to opening further beds (up to 140) to meet growing demand. UCPH will also have a hydrotherapy pool for both inpatient and outpatient therapy.

The 75 day places will allow greater flexibility for patients to access daily rehabilitation without the need to stay overnight in hospital. This will allow some patients to be discharged earlier and still receive the rehabilitation therapy they require.

The purpose of a specialist rehabilitation hospital is to deliver effective goal based treatment and rehabilitation to people whose needs cannot be met by less intensive community based services. The primary goal of treatment will be the enhancement of the person’s quality of life and improvement in their functional status through the engagement in a variety of rehabilitation services.

3 General Services & Amenities

3.1 Customer Service Reception

The customer service reception is located inside the main entrance of the facility. This main entrance provides the central access point for the Mental Health, RACC inpatient and ambulatory services including hydrotherapy.


The core opening hours for the facility is between 0600 hours - 2100 hours daily, this is consistent with The Canberra Hospital.

The reception will provide customer service advice and assistance, management of security access cards and car parking access as required.

3.2 Access to the Facility

3.2.1 Opening Hours

All access entry doors to the facility are unlocked during opening hours.

There are four main access points to the facility:

1. The main entrance;

2. Adjacent to the public transport drop off and pick up points for taxi and bus transportation;

3. The basement carpark entry; and

4. The northern entry adjacent to Adult Mental Health Rehabilitation Unit

3.2.2 After Hours

After-hours access for inpatients and members of the public will be via the main entrance utilising an assistance button. A member of the security personnel will attend to the call for assistance and provision access and entry to the facility as deemed appropriate.

After-hours entry for staff will be via the main entrance using swipe card access.

3.2.3 Equipment Loan Service

Access to the Equipment Loan Service (ELS) for patients, family/carers, visitors, staff and contractors is via a separate pick-up and drop-off point.

The ELS has designated areas for the collection of clean equipment and the return of used equipment.

3.2.4 Loading Dock

The loading dock has a dedicated entry and exit point which has restricted access for support service and delivery vehicles.

3.3 Car Parking

On site car parking at UCPH will offer 310 spaces, including bike parking, accessible parking and ACT Government vehicle parking.

A car park management plan is being developed which will define the policy for use by patients, staff, and visitors of the hospital. The car park will be controlled via boom gates and tickets machine. It is intended that patients can have their ticket validated at the main reception for the provision for free parking. Tickets which cannot be validated by proof of appointment will be charged at the rate determined, this policy will comply with the broader ACT Government policy for paid parking.

A further 400 spaces will be provisioned by the University for Canberra in a multi-storey car park.

3.4 Patient Scheduling

The patient booking and scheduling system will be designed to link with patient flow management systems used in the outpatient and ambulatory areas, such as a queue management system.


The system is capable of notifying patients of appointment times and delays on the day of their appointment. A trial of this new patient booking system is currently underway in the ACT Health Belconnen Health Centre.

Integration to other systems, such as the bed management system and patient transport systems will be investigated to support the discharge planning of patients.

A seamless facility wide process for acceptance of referrals and intake will be established, consistent with the ACT Health wide approach. The referral and intake process will be supported through ICT infrastructure and will be linked to the patient booking and scheduling system.

The specific details of the referral management processes to be used by RACC and Mental Health are defined in the Models of Care.

3.5 Room Booking System

An electronic room booking system will be available. The coordinated system will display all meeting rooms, interview rooms, clinical assessment and consult rooms to enable staff to efficiently manage most appropriate allocation of room bookings.

The room booking system will also provide the facility for non-clinical functions, for example, the scheduling of shared teaching and learning spaces.

All shared will be bookable with the exception of the Mental Health de-escalation room.

3.6 Video-Conferencing Facilities

State-of-the art video-conferencing and webcam capability will be installed into a number of the meeting rooms available for bookings, such as the Mental Health Tribunal and Guardianship Board Hearings, which enables Mental Health consumers to participate in court proceeding remotely.

The technologies also support the University of Canberra students and ACT Health clinicians in interactive simulated learning and tutorial sessions.

3.7 Tele-Health

Tele-health will be used for a range of functions including the provision of care for patients at UCPH as well as the provision of care for patients who are off-site. Tele-health will also be used for a range of teaching and training activities.


4 ACT Health Corporate Services

The existing ACT Health Corporate Services will be extended to cater for UCPH.

4.1 ACT Health Records Management

Records management will be provided by the current services operating out of Canberra Hospital.

4.2 ACT Health Revenue and Financial Services

A remote service will be provided to UCPH with all inpatient election documents and other related files for billing and revenue scanned to a centrally managed revenue and finance service with hard copies to follow.

Clinical and clerical admissions will be undertaken within the inpatient units and ambulatory/day services. There will be agreed principles for admission. A central cashier service will not be provided. Cashier and billing services will be provided remotely which is consistent with a CHHS wide approach.

Pharmacy have capability for Electronic Funds Transfer (EFT) only. Secure storage for petty cash will be provided; after-hours access will be limited to key individuals.

4.3 Patient Transport

All existing services currently being utilised throughout the territory and surroundings for transport remain as normal business, day service consumers will utilise these services as required.

If an individual’s condition is deteriorating and/or there are changes in their function, they will be assessed by the medical team based at the UCPH. In the event a patient requires emergency treatment, an ambulance will be called and the ACTAS will triage the patient and transfer them to the most appropriate emergency department.

4.4 Disaster Response

The disaster management coordination and meeting room will be located on the ground floor and will provide a disaster coordination room for ACT Health. This room will have video capability and direct links to the Disaster Coordination Room at The Canberra Hospital (Building 24). It will be equipped with multiple dedicated lines for external calls in emergency situations; multiple data access ports provisioned for computers, and dedicated storage facilities for items and equipment required for use in a Disaster Coordination Room. The management of disasters will be in accordance with the broader CHHS Disaster Response and Management Plan.


5 Clinical Services

5.1 Rehabilitation Aged and Community Care

The MoSD provides an overview of services to be provided by RACC. Details of the models of care for these services are provided in the RACC MoC. At UCPH, allied health services will be available, providing service to the inpatient and day service units.

5.1.1.1 Hydrotherapy

Hydrotherapy may be accessed by Mental Health and RACC patients at UCPH and other patients/users as detailed within the RACC UCPH Model of Care. The Hydrotherapy service is being extended to provide services to inpatients and external consumers.

The Hydrotherapy service for UCPH patients is available during business days and may be extended to weekends and after hours based on joint demand from inpatients and outpatients.

Community groups and external consumer can use the Hydrotherapy service and will use an electronic booking service for scheduling.

5.1.1.2 Inpatient Unit

The rehabilitation inpatient services will include an expanded range and capacity of services by specialist teams.

Service streams have been developed to ensure that multi-disciplinary teams with specialised therapeutic expertise can be established to best meet the care needs of patients and to facilitate continuity of service:

The service streams at full capacity are:

Neurological Rehabilitation Unit;

General Rehabilitation Unit;

Older Person’s Rehabilitation Unit; and

Slow Stream Rehabilitation Unit.

5.1.1.3 Day Service

The provision of RACC day programs at UCPH will represent a new service for ACT Health. The rehabilitation, day programs and sessional therapy to be provided at UCPH will be characterised by specialised services provided by dedicated care streams. The day program will provide an alternative to inpatient care.

5.1.2 Mental Health

5.1.2.1 Adult Mental Health Rehabilitation Unit

The Adult Mental Health Rehabilitation Unit (AMHRU) will be a purpose built rehabilitation unit. The AMHRU will include 20 beds configured in four groups of five beds and offer inpatient rehabilitation as well as placements for assessment.

It is anticipated that people will stay at the AMHRU for a period of 3 - 12 months. This broad length of stay reflects the range of needs of people, which may be difficult to predict and may require longer periods of intervention to facilitate lasting benefits.


5.1.2.2 Adult Mental Health Day Service

The new AMHDS includes 25-person capacity for treatment for adults aged 18 – 65 years and will offer programs to meet various needs including offering support services and programs to circumvent an acute psychiatric admission where possible, offer day treatment therapies, transitional support for those exiting acute services and reintegrating back into the community, provide intensive psychological therapy and extended treatment and recovery programs to meet specific consumer needs.

The primary function of the AMHDS will be to offer a multidisciplinary approach to the biopsychosocial assessment and treatment of people with moderate to severe mental illness in a supportive and recovery oriented environment. The primary goal of the service will be to optimise symptom relief, build capacity for self management and resilience, and develop skills and resources for living in the community.

The AMHDS will complement existing services and enhance available options for intensive treatment, therapy and rehabilitation available through community mental health teams, inpatient units, and the adult mental health rehabilitation unit.

5.1.3 Management of the Deteriorating Patient

Safe management of a deteriorating patient at UCPH will be undertaken as follows:

Medical emergency (e.g. acute coronary or cerebral event) – UCPH will have a first response team for medical emergencies.

Non-urgent deterioration (e.g. increased pain, deteriorating mental health, increased agitation) – assessment, intervention and monitoring by medical and nursing staff within the patient’s clinical area. This includes the development of Sub Acute Vital signs policy and Sub Acute Modified Early Warning Score (MEWS) based on interstate models.

UCPH will have 24 Hour medical cover and onsite After-Hours Nursing Managers (linked with After Hours Management at TCH)

Modified Basic Life Support training

Effective use of ICT to enable tele monitoring and tele conferencing

Appropriate selection of patients: patients who meet sub-acute admission criteria


6 Clinical Support Services

6.1 Clinical Records

The Division of Mental Health, Justice Health, and Alcohol and Drug Services (MHJHADS) currently use Mental Health Assessment Generation Information Collection (MHAGIC) database and paper records, which will be supported at UCPH.

RACC clinical records will be operational at UCPH as they currently exist. Paper records will be digitised upon discharge as per existing policies and procedures. Records will be digitised by staff based at the Canberra Hospital and stored on the Clinical Record Information System (CRIS). A regular courier service between UCPH and Canberra Hospital will support this process.

6.2 Courier Service

The courier service provided at UCPH will include courier for clinical records, mail, pathology and pharmacy. The service will provide appropriate vehicle equipped with required resources to manage the transportation of blood and blood products. The staff of the courier service will be equipped with the necessary skills and knowledge to courier these items.

6.3 Medical Imaging

Patients will be transferred off-site for medical imaging services e.g. X-Ray and video fluoroscopy or after-hours services will be undertaken via a transport vehicle.

6.4 Tissue Viability Unit and Infection Prevention and Control

It is proposed that a range of specialist skills (e.g. tissue viability and infection control) be provided at UCPH through structured training programs such as the existing tissue viability training program. UCPH staff would be invited to indicate an expression of interest to participate in a CHHS training program and would return to their clinical role at UCPH with specialist skills. The TVU will provide support to UCPH as an extension of the existing service.

The Infection Prevention and Control service at UCPH will be an extension of the existing services at Canberra Hospital Infection Prevention and Control Unit as per normal business within its current workforce allocation.

6.5 Pathology

Pathology collection will be undertaken within the inpatient units (for inpatients) or in the pathology collection area located adjacent to ambulatory services. Pathology collection will be provided for UCPH patients only. Pathology collection will be undertaken by ACT Pathology staff during agreed hours from Monday to Friday. A pathology courier service, transporting specimens to Canberra Hospital, will be scheduled at agreed times to ensure timely assessment of specimens.

After-hours pathology collection will be undertaken by clinical staff. If clinically indicated an after-hours courier service will transport specimens for analysis. Point of care testing may be utilised for monitoring blood glucose levels and anti-coagulant therapy levels.

6.6 Pharmacy

On-site pharmacy services will be comprised of:

Clinical service is to provide the onward service of medication chart reconciliation to both the inpatient and day service


Supply services including supply of medication to inpatient units, restocking and supply of discharge medications

When clinically indicated, self management of medication will be encouraged as part of each patient’s rehabilitation program. Pharmacy supply includes the provision of some medication in dose administration aids as well as original packaging to support self-management of medication. Each inpatient unit will store Schedule 4 and Schedule 8 medication in the locked safe in the medication room.

The clinical and supply components of the pharmacy service will incorporate pharmacists and support staff e.g. technicians, who will assist in undertaking medication reconciliation (review of medication changes along a care pathway) and review of medications for inpatients and the home medicine review program.

A pharmacy service will provide support for efficient care provision for patients including weekend admissions and discharges. After-hours medication may be accessed from the after-hours medication automated dispensing machine and an after-hours on-call service will be provided by arrangement with the CHHS Pharmacy service.

6.7 Aboriginal Liaison Service

This service will be coordinated through the CHHS Aboriginal Liaison Service. Aboriginal Liaison Officers will access the multipurpose space when on-site. The service to UCPH will be an extension to the service provided at the Canberra Hospital. The registration of patients in ACTPAS will provide the ALSO with the report of the support profile required at UCPH. Patients and staff can also request these services through Canberra Hospital.

6.8 Administration Services

A facility wide approach to administrative services will include provision of a wide range of support services throughout UCPH. Clinical services will have dedicated administration teams designed to meet the specific needs of each service whilst utilising service wide standard processes where appropriate. Administration staff will report to a professional discipline lead. The provision of administration services will be consistent with the organisation wide approach. A centralised booking and scheduling process will be utilised to coordinate the appropriate care team and access to appropriate clinical spaces.

6.9 Facility Wide After Hours Management

Facility wide after-hours management of UCPH will be undertaken by an ACTH clinical staff member. This role would undertake a number of activities across the facility including coordination of after-hours requests for admissions and afterhours emergency and maintenance situations. This role will also be the central coordination point for nursing services after-hours e.g. for the management of the deteriorating patient and the provision of clinical support.

It is expected that the principles for after-hours management will be consistent across the facility, however Mental Health and RACC will separately manage coordination of relief and casual nursing staff, staff requests and replacement of unplanned personal leave.

After hours medical cover will be provided in an integrated model addressing the specific requirements for the client care needs.

In the event of unplanned leave for staff, the after hours manager position will be the point of contact for the facility.


6.10 Demand Management

The UCPH demand management process will facilitate Mental Health and RACC coordinating the movement of patients into and out of inpatient and ambulatory/day services at UCPH. It will facilitate active uptake of patients to the UCPH facilities and will optimise continuum of care. These roles will link closely with existing bed management positions (e.g. Mental Health Patient Flow Manager, Canberra Hospital Patient Flow). The demand management unit at Canberra Hospital will coordinate the transport for patients from Calvary.

Direct Admissions for RACC will be accepted by the medical team and placed on the waiting list. All decisions to admit patients accepted to UCPH either as a direct admission or as a hospital transfer will be made in collaboration between the UCPH

6.11 Multi Faith Services

A multi-faith room will be provided centrally within UCPH and be accessible for patients, staff, support people and visitors 24 hours a day, seven days a week. The multi-faith service will provide physical, social, emotional and spiritual care and support to patients, staff and visitors of UCPH.

Multi-faith staff will be based at UCPH and coordinated through the Canberra Hospital service. Visiting multi-faith staff will have access to counselling rooms, office space and change facilities. Multi-faith staff will have access to clinical records in order to record their input; however, will not be able to read the clinical record. This service will be supported by volunteers.

6.12 Department of Veteran Affair’s Liaison Service

The CHHS Veteran’s Liaison Service, based at Canberra Hospital, will provide a visiting service to eligible UCPH inpatients. The visiting Veteran’s Liaison Officer will access shared bookable workspace and meeting space. The volunteer service will support this function e.g. visits to Veterans.

6.13 Bio Medical Engineering

Biomedical Engineering will provide an on-site service including an on-site workshop and storage of biomedical equipment used at UCPH. Services will be provided by staff from CHHS Biomedical Engineering. Biomedical engineering services will be centrally coordinated.

6.14 Equipment Loan Service

The existing ELS service (based at the Village Creek Centre) will provide mobility and Activities of Daily Living (ADL) equipment to eligible UCPH ambulatory patients and inpatients at point of discharge for short term loan via a satellite service at UCPH. This service is separate to the Central Equipment Store which manages equipment used within UCPH.

Equipment tracking, cleaning and maintenance will use current business policies and procedures ensuring that all equipment is appropriately monitored, cleaned, repaired, maintained and is available as required.

6.15 Central Equipment Store

The central equipment store provides equipment for UCPH inpatients for use throughout their stay. Central Equipment Store provides loan equipment for use by UCPH inpatients, day and sessional patients at UCPH.

On discharge, the clinician will provide a referral as is normal business for the patient if equipment is required on discharge via ELS. The management, maintenance and delivery of equipment from the CES will be managed by BGIS, please see below.


Please note: the ELS equipment and central equipment are two entirely separate pools of equipment.

6.16 Body Holding

Certification of death processes will be unchanged from that for managing death of inpatients at Canberra Hospital.

As full mortuary service is not required at UCPH, a body holding bay has been included. Access for removal of bodies will be via a dedicated location within the loading dock.


7 Business Support

7.1 Café

A café will be situated within the UCPH. The café will be subject to a retail lease managed by Business Support within ACT Health.

7.2 Linen

Service contracts will be managed by Business Support as per normal CHHS business. The delivery of linen to the dock will be via this contract. Service delivery internally will be supported by BGIS, please see below.

7.3 Waste Management

The contract for waste management is via Business support as per normal business arrangements for CHHS. BGIS will remove waste from the internal areas to the dock, please see below, and waste management will be as per CHHS normal business.

7.4 Volunteers

It is envisaged that UCPH will be supported by an extensive group of volunteers providing a range of services including a volunteer concierge/way finding service. Volunteers will also undertake a range of activities throughout the facility including within clinical areas.

Volunteers will not replace anyone in a paid role; however, their presence in various areas of the UCPH will help to enhance the patient and visitor experience. A range of roles and opportunities that are tailored to the rehabilitation environment will be considered, such as companionship, facilitating activities (for example, art and craft), music, gardening, providing therapy dogs and way-finding will also be considered. Volunteers will be based within the main entrance and operate a shop-front service.


8 Facility Management Services

The facility management for the UCPH has been outsourced to a service provider, Brookfield Global Integrated Solutions (BGIS).

BGIS will provide the following services at UCPH with operating times from 0600hours-1830hours, and additionally a 24-hour operational support will be provided as per the contract terms.

8.1 Contract Management and Administration Services

BGIS will be an integrated element of the principle support services within the facility and will operate autonomously under the guidance of the key principal staff. A governance committee will be established to oversee the contract performance. The day to day contract management of performance will be undertaken by the Principal’s Authorised Person.

8.2 Facility Management (FM) Help Desk Services

The FM Help Desk will provide a consolidated contact point for Facility personnel in respect of all FM services. This will be provided through a single “call centre” type facility, although it is understood that in the interests of efficiency, the FM Contractor may provide a number of service specific interface points. The help desk services will be provided 24 hours a day 365(6) days a year.

8.3 Building Engineering Maintenance (BEM) Services

The role of the BEM Services is to maintain the building fabric and systems as well as Maintained Equipment to that they are functional, safe and compliant and support a positive image for the Facility. This service includes all planned and preventative maintenance, unscheduled repairs, periodic refurbishment and replacement and compliance with statutory requirements.

8.4 Grounds and Gardens Maintenance Services

BGIS will provide comprehensive services that are responsive to seasonal weather and growing conditions. In addition, BGIS will maintain an aesthetically pleasing landscape, facilitate smooth running of the facility ensuring unobstructed access to the facility, and maintain the grounds to promote a positive image and reduce the risk of bush or scrub fire.

8.5 Food Services

The role of Food Services is to meet the nutritional requirements of all patients taking into account age, clinical need, nutritional status, psychosocial, cultural and religious diversity and length of stay. BGIS will provide a high quality, safe and flexible Food Service to support the health functions of the Facility.

BGIS will work closely and collaboratively with the Staff, in particular the dieticians, speech pathologists and other clinical staff to support them in delivering their clinical intent. Services include patient meal preparation, production and delivery, stocking of unit and Food Service pantries, patient and staff beverage bays and machines, ADL Kitchens, purchase and provision of foodstuffs, menu monitoring and management service and kitchen cleaning services.

8.6 Distribution and Patient Support Services

The role of the Distribution and Patient Support Services is to ensure safe and efficient transporting of people, equipment and sundry items across the Facility and to provide co-ordinated unit support duties to support Principal clinical employees, with the exclusion of pharmaceutical items.


Service response requirements are a high quality service which offers a timely, responsive and pro-active system for the movement of patients, waste, equipment etc., within the Facility and undertake a number of other specified support services and ancillary tasks in support of Health Functions.

BGIS will provide a comprehensive, programmed and reactive service that maintains patient confidentiality, is reliable, helpful, and responsive to the needs of the facility and an integrated, flexible approach with a service culture that incorporates continuous development and innovation relating to changes in patient and principal needs, principal demand and the particular facility environment.

8.7 Cleaning Services

The role of Cleaning Services is to provide a responsive and comprehensive cleaning service, which meets the Cleaning Services Standards and all infection prevention and control guidelines. BGIS will provide the Cleaning Services to the Facility 24 hours per day, 365(6) days per year on a scheduled and unscheduled basis as may be required to meet the Cleaning Services Standards.

The scheduled Cleaning Services include a planned service in respect of day-to-day activities and a planned program for periodic cleaning. The unscheduled Cleaning Services will include ad-hoc reactive requests to bring an element up to the requirements of the Cleaning Services Standards, any additional activities identified, undertaking increased cleaning activity when an outbreak occurs, discharge cleaning and bed making services and other infection control cleans.

8.8 Materials Distribution Services

BGIS will provide Materials Distribution Services to support the carrying out of the Health Functions. This will ensure that all materials are distributed efficiently and expediently, monitor stock items at impress level (except Pharmacy supplies) to ensure that all stock levels are maintained so as to maintain the continuity of the health functions, ensure that materials are unpacked and out of boxes and no materials are left on the floor (including boxes); and provide security and safety for materials in its control within the Facility.

The Materials Distribution Service for UCPH will be provided between 07:30 to 16:00 5 days a week. Where a public holiday results in there being more than a 3 day break in service delivery, normal Monday to Friday operating hours will apply on the fourth day. Outside of these hours, an ad-hoc service for other deliveries including urgent and emergency operational requirements will be provided.

8.9 Pest Control Services

BGIS will provide a comprehensive pest control service in order to ensure UCPH is appropriately designed to reduce the risk of pest infestation, that effective pest control measures are implemented, and undertake all work in a safe manner.

8.10 Security

BGIS will provide comprehensive security services to ensure the safety and security of all users at UCPH. The services supplied will be high profile friendly and visible, professional scheduled and ad-hoc services, respond to immediate threats of violence, and comply with the security frameworks and Territory policies and protocols.


9 University of Canberra

University of Canberra, and particularly the Faculty of Health, anticipates that UCPH will provide the opportunity to create an innovative teaching, learning and research hospital. The MoSD and MoC will form the core of the collaboration between the service delivery, education and research to truly capitalise on the benefits of a teaching and training hospital. It is through these models that the potential of the UCPH shared spaces, UCPH collocation on the UC campus, ACT Health staff working alongside UC educators, and the excellent opportunity for service delivery along-side student training, will be recognised.

9.1 Faculty of Health

The University of Canberra, Faculty of Health will:

Provide improved effectiveness and access to services by creating opportunities for an innovative teaching, learning and research environment within UCPH, that up skills the workforce.

Provide education to the current and incoming workforce across a broad range of disciplines that support activity within UCPH, including inter-professional learning and practice, for better patient outcomes.

Undertake collaborative translation and implementation of research for the benefit of patients.

30 January 2018 Page 1 of 8

Staffing the new Rehabilitation Hospital at the University of Canberra

Information for staff

What will be different about the new hospital? Opening in July 2018, the hospital will be Canberra’s first purpose-built rehabilitation hospital for

people recovering from surgery or injury, or experiencing mental illness.

Leading the way as the largest rehabilitation centre in Canberra and surrounds, at full capacity it will

have 140 overnight in-patient beds, 75 day places and additional outpatient services.

The hospital will focus on delivering the highest standard of person-centred care through innovative,

purpose-built spaces and state-of-the-art technology. It will have:

dedicated therapy spaces, including therapeutic gyms and kitchens to promote

independence

therapeutic outdoor spaces that include a rehabilitation courtyard and recreational spaces

outpatient consulting and interview spaces designed to meet the specific needs of people

participating in a rehab program

hydrotherapy pool

a Clinical Education and Research Centre shared with the University of Canberra.

The hospital will bring experienced staff together in one place, encouraging better collaboration

within multidisciplinary teams of health professionals, resulting in better outcomes for people. It will

also be a hub for rehabilitation research, education and training, in partnership with the University

of Canberra.

Services will move to the new hospital from Canberra Hospital, Calvary Public Hospital Bruce’s Aged

Care Rehabilitation Service (ACRS), Brian Hennessy Rehabilitation Centre, and a range of ACT Health

community based health centres.

This will streamline appointments and save people from having to travel to various locations across

Canberra.

What staff are needed? Most importantly, the new hospital needs staff who want to provide best practise, multidisciplinary

rehabilitation, and who want to enable people to achieve their individualised goals. Staff will support

individual patients and deliver tailored care and recovery plans.

We want staff who want to be part of this significant milestone in Canberra’s history—and help build

its culture of excellence and innovation. Staff who are interested in supporting an environment of


research and education to grow tomorrow’s health professionals, will also enjoy working at the new

hospital.

Upon opening, the hospital’s workforce will be made up of nursing, mental health clinicians, allied

health professionals, medical staff and clinical support staff including radiography, pathology,

pharmacy, and administrative staff. The staff profile is broad, including graduates through to senior

positions.

How will positions be filled? In accordance with the ACT Public Sector Management Act and relevant enterprise agreements, the

workforce for the new hospital will be established in a number of different ways to make sure we

meet service needs and Models of Care. There will be a combination of direct transfers (relocations),

internal staffing activities and external recruitment processes.

A small number of key positions have already been advertised, including additional medical positions

i.e. Geriatrician, Rehabilitation Registrar and junior medical officers, and senior nursing positions

such as Rehabilitation, Aged and Community Care’s Assistant Director of Nursing, After Hours Nurse

Managers and clinical nurse educator. The majority of positions are yet to be advertised.

Which positions will transfer (relocate)? Current ACT Health positions that directly correspond with services to be provided at the new

hospital will relocate, and the permanent staff in those positions will work in the new hospital. This

includes staff who work on ward 12B and RILU of the Rehabilitation, Aged and Community Care

(RACC) Division; some mental health positions in Mental Health, Justice Health, Alcohol and Drug

Services (MHJHADS) Division; and some support positions.

Additionally, ACT Health staff who typically rotate through different services and locations across

ACT Health as part of their role, for example speech pathology graduates and Resident Medical

Officers, will continue to do so. The new hospital will simply be another location they may work in.

Which positions will be part of the internal staffing process? An internal staffing process is only suitable for existing ACT Health positions, where the position

description remains mostly the same or where there are more suitably qualified people than

positions relocating to the new facility.

A number of positions in RACC, MHJHADS and support services that are moving to the new hospital

will be open to applicants through an internal staffing process. An internal staffing process will

ensure a fair and merit based process.

Which positions will be part of an external recruitment process? The new hospital brings together a number of services and presents great opportunities for staff. As

such, some position descriptions will need to change to meet the new Models of Care. ACT Health

positions that change significantly, are new, or cannot be transferred will be advertised externally

and everyone will be able to submit an application.


Rehabilitation activities provided in ACRS at Calvary Public Hospital Bruce will move to the new

hospital. As Calvary staff are not ACT Government employees, they cannot be transferred directly

into a position.

The ACRS positions in the new hospital will be advertised in an external, merit based recruitment

process, and all Calvary staff will be encouraged to apply.

When and where will jobs be advertised? Positions included in an internal staffing process or external recruitment process will be advertised

between early February and March 2018. Externally advertised positions will be published in the ACT

Public Service Gazette and on the Employment page of the ACT Health website at

health.act.gov.au/employment

Positions included in the internal staffing process will be published on the ACT Health intranet.

What will be required from applicants and referees in each staffing process? The requirements will vary depending on the position and whether the process is an internal staffing

process or external recruitment.

As a minimum staff will be expected to submit a resume, provide a covering letter that responds to

either selection criteria or relevant questions, and contact details of two referees. Each job

advertisement will clearly specify the requirements for applicants.

ACT Health will aim to make the process as clear and simple as possible for applicants and their

referees, while taking steps to make sure the processes are fair and based on merit.

What will happen next? Anyone interested in working at the new hospital should keep an eye on the ACT Health website at

health.act.gov.au

New information will be published on both the University of Canberra Public Hospital page and ACT

Health’s Employment page. Any new information will also be shared with staff through managers,

staff bulletins and the ACT Health intranet.

Applicants will be advised of the outcome of all internal staffing processes and recruitment

processes. All staff who are relocated or successful in gaining a position will receive orientation and

training at the new hospital.

How will staff be kept up to date? In addition to the initial meetings held with staff, information will be published to the ACT Health

website, and shared with ACT Health and Calvary staff via their intranet, staff bulletins and through

managers.

What are the staff facilities at the new hospital? There will be ample car and motorbike parking for staff. There will be 55 metres of secure bike

storage, as well as change rooms, shower facilities and shift lockers. Two Action Bus routes will

travel past the entrance of the hospital, which is located approximately two kilometres from

http://www.health.act.gov.au/


Belconnen town centre and one kilometre from services at the University of Canberra. The new

hospital will have free Wi-Fi, a café in the central atrium, vending machines, and dining and meeting

areas.

Will the new hospital have a child care centre? The new hospital will not have a child care centre.

I have more questionswho can I speak to? All staff should read the information on their intranet and the ACT Health website in the first

instance, and then speak to their manager if they have further questions.

Further information for ACT Health staff

My position is being transferredcan I choose not to move? No, permanent staff in a position that is transferring directly to the new hospital will relocate. The

new hospital has been purposely built to support the delivery of rehabilitation services. It will greatly

improve health outcomes for Canberrans, and we hope all staff will be eager to work at this great,

state-of-the-art facility.

My position is being transferredwill my job description change? For the majority of roles, there may be minor changes to your job to accommodate the new facilities

and Model of Care at the new hospital, but it won’t change significantly.

Orientation and training will be held for all staff working at the new hospital.

My position will go through an internal staffing processwhat will happen if I choose not

to apply? If you choose not to apply for a position at the new hospital you will be supported to secure a

different role within ACT Health. If you have questions specific to your employment, please speak

with your manager in the first instance.

Will teams be restructured, and reporting lines changed, at the new hospital?

The majority of teams will retain their current reporting lines.

It is important that the inpatient nursing teams represent a balance of new and transferred/existing

staff to help build cohesive teams in the new hospital. Therefore some transferred nursing staff may

have a change in reporting lines to reflect this i.e. they may report to a new CNC.

A balance of new and existing staff provides an ideal opportunity to support and orientate new staff

into both a rehabilitation and new hospital environment.


What will happen to my entitlementswork hours, pay rate, flex hours, salary

packagingif I move to the new hospital? The new hospital is simply another facility providing ACT Government services, delivered by ACT

Government staff. Staff will continue to work under the same enterprise agreement as the rest of

ACT Health employees and the same salary packaging arrangements will be in place.

With the exception of staff already working in RACC and MHJHADS positions that are directly

transferring to UCPH, staff will not be able to transfer their flex.

What uniform will I need to wear at the new hospital? The ACT Health uniform will continue to be worn. MHJHADS clinical staff will not be required to wear

the uniform.

Will any ACT Health staff lose their jobs?

There will be no job losses. Permanent employees who are not successful in obtaining a position at

UCPH will be placed according to their skill set, in other areas within ACT Health.

Nursing staff

What will the nursing team model look like? The RACC inpatient nursing team will be a team-based nursing model, with AINs, ENs and RNs on

each shift.

The Adult Mental Health Rehabilitation Unit staff will comprise RNs and ENs and the Mental Health

Day Service will be supported by RNs.

Will there be a doctor on the ward after hours? Yes, there will be two medical officers on an evening shift, a night shift and on weekends. You can

contact them at any time for assistance. They will be available for the RACC and Mental Health

Inpatient Units.

Will there be a senior nurse for support after hours? Yes, there will be an After Hours Hospital Manager (AHHM) who will have responsibility for staffing,

emergencies and any clinical questions and situations. The AHHM will be able to help with similar

things as the AHHM or AHCNC at Canberra Hospital does. This person will have an office in the

Stromlo Ward and will be accessible to RACC and Mental Health inpatient units.

Will there be opportunities to apply for RN L2 and Personal L2 positions? Yes, RN2 positions are available at the new hospital. The process for staff applying for a personal RN

Level 2 position will be no different to the current process in place for staff across ACT Health.


Mental Health Staff

What will Adult Mental Health Rehabilitation Unit (AMHRU) teams look like? The AMHRU will work within a multidisciplinary team framework consisting of psychiatrists,

registrars, registered nurses, enrolled nurses, allied health and allied health assistants.

It is anticipated that some specialist mental health positions will work across both the mental health

day service and the mental health inpatient unit to provide a broader range of services to more

people.

What will Adult Mental Health Day Service (AMHDS) teams look like? The AMHDS will work within a multidisciplinary team framework comprising psychiatrists, registrars,

allied health, registered nurses, and allied health assistants including peer workers.

It is anticipated that some specialist mental health positions will work across both the mental health

day service and the mental health inpatient unit to provide a broader range of services to more

people.

Allied health staff

What allied health staff will be at the new hospital?

As the new hospital is a specialised rehabilitation hospital, allied health will have a significant

presence in the facility. This will include speech pathologists, dieticians, physiotherapists,

occupational therapists, psychologists, pharmacists and social workers. Allied health assistants will

also be employed.

Support staff

How will facility management services be delivered at the hospital?

As part of the Design, Construct and Maintain (DCM) contract some facility management services

will be undertaken by Brookfield Global Integrated Systems (BGIS). These services include cleaning,

patient support services, building maintenance, food services, materials distribution services,

security services and grounds and gardens maintenance.

What will the administrative model look like? The new hospital will have an integrated, facility-wide administrative model delivering services

across the facility. Staff working in the administrative team will include administrative officers, ward

clerks and reception staff and will be known as Customer Service Officers.


Further information for Aged Care Rehabilitation Service (ACRS) staff at Calvary Public Hospital Bruce

Why is ACRS activity transferring to the new hospital? The new hospital will be solely focused on rehabilitation, and activity across Canberra that is funded

by the ACT Government to deliver rehabilitation services that meet the new hospital’s Model of Care

will be co-located together at the new hospital.

This will bring experienced staff together, encouraging better collaboration within multidisciplinary

teams of health professionals, resulting in better outcomes for people. It will also streamline

appointments and save our people from having to travel to various locations across Canberra.

Services will move to the new hospital from ACRS, Canberra Hospital, Brian Hennessy Rehabilitation

Centre, and community based health centres.

Why can’t ACRS staff transfer directly with an activity? The ACT Public Sector Management Act does not allow for the direct transfer of employees from

organisations that are not administrative units of the Territory, and therefore staff from Calvary

cannot be transferred directly. Positions in the new hospital will be advertised and Calvary ACRS

staff are encouraged to apply.

What happens if I choose not to apply for a position at the new hospital?

All ACRS staff are encouraged to applywe hope all staff will be eager to work at this great, state-

of-the-art facility.

If you choose not to apply for a position at the new hospital you will be supported to secure a

different role within Calvary Public Hospital Bruce.

If you have questions specific to your employment, please speak with your manager in the first

instance.

What happens if I apply for my position but I am unsuccessful? Staff will be supported to secure a different role within Calvary Public Hospital Bruce.

Will any Calvary Public Hospital Bruce staff lose their jobs?

Staff who do not secure employment at the new hospital will be supported to secure a different role

within Calvary Public Hospital Bruce.

What will happen to my entitlementswork hours, pay rate, salary packagingif I move

to the new hospital? Staff at the new hospital will be employees of the ACT Government, and will work under the same

enterprise agreement under which they are currently employed. This is the same enterprise

agreement as the rest of ACT Health employees.


Staff will continue to have access to the same salary packaging arrangements, however this will be

through the provider arrangement in place for ACT Health employees. Calvary staff who secure

employment at the new hospital should immediately seek advice from their salary packaging

provider, Maxxia, so they can optimise their salary packaging benefits.

What uniform will staff wear at the new hospital? Staff who gain positions at the new hospital that require a uniform will receive ACT Health uniforms

as part of their on-boarding process.

NOTE: The information contained in this document is current as of January 2018. ACT Health may update this information

overtime.

The Employee Assistance Program (EAP) is available free to all staff Both ACT Health and Calvary Public Hospital Bruce staff can access their Employee Assistance

Program (EAP). The EAP offers free, professional and confidential services to support you and

your immediate family members through both personal and work related issues. You can access

help now, or any time you need it. You can find more information about EAP providers on your

intranet.

Rehabilitation, Aged and Community Care

University of Canberra Public Hospital Model of Care

6.0

August 2017

RACC UCPH Model Of Care V6 Page 2 of 57

1 CONTENTS

2 Version Control ............................................................................................................................... 7

3 Acronyms and Glossary ................................................................................................................... 8

3.1 Acronyms ................................................................................................................................ 8

3.2 Glossary ................................................................................................................................... 9

4 Executive Summary ....................................................................................................................... 12

5 Key Vision ...................................................................................................................................... 13

6 Purpose Of Document ................................................................................................................... 13

6.1 Assumptions .......................................................................................................................... 14

7 Innovations ................................................................................................................................... 14

7.1.1 Centralised Care Provision Innovations ........................................................................ 14

7.1.2 Implementation of Day Program Innovations .............................................................. 15

7.1.3 Enhanced Patient Centred Care Through Service Delivery Innovations ....................... 15

7.1.4 Flexible Service Delivery Innovations ............................................................................ 16

7.1.5 Robotic Therapy and Clinical Technology Innovations ................................................. 16

7.1.6 Information and Communication Technology Innovations .......................................... 16

7.1.7 Quality and Safety Innovations ..................................................................................... 17

8 Key Functions of Rehabilitation at UCPH ...................................................................................... 17

9 Principles of Care .......................................................................................................................... 18

9.1.1 Safe and High Quality Care ........................................................................................... 18

9.1.2 Enhanced Person Centred Care .................................................................................... 19

9.1.3 Advance Care Planning ................................................................................................. 19

9.1.4 Early Intervention/Canberra hospital acute subacutre early rehabiliation service

(CHASERS) ..................................................................................................................................... 20

9.1.5 Enablement ................................................................................................................... 20

9.1.6 Multidisciplinary and Collaborative Services ................................................................ 20

9.1.7 Accessibility ................................................................................................................... 21

9.1.8 Culturally Appropriate and Inclusive Services............................................................... 21


9.1.9 Efficient, Cost Effective Care ......................................................................................... 22

9.1.10 Evidence Based Care ..................................................................................................... 22

9.1.11 Appropriate Use of Information, Communication and Technology (ICT) ..................... 22

10 Standards and Best Practice Care Provision ............................................................................. 23

11 Clinical Governance ................................................................................................................... 23

12 Inpatient Unit Model of Care .................................................................................................... 24

12.1 Neurological Rehabilitation Unit ........................................................................................... 25

12.1.1 Key Elements ................................................................................................................. 25

12.1.2 Transition Unit .............................................................................................................. 25

12.2 General Rehabilitation Unit .................................................................................................. 26

12.2.1 Key Elements ................................................................................................................. 26

12.3 Older Person’s Rehabilitation Unit ....................................................................................... 26

12.3.1 Key Elements ................................................................................................................. 26

12.3.2 Dementia Care in Hospitals Program ............................................................................ 29

12.4 Slow Stream Rehabilitation Unit ........................................................................................... 29

12.4.1 Key Elements ................................................................................................................. 29

12.5 Common Elements of an Inpatient Admission ..................................................................... 29

12.5.1 Therapy Sessions ........................................................................................................... 29

12.5.2 Activities of Daily Living (ADL) ....................................................................................... 30

12.5.3 Therapy Spaces ............................................................................................................. 30

12.5.4 Length of Stay ............................................................................................................... 30

12.5.5 Falls Assessment ........................................................................................................... 31

12.6 Additional Services ................................................................................................................ 31

12.6.1 Medical Consultation Services ...................................................................................... 31

12.6.2 Residential Aged Care Liaison Nurse (RACLN) .............................................................. 31

12.6.3 Palliative Care Consultation .......................................................................................... 31

12.6.4 Pain Management ......................................................................................................... 31


12.6.5 Diabetes Educator ......................................................................................................... 31

12.6.6 Tissue Viability Team ..................................................................................................... 32

12.6.7 Infection Control ........................................................................................................... 32

12.6.8 Aboriginal and Torres Strait Islander Liaison Service .................................................... 32

12.6.9 Veterans Affairs ............................................................................................................. 32

12.6.10 Multi-faith staff ......................................................................................................... 32

12.6.11 Volunteers ................................................................................................................. 33

12.6.12 Consumer Engagement Team ................................................................................... 33

12.7 Admission .............................................................................................................................. 33

12.7.1 Admission Criteria ......................................................................................................... 34

12.8 Discharges and Transfers ...................................................................................................... 34

12.8.1 Discharge or Transfer of Care Process from the Inpatient Units .................................. 35

12.8.2 Transition from UCPH Inpatient Services To Other Care Settings ................................ 35

13 After Hours Management ......................................................................................................... 35

13.1 Admissions and Discharges ................................................................................................... 35

13.2 After Hours Clinical Care and Management ......................................................................... 36

14 Hours of Operation ................................................................................................................... 36

14.1 Visiting Hours ........................................................................................................................ 36

15 Carers, Friends and Family ........................................................................................................ 37

16 Engagement and Care Coordination: ........................................................................................ 37

17 Deteriorating Patients ............................................................................................................... 38

18 Day Rehabiliation Service .......................................................................................................... 38

18.1 Neurology Stream ................................................................................................................. 39

18.2 General Stream ..................................................................................................................... 39

18.3 Older Person’s Stream .......................................................................................................... 40

18.4 Day Rehabilitation Service Admission Criteria ...................................................................... 40

18.5 Key Elements of All Day Rehabilitation Programs ................................................................ 41


18.5.1 Frequency and Modes of Day Rehabilitation Service ................................................... 41

18.6 Hours of Operation of Day Rehabilitation Service ................................................................ 41

19 Ambulatory Model of Care (Sessional Therapy/Services) ........................................................ 41

19.1 Rehabilitation Ambulatory Services: ..................................................................................... 42

19.1.1 Rehabilitation Medicine Outpatient Clinics .................................................................. 42

19.1.2 Rehabilitation Medicine Multi-disciplinary Outpatient Clinics ..................................... 42

19.1.3 Rehabilitation Nurse Practitioner Clinics ...................................................................... 42

19.1.4 Rehabiliation-at-home .................................................................................................. 43

19.2 Geriatric Ambulatory Services: ............................................................................................. 43

19.2.1 Geriatric Medicine Outpatient Clinics ........................................................................... 43

19.2.2 Aged Care Assessment Team (ACAT) ............................................................................ 43

19.2.3 Aged Care Nurse Practitioner ....................................................................................... 43

19.2.4 Falls and Falls Injury Prevention Program ..................................................................... 43

19.2.5 Memory Assessment Service ........................................................................................ 44

19.3 Rehabilitation and Geriatric Sessional Allied Health ............................................................ 44

19.4 Clinical Services Based Off-site That Will Provide a Service to UCPH Inpatient and Ambulatory

Services ............................................................................................................................................. 44

20 Hydrotherapy ............................................................................................................................ 45

21 Referrals .................................................................................................................................... 46

21.1 How to Book into the Day Rehabilitation Service ................................................................. 46

21.2 Generalised UCPH Patient Pathway ...................................................................................... 46

21.3 Referral/Intake Process for transfer of care for an existing ACT Health patient .................. 47

21.4 Referral/intake process for a new act health patient ........................................................... 48

21.5 Referral Submitted ................................................................................................................ 49

21.6 Screening/Sorting of Referrals and Waitlist .......................................................................... 49

22 Booking and scheduling ............................................................................................................ 49

23 Workforce/Staffing ................................................................................................................... 49

23.1.1 Consultation .................................................................................................................. 50


23.1.2 Nursing .......................................................................................................................... 50

23.1.3 Allied Health .................................................................................................................. 50

23.1.4 Medical .......................................................................................................................... 51

23.1.5 Administration .............................................................................................................. 51

24 Appendices ................................................................................................................................ 52

24.1 Consultation Process undertaken to inform this document ................................................. 52

24.2 Membership of the Reference groups and user groups: ...................................................... 52

24.3 Rehabiliation and Aged Care UCPH Service Streams ............................................................ 56

24.4 Reference Documents ........................................................................................................... 57


2 VERSION CONTROL

NO. DATE REMARKS

1.0 28- Jul-14 Extracts of report issued for Round 1 User Group consultation (sections 2, 3 & 4)

1.1 8- Aug-14 Updated following Round 1 User Group meetings

1.2 12-Aug-14 Extract of report for Round 2 User Group meetings

1.3 30- Sept- 14 Updated extract for Round 2 User Group meetings incorporating feedback from Linda Kohlhagen – for reference at meetings only (not for circulation)

1.4 8-Oct- 14 Updated draft following Round 2 User Group meetings

1.5 28- Nov- 14 Updated draft incorporating feedback following Round 2 User Group meetings and targeted work re ambulatory services.

1.6 5-Dec-14 Updated draft incorporating feedback and outcomes of targeted work re inpatient services.

1.7 19-Dec-14 Updated draft following Round 3 User Group meetings

1.8 9-Jan-15 Updated draft for Round 4 User Group meetings

1.9 23-Jan-15 Updated draft for Reference Group meeting 28/1/15. Incorporates feedback received from Round 4/5 User Group meetings including document restructure.

2.0 13-Feb-15 Final incorporating outcomes of Reference Group meeting and other feedback provided.

3.0 9-Mar-15 Final incorporating feedback provided

4.0 1-Oct-15 Final incorporating definitional clarification around models of care and models of service delivery and structural changes

5.0 5-May-16 Incorporating information comments received during Community Consultation of the MOC in late 2015. Additional information to provide clarification to some services areas.

5.2 Sep-16 Final incorporation of information and comments received during Community Consultation of the MOC in late 2015. Additional information to provide clarification to some services areas. Includes document restructure.

6.0 August -17 Update of version number


3 ACRONYMS AND GLOSSARY

3.1 ACRONYMS

ACRONYM MEANING

ACAT AGED CARE ASSESSMENT TEAM

ACE ACUTE CARE OF THE ELDERLY (CANBERRA HOSPITAL)

ACRU AGED CARE REHABILITATION UNIT (CALVARY HOSPITAL)

ACTES ACT EQUIPMENT SERVICE

ACTPAS ACT PATIENT ADMINISTRATION SYSTEM

ADL ACTIVITIES OF DAILY LIVING

CALD CULTURALLY AND LINGUISTICALLY DIVERSE

CHC COMMUNITY HEALTH CENTRE

CHHS CANBERRA HOSPITAL AND HEALTH SERVICES

CRT COMMUNITY REHABILITATION TEAM

CSP CLINICAL SERVICES PLAN

CTW CLINICAL TECHNOLOGY WORKSHOP

DARS DRIVER ASSESSMENT AND REHABILITATION SERVICE

DORSS DOMICILIARY OXYGEN AND RESPIRATORY SUPPORT SCHEME

EP EXERCISE PHYSIOLOGY

ELS EQUIPMENT LOAN SERVICE

FTE FULL TIME EQUIVALENT

GEM GERIATRIC EVALUATION AND MANAGEMENT

GP GENERAL PRACTITIONER

HIP HEALTH INFRASTRUCTURE PROGRAM

HITH HOSPITAL IN THE HOME

LOMT LIMITATIONS OF MEDICAL TREATMENT

MEWS MODIFIED EARLY WARNING SCORES

NDIS NATIONAL DISABILITY INSURANCE SCHEME

OT OCCUPATIONAL THERAPY


ACRONYM MEANING

PAS PATIENT ADMINISTRATION SYSTEM (E.G. ACTPAS)

PSP PRELIMINARY SKETCH PLAN

P&O PROSTHETICS AND ORTHOTICS

RACC REHABILITATION, AGED AND COMMUNITY CARE

RACLN RESIDENTIAL AGED CARE LIAISON NURSE

RADAR RAPID ASSESSMENT OF THE DETERIORATING AT-RISK

RILU REHABILITATION INDEPENDENT LIVING UNIT (CANBERRA HOSPITAL)

RG REFERENCE GROUP

SAGU SUB-ACUTE GERIATRIC UNIT (CANBERRA HOSPITAL)

SWAPS SPECIALISED WHEELCHAIR AND POSTURE SEATING

TTCP TRANSITIONAL THERAPY AND CARE PROGRAM

UCPH UNIVERSITY OF CANBERRA PUBLIC HOSPITAL

UG USER GROUP

VARS VOCATIONAL ASSESSMENT AND REHABILITATION SERVICE

3.2 GLOSSARY

Key terms used throughout this document are defined below.

Acute Care

An episode of acute care for an admitted patient is one in which the principal clinical intent is to do one or more of the following:

Cure illness or provide definitive treatment of injury

Perform surgery

Relieve symptoms of illness or injury (excluding palliative care)

Reduce severity of illness or injury

Protect against exacerbation and/or complication of an illness and/or injury which could threaten life or normal functions

Perform diagnostic or therapeutic procedures

Manage labour (obstetric)

Admitted Services

Admitted services are those which are provided to patients who require formal admission to hospital

and care within a hospital bed. Care provision may be overnight or day only.


Ambulatory Services

Ambulatory services are health services provided on an outpatient basis to patients who attend a

hospital or health care facility and depart after treatment on the same day.

Care Plan

A care plan is a patient-centred plan agreed to with the patient and their family/support people with

the clinicians. It will identify care/treatment goals and timeframes, intensity of therapy required and

the multi-disciplinary team members or in reach services required.

Community Based Services

A range of community based health services for people of any age including a range of technical

nursing services, allied health services, health promotion and self management of chronic conditions.

Service provision may be health centre based or provided within a range of community settings e.g.

patient homes, workplaces and public spaces.

Consultation Liaison Services

Consultation liaison services are services that are not managed by UCPH but which provide

consultation services to UCPH patients when necessary.

Day Rehabilitation Service

A day rehabilitation service or program provides an alternative to inpatient care. It is designed for

patients who require an intensity of regular rehabilitation therapy, but who can also safely live in the

community and does not require overnight nursing or medical care. The therapy required generally

could not be provided in the community setting due to the nature of specialised requirements and

intensity of care provision.

Geriatric Services

The provision of care for patients who have conditions associated with ageing. Care provision is

typically provided for patients over the age of 65 years or over the age of 50 years for Aboriginal and

Torres Strait Islander peoples; however, younger patients may be seen if they have a condition which

is associated with the ageing process. Patients aged above 65 years or 50 years for Aboriginal and

Torres Strait Islander peoples may access a range of clinical services of which geriatric services are

one.

Inpatient Services

Inpatient overnight services are provided to patients whose condition requires formal admission to

hospital. Patients receiving inpatient care require care within the hospital overnight in order to treat

their condition and/or safely undertake activities of daily living.

Note: there are some inpatient services where the patient does not reside in the hospital e.g. Hospital

in the Home (HITH).


Model of Care

The Model of Care describes how clinical services are/will be delivered to a patient or client.

The focus of the Model of Care description is on direct clinical service provision, however, aspects of

support services which are integral to care provision (e.g. information and communications

technology and administration/booking/scheduling) are also described as part of the Model of Care.

Model of Service Delivery

A Model of Service Delivery describes the clinical and non clinical services to support the Models of

Care being delivered.

Rehabilitation

Rehabilitation is the provision of care that aims to:

Restore functional ability for a person following a period of illness or injury;

Enable restoration of function consistent with pre-injury/illness status and the constraints of the medical prognosis; and

Develop compensatory functional skills to address deficits that cannot be reversed.

Sub-acute Care

Sub-acute care at UCPH is the provision of specialised multi-disciplinary care in which the primary

need for care is optimisation of patient functioning and quality of life. A person’s functioning may

relate to their whole body or a body part, the whole person, or the whole person in a social context,

and to impairment of a body function or structure, activity limitation and/or participation restriction.

UCPH will be a sub-acute facility providing adult rehabilitation and Geriatric Evaluation and

Management (GEM) services. Emergency Department and other acute services will not operate from

the site.


4 EXECUTIVE SUMMARY

The University of Canberra Public Hospital (UCPH) will be a purpose built rehabilitation hospital

located on the University of Canberra campus on the corner of Aikman Drive and Ginninderra Drive.

UCPH will form part of a planned network of ACT Health hospitals and facilities designed to meet the

needs of our ageing and growing population. It will contribute to the continuum of rehabilitation

services provided across the Division of Rehabilitation, Aged and Community Care (RACC) through ACT

Health.

Extensive planning has been undertaken to define the services to be provided at UCPH. This planning

information is publicly available in the Service Delivery Plan and Functional Brief, both of which are

available on the ACT Government ‘Time to Talk’ website. UCPH will deliver sub-acute adult care

consisting of:

Mental Health inpatient rehabilitation

Mental Health day services

General inpatient rehabilitation

Geriatric inpatient rehabilitation

General and Geriatric day and ambulatory services

At full capacity UCPH will have 140 inpatient beds, 75 day places and additional ambulatory clinics and

services. UCPH will open with capacity to meet the current demand in ACT and a have a staged

approach to opening further beds (up to 140) to meet growing demand. The 75 day places will allow

greater flexibility for patients to access daily rehabilitation without the need to stay overnight in

hospital. This will allow some patients to be discharged earlier and still receive the rehabilitation

therapy they require.

The purpose of a specialist rehabilitation hospital is to deliver effective goal based treatment and

rehabilitation to people whose needs cannot be met by less intensive community based services. The

primary goal of treatment will be the enhancement of the person’s quality of life and improvement in

their functional status through the engagement in a variety of rehabilitation services.


5 KEY VISION

The University of Canberra Hospital (UCPH) aims to be recognised as a centre of excellence with a

national and international reputation in the provision of specialist rehabilitation, teaching, research

and clinical services. This will be achieved through developing and utilising the skills of a specialised

workforce, introducing innovations and leading technology in the care and treatment of patients and

encouraging close collaborations between clinicians and researchers to ensure translation of

contemporary, evidence based knowledge into practice.

The vision for the future of adult rehabilitation services is to provide integrated and coordinated

services across the entire continuum of care. This reflects the reality that people accessing services

may commence treatment at any point along the care continuum and may move between different

settings as required to meet their care needs. Strong links between all ACT Health services with

relevant external services will be maintained to enable provision of the most appropriate clinically

indicated care for all.

Rehabilitation at UCPH will be aligned to the strategic priorities and goals of ACT Health and the ACT

Government.

6 PURPOSE OF DOCUMENT

This document outlines the proposed Model of Care (MOC) for Adult Rehabilitation at the University

of Canberra Public Hospital. The Models of Care for the adult Mental Health services to be provided

at UCPH have previously been consulted on in 2014. These documents are available on the ACT Health

website.

This plan provides details regarding:

Principles of Care

Inpatient Service description

Day Service and Ambulatory Service Description

The overarching Model of Care for Rehabilitation Services to be delivered at UCPH is characterised by:

Enhanced person centred care with appropriate family/support people involvement;

Provision of the ‘right’ care in the ‘right’ place at the ‘right’ time;

Provision of flexible and adaptable care which is responsive to changing patient needs over

time;

Accessible community based services covering a broad range of primary health care and other

needs of patient of all ages; and

Provision of specialised multi-disciplinary acute and sub-acute rehabilitation services to adult

and older patients within inpatient and ambulatory settings.


6.1 ASSUMPTIONS

The development and ongoing future of this Model of Care is based on the following assumptions:

The Model of Care document is a point in time document and is intended to be a living

document that will be updated along the development of UCPH.

Ongoing reform processes that are underway across ACT Health my influence the future

governance and service operations at UCPH.

7 INNOVATIONS

UCPH will provide leadership and expertise in the provision of client-centred, quality and evidence

based rehabilitation programs which include stroke and neurological, amputee, orthopaedic, older

persons and general reconditioning programs.

A number of innovations and technologies will be introduced to differentiate rehabilitation services

offered at UCPH to that currently offered anywhere in the ACT. Innovations that aid and enhance

clinical practice will be evidence based and guided by best practice. UCPH will also aim to be early

adopters of emerging rehabilitation innovations and technologies with a future goal of producing

leading research in rehabilitation practice.

Known innovations that will be incorporated into future services are:

7.1.1 CENTRALISED CARE PROVISION INNOVATIONS

Inpatient and outpatient care provided from a single facility;

Develop sub-acute services away from an acute campus, in a less clinical environment with

access to outdoor space, enhancing the patient perception of progress towards rehabilitation

and supporting the recovery model.

Co-location and integration of rehabilitation services and specialised staff, reducing time

required for assessment and repeated clinical handover.

Centralised specialised services with a greater critical mass enabling the maintenance of

specialised skills (e.g. physiotherapists with specialised amputee gait training skills).

Optimised sharing of knowledge and staff training.

Capacity to flex up/down rehabilitation specialised wards to meet changing patient demand.

Ability to provide a greater intensity and frequency of therapy to all patients, enhancing

neuro-plastic changes and improving recovery for neurological and physical injury.

Inpatient ward design has been applied to enable “purposeful wandering”, with no dead-end

passage ways that frustrate confused patients and the incorporation of outdoor spaces in each

inpatient area.


Inpatient ward design has minimised distances staff are required to travel, improving

nurse/patient interaction, and the time staff can spend at the patient bedside.

Driver Assessment and Rehabilitation services (DARS) will be available to Inpatient, Day

programme and ambulatory care patients at UCPH. This will contribute to an enhanced and

coordinate programme for both rehabilitation patients and older drivers where driver

screening and assessment programmes can be provide in conjunction with physical and

cognitive therapy. This will better enable therapists to respond to the physiological, cognitive

and sensory changes associated with ageing and neurological injury, enhancing strategies to

improve driver safety in these populations.

Vocational Assessment and Rehabilitation services (VARS) will be available to Inpatient, Day

programme and ambulatory care patients at UCPH. Coordinated with cognitive and physical

therapies, VARS services provide instruction and teaching on the use of technology in a

purpose built space as part of a holistic programme. It provide patients with strategies in the

use of smart technologies, such as tailored internet programs, that may help all patients better

manage and understand various health conditions, resulting in subsequent improvements in

aspects of social connectedness.

7.1.2 IMPLEMENTATION OF DAY PROGRAM INNOVATIONS

The Rehabilitation Day Service is a predominantly new service for ACT Health.

The rehabilitation and geriatric day programs and sessional therapy to be provided at UCPH

will be characterised by specialised services provided by dedicated care streams.

The day program will provide an alternative to inpatient care for patients who require the

intensity of rehabilitation therapy but do not require 24/7 nursing or medical care.

Such services could not be provided in the community setting due to the nature of specialised

requirements and intensity of care provision.

7.1.3 ENHANCED PATIENT CENTRED CARE THROUGH SERVICE DELIVERY INNOVATIONS

Improved transmission of referral and clinical record information through integrated

electronic systems that are easily accessible.

Established multi-disciplinary intake process for both inpatient and ambulatory services.

Early and consistent establishment of care plans (including most appropriate care setting).

An electronic medication management system will be implemented...

Electronic Observations will be implemented following a successful pilot in 2017.

Electronic orders for Pathology and Medical Imaging will be in place.

Self-management of medication will be an important aspect of people’s rehabilitation.


UCPH will work with community partners and volunteer groups to integrate evidence based

diversional therapies, such as art, dance and singing, to enhance and promote patient

recovery.

Through the appointment of a Clinical Research Lead and collaborative working with tertiary

facilities, researchers will be integrated into the clinical environment. UCPH will encourage

researchers and clinicians to work side by side to enable knowledge translation in the clinical

environment where research is applied directly during patient care.

7.1.4 FLEXIBLE SERVICE DELIVERY INNOVATIONS

Flexible shift hours for different clinicians based on patient clinical need, enabling:

o Interventions to occur early in the day such as a shower assessment, or late in the day

such as a consultation or education session with family members who can attend after

work;

Allied health staff will have flexible hours of service to enable to provision of therapy at the

right time and right place for every patient. This will include extended hours of coverage, with

certain Allied Health professionals available from 7am to 6pm. Physiotherapy and

Occupational Therapy may be offered from Monday to Saturday if there is patient demand,

and the RACC Allied Health service will investigate the option of “open” therapy spaces for

appropriate patients.

The development of a generic Allied Health/therapy assistant roles that will work across

professions and work settings.

Optimised administrative and other support staff models to ensure that the workload for all

staff is ideally suited to their skill set and role description (i.e. minimise the volume of

administrative tasks that clinicians are required to undertake).

7.1.5 ROBOTIC THERAPY AND CLINICAL TECHNOLOGY INNOVATIONS

Incorporate new therapeutic technologies and other treatment advances consistent with

evidence based practice and in consultation with benchmark facilities.

Incorporation of cutting edge therapeutic technology into the Inpatient and Day

Rehabilitation therapy such as upper and lower limb robotics and augmented and assisted

communication devices.

Neuro-feedback and Cognitive Remediation therapies, using contemporary technology will

continue to be provided by RACC physiologists, Speech Therapists and Occupational

Therapists.

7.1.6 INFORMATION AND COMMUNICATION TECHNOLOGY INNOVATIONS

Incorporate other new technologies such as automated queuing and systems for ambulatory

services patients, to check-in for services.


Optimised online information services so that patients and family/support people can be fully

informed of available services and their location.

Centralised integrated intake, booking and scheduling consistent with a whole of organisation

approach.

Optimised use of telehealth for remote consultation and therapy.

Introduction of “Activity Bar Coding” or similar technology for more efficient and accurate

data capture, freeing up time of clinicians to provide therapy to patients.

The inclusion of electronic patient journey boards, patient information systems and

therapeutic apps at the patient bedside to improve sharing of patient information. This will

enable patients to interact in real time with their therapy programme and enable therapists

to provide individualised education and therapy plans directly to the patient and carers.

7.1.7 QUALITY AND SAFETY INNOVATIONS

The hospital design will include a number of features to help reduce falls, such as improved

visibility of patients, seating areas to act as rest stops along corridors for people to pause and

sit down, a falls identifier on the wall to alert staff, clear way-finding so people have less

confusion about their destination, floor coverings that will help ensure ease of walking and

have no dramatic changes in texture or colour.

The design of the bedrooms and the presence of an AIN (under the direction of a Registered

Nurse) will allow close supervision/observation of high risk individuals to help reduce the risk

of falls. Careful consideration will occur with respect to the patients who will be admitted into

these rooms.

An integrated IT solution will be used to record and display risk warnings for patients following

holistic assessment providing a comprehensive identification of patient risk

8 KEY FUNCTIONS OF REHABILITATION AT UCPH

Centralised care provision for rehabilitation services at UCPH will be facilitated by:

o Inpatient and ambulatory services provided from a single facility;

o Co-location and integration of rehabilitation services and specialised staff;

o Centralised specialised services with a greater critical mass enabling the maintenance

of specialised skills;

o Optimised sharing of knowledge and staff training; and

o Capacity to flex up/down the rehabilitation specialised ward to meet changing patient

demand.

Improved patient care:


o Streamline care and develop best practice protocols and pathways across care

settings;

o Support early detection and prevention of complications that might adversely impact

rehabilitation outcomes;

o Provide early intervention to prevent de-conditioning, maintain and improve function

while in the hospital, thereby potentially reducing length of stay and improving

patient outcomes;

o Cohort patients to ensure staff have the appropriate skill sets to manage their

complex rehabilitation needs; and

o Availability of emerging, innovative therapeutic technology to assist in maximising

patients outcomes.

Optimise bed management and the patient journey:

o Provide earlier specialist rehabilitation assessment, management and discharge

planning;

o Using ambulatory rehabilitation services optimally to enable early discharge; and

o Provide earlier transfer from an acute bed and reduce total length of stay.

9 PRINCIPLES OF CARE

9.1.1 SAFE AND HIGH QUALITY CARE

Services will be evidence based;

Services will be provided in the ACT where there is an appropriate level of demand to ensure

ongoing clinical competence, or will be referred elsewhere as necessary;

Safety for patients, family/support people and staff will be paramount and include provision

of safety measures, such as dual access to clinical spaces where necessary and use of duress

alarms; procedures to support safe medication management; appropriate provision of

security staff presence and systems; appropriately trained staff including first aid procedures;

implementation of quality improvement procedures and systems; standardised care across

facilities;

Clinical areas will be designed in a way which facilitates safe care including uniform efficient

design of inpatient units to aid orientation, flexibility of use and co-horting of patients

(grouping of like patients). Safe care will also be optimised through the placement of staff

spaces that enable observation of patient and visitors in key clinical and gathering areas; and

Continuity of care comprised of organised and coordinated care with a steady flow of patients

through the various elements of the system/services.


9.1.2 ENHANCED PERSON CENTRED CARE

Care will be delivered in the right place at the right time for all patients.

The person will be the driver of their care.

Inclusion of family and carer support:

o When available and with patient permission, family and support people will be

encouraged to be involved;

o Care provision will consider the needs of the family/support people; and

o It is acknowledged that some patients may need support to drive their own care, for

example, people with cognitive impairment. An alternative approach will be agreed

with the patient/family/support people and the clinical team if necessary.

The extent to which the patient story has to be retold will be minimised.

Key components of the patient pathway including assessment, goal setting and reviews, care

planning and discharge planning will be undertaken using a collaborative approach between

the patient, their family/support people and the care delivery team.

Patients, families and support people will be well-informed through the provision of

understandable and accessible educational health information and community resources.

Resources will be provided in simplified language and structure to make information

accessible to persons of all literacy levels, and provide clear, focused and usable information.

Care will be provided using effective communication characterised by plain language and clear

verbal communication. Messages will be tailored to the needs and preference of the receiver.

Care provision will respect and promote patient and family/support people choice.

Care provision will empower individuals to actively participate in the planning and

implementation of their care by embedding health literacy into all aspects of care so that

individuals can take appropriate actions and make effective decisions for their own health.

Goal setting will focus upon the social, economic and cultural factors influencing health of the

individual.

9.1.3 ADVANCE CARE PLANNING

Advance care planning will be encouraged. Patients at UCPH will be encouraged to consider

the importance and benefits of having an Advance Care Plan, this will include patients

transferring from ACT hospitals and from other regions.


9.1.4 EARLY INTERVENTION/CANBERRA HOSPITAL ACUTE SUBACUTRE EARLY

REHABILIATION SERVICE (CHASERS)

Early assessment of patients will occur in the most appropriate setting and at the most

appropriate time.

Communication between all services will be optimised (e.g. between GPs and Community

Based Services, between acute and rehabilitation inpatient services).

Clear eligibility criteria will guide appropriate and timely referrals.

Appropriate service provision in ambulatory settings will aim to avoid hospital admission

where possible.

Early intervention will include the provision of inreach services provided by rehabilitation

teams into acute care with the possibility of shared care service provision between

medical/specialised acute care and rehabilitation.

An acute illness may be treated in parallel with commencement of a rehabilitation program

to prevent functional decline during acute illness.

Early discharge planning will reduce discharge delays.

9.1.5 ENABLEMENT

Fundamental to the Model of Care is an enablement approach which addresses all aspects of

care needs for individuals including the physical, psychological, social and spiritual.

Treatment will occur at every point of contact with the patient and will be focused on the

achievement of meaningful tasks for individuals.

Within the context of rehabilitation this model seeks to ensure that each individual is

internally motivated, rather than externally motivated, to achieve their goals.

Services will be provided within an enabling environment which includes effective way finding.

9.1.6 MULTIDISCIPLINARY AND COLLABORATIVE SERVICES

A coordinated and integrated approach to the provision of health services will include:

o Patients have access to a specialist rehabilitation multi-disciplinary team who works

collaboratively;

o referral systems to support a seamless transition between services;

o clearly defined roles for each multi-disciplinary team member with efficient and

effective communication between team members;

o future use of a single electronic health record;


o holistic coordination of care involving the individual;

o use of shared, bookable and multipurpose clinical spaces where appropriate; and

o professional multidisciplinary education.

Shared care, collaboration and partnership between the rehabilitation service, community

services and teams in acute hospitals.

9.1.7 ACCESSIBILITY

Service delivery will be timely, equitable and appropriate.

Environments that are easily accessible for people of all ages and abilities will be provided

(e.g. parking that is appropriate for people with a disability, wheelchair access throughout

facilities etc.). This will include careful design for way finding and selection of signage, central

telephone number to access services, and a central entry point for services.

Service accessibility will be optimised including ‘one stop shop’ concept:

o access to services at a time that addresses care needs; and

o easy patient access to relevant components of health records.

Access to services will be timely and fair utilising a waitlist and priority booking system and

ensuring effective communication to patients and their families.

9.1.8 CULTURALLY APPROPRIATE AND INCLUSIVE SERVICES

Environments will be provided that are sensitive to a variety of cultures with appropriate

selection of artwork and support spaces.

Appropriate access to interpreter services will be monitored and reviewed when necessary.

Services will be culturally competent, safe and appropriate for Aboriginal and Torres Strait

Islander peoples.

Services will be accessible in culturally safe and appropriate ways to people from culturally

and linguistically diverse (CALD) communities, and will increase health literacy.

Care provision will be provided consistent with the approach outlined in ACT Health’s Stretch

Reconciliation Action Plan 2015–18 for which the vision is “ACT Health will continue on the

journey of healing by walking together with Aboriginal and Torres Strait Islander peoples so

that they may enjoy a quality of life, life expectancy and health status equal to all Australians.”

Care provision will include ongoing engagement with Aboriginal and Torres Strait Islander

communities as appropriate.

Care provision will be provided consistent with ACT Health’s Towards Culturally Appropriate

and Inclusive Services, A Co-ordinating Framework for ACT Health 2014–2018 for which the


key objective is to “provide a co-ordinating framework to guide ACT Health in delivering

culturally appropriate and inclusive services and information, based on national and

international best practice”.

Care provision will include ongoing partnering with consumers and engagement with CALD

communities as appropriate when developing services.

9.1.9 EFFICIENT, COST EFFECTIVE CARE

Ensuring efficient and effective allocation of resources based on priority needs and evidence

based practice:

o grouping of patients with like needs;

o placing services close to where patients are located;

o simplifying administration processes; and

o decreased waiting times.

9.1.10 EVIDENCE BASED CARE

All staff will be encouraged to undertake education, practical skills training and quality

improvement.

Research will be undertaken in conjunction with education partners where appropriate.

The latest research and best practices are incorporated into care provided through the

establishment of a centre of excellence in rehabilitation and geriatric services, with strong

collaborative arrangements for teaching and research.

Collaborative practice with academic colleagues from the University of Canberra and other

educational facilities will enable multidisciplinary knowledge translation into clinical practice.

9.1.11 APPROPRIATE USE OF INFORMATION, COMMUNICATION AND TECHNOLOGY (ICT)

Incorporating the most contemporary systems for:

o patient management (patient information, referral, registration, ticket and queuing

systems and care coordination);

o patient access to information;

o data capture;

o telemedicine and videoconferencing;

o wireless technology;


o facility systems (scheduling of rooms, equipment monitoring and tracking, safety and

security, building management etc.); and

o rehabilitation therapeutic/assistive technology.

Access to ICT systems to be facilitated through adequate provision of fixed and mobile devices

(e.g. tablets).

ICT systems will enable integration between patient booking and scheduling systems, ACT

Patient Administration System (ACTPAS) and queuing systems.

ICT will accommodate future therapeutic technologies e.g. Occupational Therapy home

assessment undertaken remotely in conjunction with the patient/family to review a patient’s

home environment, use of robotic limbs etc.

10 STANDARDS AND BEST PRACTICE CARE PROVISION

The safeguarding standards at UCPH will align with those of ACT Health’s clinical services. The quality

standards ACT Health works to are the National Safety and Quality Health Service Standards as

developed by the Australian Commission on Quality and Safety in HealthCare.

All staff are expected to work within their professional standards inherent in their registration with

the Australian Health Practitioner Regulation Agency.

The multidisciplinary team will operate in accordance with the Australasian Faculty of Rehabilitation

Medicine standards for inpatient rehabilitation.

The best practice elements of care provision in the RACC UCPH Model of Care include;

Creation of an enriched hospital environment with spaces that provide opportunity for

activity;

Development of services in a less clinical environment with access to outdoor space, to

enhance the individual’s perception of wellness and progress;

Safe care will be optimised through the placement of staff spaces that enable observation of

patients in key clinical and gathering areas;

The individual will be the driver of their care, involving family and carers where appropriate;

and

Joint teaching and research ventures between UCPH based staff and the University of

Canberra.

11 CLINICAL GOVERNANCE

Clinical governance provides a framework which ensures that organisations are accountable and have

systems in place for continuous quality improvement to safe guard high standards of clinical care.


Rehabilitation Services at UCPH will operate as an entity within ACT Health and as such will operate

within the overarching clinical governance framework of ACT Health.

Clinical governance activities are dynamic; changed as new evidence is reviewed. They are created in

an environment and culture that:

Encourages communication and feedback from all people affected by clinical practices;

Ensures best evidence-based practice is maintained and processes improved to ensure that

services are “fit for purpose” in terms of accessibility, acceptability, effectiveness and equity;

Has strong leadership that supports team work, organisational values and positive culture

change;

Gives opportunities for people to be involved in the decision-making related to their health

care because they are the experts; and

Incorporates strategies for individual and family/carer involvement in the planning of health

care both at the clinical and organisational level.

Examples of current good clinical governance practices include undertaking clinical audits, maintaining

staff training and education, critical incident reporting, risk assessment and management and

responding to feedback.

12 INPATIENT UNIT MODEL OF CARE

The future Model of Care for UCPH rehabilitation inpatient services will include an expanded range

and capacity of services by specialised multi-disciplinary teams.

Service streams have been developed to ensure that multi-disciplinary teams with specialised

therapeutic expertise can be established to best meet the care needs of patients and to facilitate

continuity of service. Different streams will have different patterns of service delivery. Inpatient and

ambulatory service streams are aligned to facilitate continuity between services. It should be noted

that the service stream for some patients may be unclear due to complex needs (e.g. younger adult

with early onset dementia). Patients will be allocated to the service stream which best meets their

clinical needs, as determined by the multi-disciplinary team, and where necessary specialised staff

may be consulted across the different service streams.

Rehabilitation will focus on assessing each person’s activity performance, participation and

environmental considerations and treating their impairments and restrictions. Care provision will

address each person’s health and wellbeing, mobility capacity, activities of daily living (ADL)

performance (including their vocation), communication and cognitive capacity, community

participation and environmental considerations. It will include a wide range of interventions as

clinically indicated and may include cognitive activities, independent practice, recreational and leisure

activities and self management of medication (where appropriate through the use of secure

medication storage within bedside lockers).


Rehabilitation services will be based on individualised rehabilitation assessments and agreed goals.

Patients accepted for rehabilitation will have a demonstrated potential to benefit from the service.

Patients will be allocated to one of the inpatient units based on their presenting condition and their

rehabilitation needs and tolerance. Both fast stream and slow stream rehabilitation programs will be

provided as noted above.

Inpatient services to be provided at UCPH are:

12.1 NEUROLOGICAL REHABILITATION UNIT

Providing care for patients with a range of neurological conditions including but not limited to stroke,

brain injury, spinal cord injury, motor neurone disease, multiple sclerosis and Guillain-Barre syndrome.

12.1.1 KEY ELEMENTS

Patients with neurological rehabilitation requirements will be co located.

Patients will attend dedicated therapy areas.

Patients will attend the dining room for all meals.

Patients will get dressed each day in day wear clothes.

The multidisciplinary workforce will reflect the acuity of the neurological rehabilitation

requirements.

The multidisciplinary team will attend progress meetings, case conferences and family

meetings as required.

A Rehabilitation Care Coordinator will be included in the multi disciplinary team.

Multidisciplinary team (MDT) assessment within 24-72 hrs of admission.

Patients are provided with agreed rehabilitation goals within 24-72 hrs of admission.

Goal achievement is reviewed regularly.

Patients will be able to participate in at least three therapy sessions per day as clinically

indicated.

12.1.2 TRANSITION UNIT

In order to support a smooth transition back to living in the community after a period of

extended rehabilitation, there will be provision of a ‘transition’ unit that can accommodate a

family member/support person. This unit will have a bedroom with a dedicated adjacent

beverage bay and sitting area to allow patients to practice functional skills and for

family/support people to practice providing care to the patient.


12.2 GENERAL REHABILITATION UNIT

Providing care for patients with a range of conditions including but not limited to: amputations, de-

conditioning and disability associated with medical illness, surgery or trauma.

12.2.1 KEY ELEMENTS

Patients with general rehabilitation requirements will be co located.







MDT assessment within 24-72 hrs of admission.



Patients will be able to participate in at least three therapy sessions per day as clinically

indicated.

12.3 OLDER PERSON’S REHAB ILITATION UNIT

Older age appropriate rehabilitation services for patients who are likely to have a range of medical co-

morbidities associated with ageing. Care provision will include GEM services. Patients may have the

following conditions/co-morbidities: cognitive impairment, hip and other fractures post surgery or

non-operative management, orthogeriatric conditions, de-conditioning, Parkinson’s disease.

12.3.1 KEY ELEMENTS

The older persons unit may be suitable for: people aged 65 and over and Aboriginal and Torres

Strait Islander peoples aged 50 years and over.

It will be prioritised for people aged 80 and over. Admissions outside of the age groups will be

considered if the patient has progressive Parkinson’s disease and/or co-morbidities typically

associated with ageing.

Patients suitable for older persons rehabilitation will be co located.








MDT assessment within 24-72 hrs of admission.



Require complex, interdisciplinary assessment or comprehensive geriatric assessment.

In addition to the specialised requirements detailed for adult rehabilitation, particular

innovative care needs recognised for the older patient will be embedded into care delivery

where appropriate. Older person’s rehabilitation, including GEM, will be characterised by:

o Specialised assessment which addresses the multidimensional problems associated

with the ageing process;

o Care provision will address physical, social and psychological needs of individuals and

facilitate patient participation with a view to optimising health and well-being and

community participation;

o Patient participation will be optimised through assessment of individual interests and

tailoring of therapy to align with individual preferences where appropriate; and

o Provision of care within an enriched environment will be of particular relevance to the

older patient. An enriched environment provides person centred care in an

environment that is home-like as well as containing specific therapeutic design

features for an older cohort of patients.

Care provision will incorporate the key principles for the care of older patients, as detailed

within Best Care For Older People Everywhere, The Toolkit 2012 (Government of Victoria) as

appropriate:

o Person-centred care and advance care planning

o Assessment

o Communication

o Mobility/vigour/self-care

o Nutrition and swallowing

o Cognition, delirium, dementia and depression


o Continence

o Medication

o Skin integrity

o Pain

o Palliative approach to care.

Geriatric Evaluation Medicine (GEM) care will be provided as a key component of the older

person’s rehabilitation service and will include specialised assessment and treatment which

addresses the multidimensional problems associated with ageing. GEM has been developed

to ensure that older people at risk of functional decline, and those with functional deficits and

the ability to reverse their functional decline, receive specialised care and leave hospital in the

shortest possible time, with the highest level of function, independence, dignity and individual

participation that can be achieved.

Other aspects of care provision specific to older person’s rehabilitation needs may include

provision of less intense rehabilitation over a longer period of time, assessment of nutritional

and oral health status, assessment of status of cognition, continence and skin integrity.

Discharge to the usual place of residence will be the primary goal of management, but transfer

to an alternative long term facility such as residential aged care or extended care may be

required.

The innovative design of the new facilities will support appropriate management of patients

with cognitive impairment including dementia. The new facilities will provide an environment

which:

o Is safe and secure (including outdoor space, the ability to ‘close’ each of the inpatient

units and the ability to use bed sensor alarms in each bedroom);

o Has effective and intuitive way finding ;

o Minimises unwanted stimulation;

o Highlights helpful stimuli;

o Provides opportunities for both privacy and community; and

o Is domestic and familiar.

A secure courtyard will be accessible from the inpatient unit accommodating GEM patients to

provide a safe environment where patients who may be confused and at risk of wandering are

able to spend time. It will also be possible to ‘close’ each of the inpatient units and to use bed

sensor alarms in each bedroom.


It may be necessary to monitor the movement of some patients in order to ensure their safety.

If necessary, this will be undertaken in the least intrusive way possible e.g. through use of

wrist or arm band linked to a hand held device carried by nursing staff.

12.3.2 DEMENTIA CARE IN HOSPITALS PROGRAM

To support patients with cognitive impairment, the Dementia Care in Hospitals Program,

which has recently been introduced at Canberra Hospital, will be rolled out across UCPH.

12.4 SLOW STREAM REHABILITATION UNIT

Rehabilitation services for patients with limited tolerance or ability to participate in rehabilitation.

Patients may have the following conditions: non weight bearing restrictions, patients who require

maintenance services whilst awaiting completion of home modifications or placement into residential

aged care after their rehabilitation episode. Patients will have a determined place of discharge before

admission to this ward.

Note: Clear protocols will ensure that this rehabilitation unit does not become an overflow ward for

other units.

12.4.1 KEY ELEMENTS

Patients with similar rehabilitation requirements will be co located.

Patients are provided with mutually agreed rehabilitation goals within 72 hrs of admission.

Patients should attend dedicated therapy areas.

Patients should attend the dining room for all meals.

Patients should get dressed each day in day wear clothes.




MDT assessment within 48 hrs of admission.


Ability to participate in at least two therapy sessions per day as clinically indicated.

Have a planned and accepted place of discharge prior to admission to the unit.

12.5 COMMON ELEMENTS OF AN INPATIENT ADMISSION

12.5.1 THERAPY SESSIONS


Will be programmed weekly to inform the patient and their family/support people of their

rehabilitation schedule to facilitate appropriate participation of family/support people in the

patient’s care as well as to inform appropriate visiting times. Therapy sessions may be

undertaken in a range of areas including gyms, bathrooms, outdoor areas and hydrotherapy

etc.

Therapy sessions will incorporate the use of therapeutic technology such as robotics for

patients for whom this would be a benefit to their rehabilitation.

12.5.2 ACTIVITIES OF DAILY LIVING (ADL)

Assessment and treatment sessions will be undertaken in the ADL kitchen, bathroom and

laundry spaces, in the community (e.g. home visit and social integration sessions held in a

shopping centre, gymnasium or other space) and other clinical/therapy areas as appropriate.

12.5.3 THERAPY SPACES

Patients will be encouraged to spend the majority of their day in the living and day therapy

spaces provided within the inpatient areas.

Patient bedrooms will be utilised as an after-hours space for patients. Appropriate rest periods

will also be encouraged and patients and their family/support people will have access to a

range of spaces to spend their leisure time (lounge, recreation and outdoor spaces). Some

functional retraining sessions including patients and possibly their family/support people may

be undertaken within the patient bedrooms.

To support the rehabilitation process, UCPH will feature a number of patient gardens, group

spaces for art and a kitchen for cooking. These spaces will be used as therapeutic spaces that

encourage people to participate.

Electronic games will continue to be used as they are currently in a range of rehabilitation

services.

12.5.4 LENGTH OF STAY

Each person’s expected length of stay (LOS) and expected discharge date (EDD) is calculated

by assessing their current function (usually with a functional assessment tool) and then

comparing it with benchmarked expected LOS when they are admitted.


12.5.5 FALLS ASSESSMENT

All patients will have a falls assessment within 24 hours of admission to an inpatient unit at

UCPH as per the Falls Policy for ACT Health

12.6 ADDITIONAL SERVICES

Services that will also be accessible to inpatients include, but are not limited to:

12.6.1 MEDICAL CONSULTATION SERVICES

Services include: cardiology, respiratory, orthopaedics, surgical, endocrinology, consultation

liaison psychiatry.

These services may be accessed by face to face consultation or via tele-health depending on

the patients needs.

12.6.2 RESIDENTIAL AGED CARE LIAISON NURSE (RACLN)

The RACLN will support clients and their families through the process of application to

Residential Aged Care Facilities by providing advice and information on Aged Care Facilities

across the ACT Region.

12.6.3 PALLIATIVE CARE CONSULTATION

Specialist Palliative Care services will not operate from UCPH. Palliative care will be available

at UCPH for patients already admitted to UCPH; if their condition deteriorates and if palliation

is the appropriate choice. Existing UCPH patients may be palliated at UCPH, at Clare Holland

House or transferred home depending on patient/family preference, the availability of

palliative care beds and clinical needs.

12.6.4 PAIN MANAGEMENT

UCPH will not have a chronic or acute pain team on site; however, chronic and acute pain can

be well managed by the Rehabilitation Physicians and Geriatricians. The management of pain

is considered when developing the rehabilitation care plan. Pain management will be on a

case by case basis and if additional or more specialised pain management services are

required, assistance can be sought from services such as the Acute Pain Service based at the

Canberra Hospital campus.

12.6.5 DIABETES EDUCATOR


Specialist diabetes education will be available as needed. These services may be accessed by

face to face consultation or via tele-health depending on the patient’s needs.

12.6.6 TISSUE VIABILITY TEAM

Consultation from the tissue viability team will be available at UCPH. These services may be

accessed by face to face consultation or via tele-health depending on the patients needs.

12.6.7 INFECTION CONTROL

The Infection Control Team will provide consultative services at UCPH as required.

12.6.8 ABORIGINAL AND TORRES STRAIT ISLANDER LIAISON SERVICE

Aboriginal Liaison Officers will be available at UCPH to support a culturally sensitive approach

for Aboriginal and Torres Strait Islander people. These staff members will travel between ACT

Health locations as needed.

Aboriginal Liaison Officers will be based at UCPH during agreed hours. This service will be

coordinated through the CHHS Aboriginal Liaison Service. Aboriginal Liaison Officers will

access multipurpose space (workspace, lounge and courtyard) when on-site.

12.6.9 VETERANS AFFAIRS

The CHHS Veteran’s Liaison Service, based at Canberra Hospital, will provide a visiting service

to eligible UCPH inpatients. The visiting Veteran’s Liaison Officers will access shared bookable

workspace and meeting space.

12.6.10 MULTI-FAITH STAFF

The multi-faith service will provide physical, social, emotional and spiritual care and support

to patients, staff and visitors of UCPH.

Multi-faith staff will be based at UCPH and coordinated through the Canberra Hospital service.

Visiting multi-faith staff will have access to counselling rooms, office space and change

facilities. Multi-faith staff will have access to clinical records in order to record their input;

however, will not be able to read the clinical record. This service will be supported by

volunteers

The Multi-faith, Aboriginal Liaison and Veteran Affairs services will be supported at UCPH by

a specially designed multi use area to accommodate the supportive needs of different patient

groups at UCPH including a lounge, meeting space and courtyard. A multi-faith room similar

to a chapel will be provided centrally within UCPH and be accessible for patients, staff, support

people and visitors 24 hours a day, seven days a week.


12.6.11 VOLUNTEERS

Volunteers are an important part of our health services in the ACT. They generously donate

their time to assist in a variety of programs and a number of new, interesting roles will be

available at UCPH.

It is envisaged that UCPH will be supported by an extensive group of volunteers providing a

range of services including a volunteer concierge/way finding service. Volunteers will also

undertake a range of activities throughout the facility including within clinical areas.

Volunteers will not replace anyone in a paid role; however, their presence in various areas of

UCPH will help to enhance the patient and visitor experience. A range of roles and

opportunities that are tailored to the rehabilitation environment will be considered, such as

companionship, facilitating activities (for example arts and crafts), music, gardening, providing

therapy dogs and way-finding will also be considered.

Volunteers will be based within the main entrance and operate a shop-front service. Details

regarding this service are still to be developed.

12.6.12 CONSUMER ENGAGEMENT TEAM

The Consumer Engagement Team will provide services at UCPH as required.

12.7 ADMISSION

Admission to UCPH would be for the rehabilitation phase of someone’s recovery following surgery,

illness or injury, or as a step-up from community-based services.

Admission to UCPH inpatient units will be effective and responsive. A multi-disciplinary team will

determine whether the patient can be accepted for admission. If accepted, the patient will go onto a

waitlist which is developed based on clinical priority and need to ensure equitable and fair access to

services. Waitlist times will be minimised and the right care will be provided in the right place at the

right time for all patients.

People being admitted to an inpatient rehabilitation unit at UCPH must be accepted for admission by

either a Rehabilitation Physician or a Geriatrician. The movement of people into and out of the facility

will be coordinated by the Assistant Director of Nursing, the Clinical Nurse Consultants of the units,

the After Hours Hospital Manager and the Bed Management Unit based at Canberra Hospital. Patient

transfer between services and wards at UCPH will be minimised unless it is clinically required.

Pre-admission meetings will be held daily or as needed in order to:

Discuss the active waitlist;

Determine the most appropriate sub-acute inpatient rehabilitation unit for each patient;

Determine the priority for admission; and

Triage NSW patients to rehabilitation units in NSW where appropriate.


Direct admissions will be accepted to UCPH. Direct admissions will be managed in the same way as

admissions from Canberra Hospital.

12.7.1 ADMISSION CRITERIA

Considerations regarding each patient’s ability to benefit from sub-acute inpatient services include:

The patient has a recent impairment of functional ability due to illness or injury;

The patient has a condition that is likely to be responsive to rehabilitation;

The patient has reasonable prospects for functional gain within a reasonable timeframe;

The patient requires the input of a multi-disciplinary rehabilitation program to achieve

functional gain; and

The patient cannot be managed in a more appropriate lower level of care (for example, cannot

be safely and effectively managed in a community based rehabilitation program).

12.8 DISCHARGES AND TRANSFERS

Discharge planning is an integral part of the rehabilitation model of care. The plan for discharge starts

at the beginning of the journey with the setting of the rehabilitation goals.

Following completion of a period of inpatient care, patients may be transferred on to other

services or discharged as follows:

o Patient achieves all of their treatment goals and further input is not required;

o Patient achieves all of their sub-acute inpatient treatment goals and is ready to

progress to another care setting (e.g. TTCP, day or sessional programs);

o Patient is no longer benefiting from treatment and may be referred on to alternative

care or discharged from the service; and

o Patient chooses to access services in another area or through alternate means such

as private treatment.

Inpatients will have access to the Rehabilitation Care Coordinator as part of the multi-

disciplinary team.

o Rehabilitation Care Coordinators and efficient flow of information will ensure that

post-discharge supports are in place prior to the person being discharged from UCPH;

There are various step down models such as the day program, ‘rehabilitation at home’ and

sessional rehabilitation to ensure people are discharged from the service as they are ready;

UCPH is not intended to be a place where people will stay waiting for placement into an aged

care or similar facility; ideally, each person will need to have identified a discharge destination,


options or plans prior to admission, this is important to the development of their individual

care plan; and

Proactive discharge planning from the multi-disciplinary team will ensure services and

supports are in place. Strong links exist with community nursing, ambulatory services and the

Equipment Loan Service (ELS) to ensure that services required are in place prior to discharge.

12.8.1 DISCHARGE OR TRANSFER OF CARE PROCESS FROM THE INPATIENT UNITS

Discharge or Transfer from the inpatient units will include:

Allocation to a care stream for day programs or sessional programs if appropriate;

Review of progress/achievement of goals;

Setting of goals for next stage (in collaboration with the appropriate stream);

Identification of best path/level of intensity;

Identification of services and referrals made as needed; and

Follow-up support and involvement of GP, other community service providers (e.g. domiciliary

services, Meals on Wheels, community pharmacy) and the NDIS as appropriate. This will

include provision of a comprehensive and timely discharge summary to the patient’s GP.

12.8.2 TRANSITION FROM UCPH INPATIENT SERVICES TO OTHER CARE SETTINGS

Care Transition will be supported through:

The provision of flexible care delivery (e.g. leave passes for patients to spend time at home

over the weekend practicing their return to living at home prior to formal discharge from

inpatient services to ambulatory services);

Forward planning of services including integration with domiciliary services, equipment loan

services and advance life care planning; and

Access to the transition unit within UCPH (independent living space with self contained

kitchen and living space).

A patient may experience an acute illness or injury which results in the need to be transferred back to

an acute hospital. This will be coordinated with the Bed Management Unit of the receiving hospital.

13 AFTER HOURS MANAGEMENT

13.1 ADMISSIONS AND DISCHARGES


After-hours and weekend admissions will be accepted and planned ahead where possible. It is

anticipated that after hours and weekend admissions will not be high frequency due to the lower

acuity of patients generally being admitted to a sub-acute facility, however those patients destined

for the Older Person’s Rehabilitation Unit may be higher acuity and/or more functionally dependent.

Weekend discharges may occur but will be planned ahead where possible.

Good quality and well-managed handover at all times will be a key feature of the service. UCPH will

have an appropriate management structure that fits within the broader ACT Health arrangements,

with appropriate channels for escalation in place. Medical coverage will be provided 24 hours, 7 days

a week onsite. This will be provided across the whole facility, with shared on-call arrangements. Junior

Medical Officers will assist in providing after-hours care. These features of the service will support

admissions and discharges during business hours and after-hours/on weekends.

13.2 AFTER HOURS CLINICAL CARE AND MANAGEMENT

After hours and on weekends, there will be rostered medical coverage. The Rostered Medical Officer

(RMO) will cover all wards and have advanced life support skills, similar to day staff. A consultant

(Rehabilitation Physician or Geriatrician) will be available on-call.

Allied health staff will have flexible hours of service to enable to provision of therapy at the right time

and right place for every patient.

UCPH will have nursing cover 24 hours a day. In addition to inpatient nursing staff, the After Hours

Nurse Manager will also have appropriate skills for supporting deteriorating patients.

Nursing Management of the hospital after-hours will be required to coordinate the following:

Clinical Leadership e.g. management of deteriorating patient after-hours, clinical education

and support;

Personal Leave replacement and the deployment of relief and casual nursing staff required to

work in clinical areas across the hospital on a shift by shift basis;

All after-hours fire, emergency and maintenance situations affecting infrastructure; and

Internal and external requests for admissions.

14 HOURS OF OPERATION

The inpatient units will be staffed to operate 24 hours per day, 7 days a week.

The multidisciplinary team will provide normal business hours services as well as services outside of

business hours to support patients and facilitate the involvement of carers/family members.

14.1 VISITING HOURS

It is anticipated that regular visiting hours will be between 06:00 to 21:00. Visiting and access will be

available after hours in consultation with the patient and nursing staff. An intercom system will be

available to contact security and the inpatient units after hours for entry.


15 CARERS, FRIENDS AND FAMILY

It is acknowledged that family members and carers are a vital part of the rehabilitation journey. As is

current practice, if the individual agrees to their involvement, family members and carers will be

welcomed to assist them in their recovery journey. Importantly this includes assisting them with their

home therapy programs when they are ambulatory patients and, when safe and appropriate, assisting

in therapy programs with inpatients.

To support the presence of carers, friends and family, UCPH will have family lounges and quiet spaces

where they can visit with patients. Within each unit there is a dedicated desk space where patients,

carers or family can access the free Wi-Fi and work quietly if needed. In instances where a family

member may need to stay overnight, roll-out overnight beds can be placed in the room but must be

organised through the nurse in charge of the ward. Additionally for those patients who are ready to

transition home, the independent living unit may be suitable. This unit includes a lounge and kitchen

with facilities for a carer or family member to stay overnight.

16 ENGAGEMENT AND CARE COORDINATION:

Rehabilitation is time limited and goal directed. It is intended that people will participate in goal setting

meetings with their multi-disciplinary team of clinicians and their families/carers, to set goals that are

attainable and will preserve the person’s dignity. Each person’s goals will be highly individualised and

specific to their needs, and their rehabilitation will reflect these goals. The goals will be monitored and

discussed with the individual, their family/carers and treating team on a regular basis. This process is

consistent across both the inpatients and day/ambulatory based services.

When setting goals, risks will also be evaluated. Goals will be matched with each individual’s capability

on a case-by-case basis ensuring they are approached as safely as possible.

Care Coordination is a key part of the RACC UCPH Model of Care. It is recognised that people benefit

from consistency and continuity of care and as such will be allocated a Rehabilitation Care Coordinator

when admitted to the inpatient units. In the inpatient setting the Rehabilitation Care Coordinators

assist with the process of transiting people from acute settings into the appropriate rehabilitation

ward. Rehabilitation Care Coordinators will be included in the Day Service Model of Care and will be

allocated to patients as required.

The Rehabilitation Care Coordinator will be the point of contact throughout the recovery journey for

people and their family in both the inpatient and day/ambulatory based services. Elements of this

role include:

Providing a focus for engagement and will maintain regular contact with people, providing

encouragement and support;

Discussing the rehabilitation process and expectations with people and their families;

Review of referrals as part of the multidisciplinary team;

Leading the process of reviewing and updating care plans; and


The instrumental coordination of the discharge process by attending goal setting and family

meetings, attending discharge meetings and generating referrals to ambulatory services.

17 DETERIORATING PATIENTS

While patients accommodated within a sub-acute hospital setting, such as UCPH, will be of a lower

medical acuity, processes and protocols are required to be able to safely manage the deteriorating

patient. This may be required for the following:

Medical emergency, for example; in the event of acute coronary and cerebral events, falls,

delirium and other unanticipated events; and

Non-urgent deterioration, for example; increased pain or wound breakdown.

For the management of medical emergencies, UCPH will not have a Medical Emergency Team (MET).

An operational model has been determined for a First Response Team. This team will consist of senior

medical and nursing staff with specific training in managing the deteriorating patient and medical

emergencies. The operational model has been informed by a review of deteriorating patient data, the

deteriorating patient program on existing wards and consultation with other stand alone facilities.

Management of the deteriorating patient will include:

The establishment of a first response team comprised of nominated medical and nursing staff

who respond in the event of a medical emergency.

Assessment, intervention and monitoring by medical and nursing staff within the patient’s

clinical area.

Appropriate escalation of care.

o A high level emergency would require a call to the ACT Ambulance Service, and

management may include transfer to an acute facility; and

o If an individual’s condition is deteriorating and/or there are changes in their function,

they will be assessed by the medical team based at UCPH and referred to an

appropriate acute service if required.

The development of the response process and team reflects the profile of the patients at UCPH. The

clinical skills and education needs required for the team will be incorporated into the workforce profile

and training schedule for UCPH. As part of mandatory training requirements, all nursing staff are

required to be credentialed in Basic Life Support annually and competent in the use of the Modified

Early Warning Score (MEWS) or equivalent tool.

18 DAY REHABILIATION SERVICE


The provision of RACC day programs at UCPH will represent a predominantly new service for ACT

Health. The rehabilitation and geriatric day programs and sessional therapy to be provided at UCPH

will be characterised by specialised services provided by dedicated care streams. The day program will

provide an alternative to inpatient care.

Such services generally could not be provided in the community setting due to the nature of

specialised requirements and intensity of care provision (as can be provided in the day programs).

Service streams will be established to ensure that multi-disciplinary teams with specialised therapeutic

expertise can best meet the care needs of patients and facilitate continuity of service. These service

streams are described below and are reflective of the inpatient service streams to facilitate continuity

between services. When necessary, specialised staff will be consulted across the different service

streams.

Day programs and sessional therapy will be provided in the following service streams:

18.1 NEUROLOGY STREAM

Recently acquired conditions.

o Providing care for patients with recently acquired conditions including acquired and

traumatic brain injury, stroke, spinal injury and newly diagnosed Parkinson’s disease.

Progressive neurological conditions.

o Providing care for patients with progressive neurological conditions such as multiple

sclerosis, Huntington’s disease, traumatic brain injury or stroke management and

motor neurone disease; and

o Care provision may include less intense, long duration services that are more likely to

be home based. Relevant community health providers will be involved in assessment,

initial goal setting and discharge planning.

18.2 GENERAL STREAM

General stream providing care for patients with complex acute and chronic conditions

including upper limb or lower amputation, musculoskeletal pain or injury including multi-

trauma, joint replacement and fractures.

It is noted that a number of diagnostic groups may be aligned with different streams as clinical

needs will vary at different stages, for example:

o Spinal cord injury rehabilitation vs. long term management – during the rehabilitation

phase care provision may focus more upon neurological care whilst long term

management may focus more upon musculoskeletal care; and

o Long term care for a patient with Parkinson’s disease may be most closely aligned

with geriatric services to address issues such as depression, psychosis, dementia,

sleep disturbances and medication management. Alternatively care provision may be


best addressed by the progressive and chronic neurological condition specialised

stream.

18.3 OLDER PERSON’S STREAM

Older person’s stream providing care for patients with conditions related to the ageing

process with a focus upon the treatment of frailty and functional decline.

A characteristic of older person’s care is that conditions may be slowly resolving with changing

medical problems and ongoing functional impairment, requiring rehabilitation/restorative

care at a less intensive level, but over a longer period of time.

Aspects of care provision specific to geriatric rehabilitation needs may include assessment of

nutritional and oral health status, assessment of status of cognition, continence and skin

integrity.

The tolerance of geriatric patients will be carefully assessed in developing the optimal day

rehabilitation program for these individuals.

Geriatric Day Program patients may also access clinics to address the major geriatric

syndromes of falls and mobility problems, continence, memory loss/dementia and others as

appropriate, via the Memory Assessment Service, Falls Injury Prevention Service, DARS and

P&O as indicated.

Note: there is some overlap between the above inpatient and ambulatory services streams with the

existing Transitional Therapy and Care Program (TTCP). Eligibility criteria for these services will be

more clearly defined to ensure that in the future there is no duplication of services.

18.4 DAY REHABILITATION SERVICE ADMISSION CRITERIA

Considerations regarding each patient’s ability to benefit from sub-acute Day Therapy services

include:

The patient has a recent impairment of functional ability due to illness or injury;

The patient has a condition that is likely to be responsive to rehabilitation;

The patient has reasonable prospects for functional gain within a reasonable timeframe;

The patient requires the input of a multi-disciplinary rehabilitation program to achieve

functional gain; and

The patient cannot be managed in a more appropriate lower level of care (for example, cannot

be safely and effectively managed in a community based rehabilitation program).

Patients transferring from the Inpatient Units to the Day Service will meet the following additional

criteria:

The patient does not require 24/7 nursing care;


The patient does not require daily or overnight medical review; and

The patient can be supported to live safely in the community.

18.5 KEY ELEMENTS OF ALL DAY REHABILITATION PROGRAMS

Within each of the service streams, a range of specialised multi-disciplinary services will be

provided based on individualised rehabilitation plans including goals and indicative

timeframes.

Treatment will focus upon functional improvement, delivered through a goal directed, time

limited, coordinated program.

Appropriate break and meal times will be incorporated into the program.

In addition to the provision of services which are focused upon therapeutic intervention to

improve function, patients may also be referred to these services for geriatric medical

assessment.

Patient selection will be well targeted to ensure that patients who require geriatric medical

assessment will have access to the necessary diagnostic services (medical imaging and senior

medical input etc.).

18.5.1 FREQUENCY AND MODES OF DAY REHABILITATION SERVICE

Full and half day programs will be provided by specialised care teams with the provision of a

number of therapy sessions per visit, typically provided over 2-5 sessions per week according

to individual patient needs. Therapy sessions may be provided in centre or within the

community (e.g. patient’s home, workplace or public spaces) and may include individual and

group sessions as appropriate.

The duration and therapy within the program will be determined based on individual goals

and care needs.

18.6 HOURS OF OPERATION OF DAY REHABILITATION SERVICE

At the opening of UCPH the Day Rehabilitation Service will be open to patients from 8am until

5pm Monday to Friday.

19 AMBULATORY MODEL OF CARE (SESSIONAL THERAPY/SERVICES)

Rehabilitation and geriatric sessional therapy/services will provide a range of services for patients who

generally require less intensive intervention than those patients attending the day programs. Patients

may attend for single discipline sessional therapy or single session service (e.g. one-off multi-


disciplinary assessment) which is scheduled according to clinical need. Care provision will be within

the service stream described above.

Future care provision will include an enhanced and expanded range of services including the following

changes to service provision:

Additional services provided at UCPH e.g. geriatric medicine and aged care nurse practitioner

outpatient clinics

Relocation of existing Community Rehabilitation Team (to be part of the future Day Programs)

and Falls and Falls Injury and Prevention Program to UCPH

Relocation of speech pathology (adult and geriatric) and psychology (adult) ambulatory

services from Canberra Hospital to UCPH

Relocation of some clinics from the Village Creek Centre to UCPH including:

o Rehabilitation Medicine Outpatient Clinics;

o Rehabilitation Medicine Multi-disciplinary Outpatient Clinics; and

o Rehabilitation Nurse Practitioner Clinics.

In addition to the provision of single discipline sessional therapy, there will be a number of services

which are likely to be provided on a sessional basis. Sessional therapy/services will include a range of

specialised services provided predominantly from the UCPH site, however, home based services may

be provided when clinically indicated. These services will be characterised by the provision of complex

specialised care which cannot be provided within the community setting. Sessional therapy/services

may be integrated with day program services e.g. Memory Assessment Service or Falls and Falls Injury

Prevention Program assessment may be a component of a day program.

19.1 REHABILITATION AMBULATORY SERVICES:

19.1.1 REHABILITATION MEDICINE OUTPATIENT CLINICS

This service will be staffed by experienced Rehabilitation Physicians who will provide a

specialised consultative service for a range of disabilities occurring in association with medical

conditions.

19.1.2 REHABILITATION MEDICINE MULTI-DISCIPLINARY OUTPATIENT CLINICS

These clinics include the spinal review amputee clinic and spasticity clinic.

This service will be staffed by experienced Rehabilitation Physicians and a multi-disciplinary

team to provide a specialised consultative service to patients with a range of complex

disabilities following illness or injury e.g. spinal review clinic, spasticity clinic, amputee clinic.

19.1.3 REHABILITATION NURSE PRACTITIONER CLINICS


The Rehabilitation Nurse Practitioner will work within multi-disciplinary teams to provide

specialised rehabilitation services to patients with needs and health issues associated with

complex neurological conditions such as spinal cord injury and brain injury. The role includes

clinical assessment, treatment, referrals, and development of nursing management care

plans, discharge planning and follow-up as required. Consultations will be conducted within

inpatient units and in nurse practitioner clinics.

19.1.4 REHABILIATION-AT-HOME

Rehabilitation-At-Home is a home-based sub-acute rehabilitation service that aims to assist

people to achieve their best level of independence through early supported discharge from

hospital or outpatient based day programs. It provides eligible clients an individualised home

based rehabilitation program with the aim of optimising their functional performance post

inpatient admission. It supports people to return or stay at home and receive rehabilitation

services in their own surroundings, with the support of their usual family and community

networks.

19.2 GERIATRIC AMBULATORY SERVICES:

19.2.1 GERIATRIC MEDICINE OUTPATIENT CLINICS

This service will be staffed by experienced Geriatricians and nursing staff who will provide a

specialised consultative service for conditions associated with ageing. Services will include

screening and preventative services to address risk factors for these conditions e.g. cognition,

falls, memory loss.

19.2.2 AGED CARE ASSESSMENT TEAM (ACAT)

ACAT comprehensively assess the care needs of frail older people and facilitate access to

available care services appropriate to their care needs. ACAT determine eligibility for a range

of Australian Government subsidised aged care services.

19.2.3 AGED CARE NURSE PRACTITIONER

Aged care nurse practitioners work as part of multi-disciplinary process to assess and

determine management care plans; including implementation, referrals, discharge planning

and evaluating outcomes to ensure the best possible outcomes for older people. Services

include education and advice to patients, family/support people, other health professional on

the assessment and management of aged related conditions. Consultations will be conducted

within inpatient units and in nurse practitioner clinics.

The nurse practitioner will provide outreach services into the community as required.

19.2.4 FALLS AND FALLS INJURY PREVENTION PROGRAM


The Falls and Falls Injury Prevention Program will provide multi-disciplinary assessment and

interventions for older people who have experienced falls or who are at risk of falls. A range

of services will be provided:

o Prevention and early intervention;

o Providing and developing local community education activities and resources;

o Providing individual advice and information;

o Education programmes for medical and other healthcare staff; and

o Stepping On (a community based education program for clients over 70 years).

19.2.5 MEMORY ASSESSMENT SERVICE

The Memory Assessment Service will consist of a multi-disciplinary clinic which aims to

determine an early diagnosis of cognitive changes. Clinics will be staffed by Geriatricians,

Registered Nurses, Occupational Therapists, Social Workers and Neuropsychologists.

The clinic will provide expert clinical diagnosis; education, support and information regarding

appropriate treatment; assistance with future planning; and will link clients and their family

with appropriate service providers.

19.3 REHABILITATION AND GERIATRIC SESSIONAL ALLIED HEALTH

Rehabilitation and geriatric outpatient services at UCPH will include a comprehensive range

of specialised allied health services provided on a sessional therapy basis and as part of a

multi-disciplinary team. Allied health services provided will include:

o Nutrition;

o Occupational Therapy;

Driver Assessment Rehabilitation Service (DARS);

Vocational Assessment and Rehabilitation Service (VARS);

o Physiotherapy;

o Psychology and Counselling;

o Social Work; and

o Speech Pathology.

19.4 CLINICAL SERVICES BASED OFF-SITE THAT WILL PROVIDE A SERVICE TO UCPH

INPATIENT AND AMBULATORY SERVICES

Prosthetics & Orthotics; and


Specialised Wheelchair and Posture Seating Service (SWAPS).

20 HYDROTHERAPY

Hydrotherapy services will be provided at UCPH. Hydrotherapy will be based on equitable access,

clinical need and will be available to eligible patients throughout the ACT. It is envisaged that in the

future there may be an increase in the number of inpatients accessing hydrotherapy. It is anticipated

that the UCPH hydrotherapy pool will operate in a similar way to the existing Canberra Hospital

hydrotherapy pool.

The provision of hydrotherapy services will be based on individualised assessments and treatment

programs. All patients attending hydrotherapy will have a land based assessment prior to

commencement of their program. Hydrotherapy treatment sessions will be conducted in group and

individual scheduled sessions to best meet the needs of each patient. Sessions may be led by

physiotherapy, allied health assistants or by approved external providers under contractual

arrangements. External providers will apply to utilise the pool and an appropriate memorandum of

understanding will be negotiated/agreed with those external providers.

Hydrotherapy treatment will be patient focused and goal orientated and may include the following:

Water assisted or resisted strengthening and range of motion exercises.

General endurance training and reconditioning.

Functional retraining in buoyancy assisted environment.

Patients attending hydrotherapy sessions will be reviewed regularly to ensure that rehabilitation goals

remain current. Following completion of a supervised hydrotherapy program, patients may be

discharged or referred to other services.

All access to the hydrotherapy pool will be supervised with all sessions being supervised by a mix of

clinical and support staff trained in annual pool rescue and basic life support training with an

accredited provider, as well as current Emergency Management Awareness Training.


21 REFERRALS

21.1 HOW TO BOOK INTO THE DAY REHABILITATION SERVICE

A person may be referred to the Day Rehabilitation Service by their General Practitioner, Specialist,

Allied Health Professional or Nurse Practitioner. The referrer will submit the referral via the online

Clinical Portal or the Community Health Intake (CHI).

People may provide a self referral to the Day Rehabilitation Service by telephoning CHI.

Once the referral is processed and accepted the patient will be contacted to book in to the therapy

session or to attend a multidisciplinary assessment clinic.

If a referral is not accepted the referrer will be notified by letter or email.

21.2 GENERALISED UCPH PATIENT PATHWAY

The RACC UCPH patient pathway will be reliant upon a robust and integrated system including

administration, clinical and clinical support functions. The pathway will incorporate timely access to

services and seamless transition between services.

In developing the key principles of the patient pathway, a number of example patient pathways have

been developed to assess the needs of different groups of patients accessing services in a range of

care settings. The patient pathway may be quite different for different patients depending upon their

clinical needs.

A generalised patient pathway accessing UCPH services is outlined below.

Referral

submitted to

centralised

Administrative

intake

Referrals sorted

by Clinician

assessment.

Assessment

undertaken

through single or

multi-disciplinary

process.

Single or multi-

disciplinary team

care as

appropriate.

May include

additional

referrals.

Transfer to

services outside

of UCPH or

discharge from

care.

The figures following provide a high level outline of the referral/intake process for an existing ACT

Health patient and a new patient.


21.3 REFERRAL/INTAKE PROCESS FOR TRANSFER OF CARE FOR AN EXISTING ACT HEALTH

PATIENT

Referral/Handover

Direct to specific UCPH Service

Rehabilitation screening assessment utilizing concise

assessment tool to determine appropriate care setting and stream

Assessment and treatment

Specific UCPH service

Assessment and Treatment GP/Primar

y health referrer

links

Note: Referral/handover processes will transfer all relevant patient information so that there is no duplication of assessment


21.4 REFERRAL/INTAKE PROCESS FOR A NEW ACT HEALTH PATIENT

Referral

Central Administrative

Intake

Clinician assessment

Specific UCPH service

Rehabilitation screening assessment utilizing concise

assessment tool to determine appropriate care setting and stream

Assessment and Treatment GP/Primar

y health referrer

links

Direct to specific UCPH Service

Assessment and treatment

Not appropriate for UCPH Rehabilitation. Feedback and recommendation to

referrers


21.5 REFERRAL SUBMITTED

Education and communication strategies will ensure that referrals to services are undertaken in a

timely and appropriate fashion. The importance of early referral and commencement of appropriate

care in a timely manner will be emphasised.

All referrals will be submitted through a centralised integrated intake point consistent with a whole of

organisation approach in order to undertake the administrative processing of referrals.

21.6 SCREENING/SORTING OF REFERRALS AND WAITLIST

All referrals submitted will be screened/sorted to ensure that they have been submitted to the

appropriate service. Inpatient referrals will be sorted by clinicians who are members of the multi-

disciplinary team for:

Confirm that a referral is appropriate for UCPH.

Determine whether the referral can be submitted directly to a particular service.

Determine that an assessment (using a concise assessment tool) is required to determine the

care needs of the patient (care setting, service setting and multi-disciplinary team

requirements).

If accepted for admission the patient will go onto a waitlist based on clinical priority and need, to

ensure equitable and fair access to services. Priority access to ambulatory services will be given to

patients transitioning from inpatient services.

Regular meetings will be held to discuss the active waitlist and determine the priority of admissions.

Waitlist times will be minimised. The right care will be provided in the right place at the right time for

all patients.

22 BOOKING AND SCHEDULING

Once a patient is moved from the waitlist to assessment and commencement of treatment a

centralised booking and scheduling process will be utilised to coordinate the appropriate care team

and access to appropriate clinical spaces to commence care delivery.

23 WORKFORCE/STAFFING

The RACC UCPH Model of Care will be underpinned with comprehensive clinical support services

incorporating the full scope of health professionals to provide clinical care, clinical assessment and

consultation, therapy, diagnostic, and interventional work. This may include new or expanded clinical

roles and clinical support roles.

The workforce plan and profile for UCPH are currently being developed, with the priority being to

ensure that the hospital will have an appropriately skilled workforce that reflects ACT Health and ACT

Government priorities. The workforce plan will explore opportunities for workforce innovations.


ACT Health will engage clinical and non-clinical staff for the new facility and will use targeted

recruitment practices to source the UCPH based operational workforce. This may include utilising

digital, online media options including social media, medical, nursing and allied health job boards,

clinical journals and publications.

23.1.1 CONSULTATION

Workforce innovations will be consulted on in accordance with the principles set out in the current

Enterprise Agreements for areas affected, actively involving staff, unions and consumers.

All roles will be reviewed before being finalised, and evaluated to ensure they address the

requirements for services based at UCPH. This includes clinical and support staff as well as reception

staff. The workforce plans and profiles will all undergo extensive consultation.

23.1.2 NURSING

The Nursing workforce for UCPH will utilise an innovative skill mix. All staff will be supported by

working within a multi-disciplinary team atmosphere, with the inpatient nursing teams supporting

each other functioning in a team nursing model.

An appropriate management structure will be in place to support the Registered Nurses and Enrolled

Nurses including Clinical Nurse Consultants, Assistant Director of Nursing and Director of Nursing.

Nursing staff will continue to have their learning and education supported by Clinical Development

Nurse and access to professional support including ACT Health education sessions, scholarships and

funding for professional development.

ACT Health currently utilises Assistants in Nursing (AINs) as supports in complementing to the role of

the Registered Nurse and nursing workforce. In their current role at Canberra Hospital, AINs work as

part of a nursing team, providing close observation and support to people with a high risk of falling,

dementia and some cognitive issues. As part of this role they also provide personal care, basic

monitoring and some diversional activities. They are also approved to provide simple exercises as

agreed by the physiotherapist. The role and inclusion of AINs as part of the workforce will be extended

to the RACC services at UCPH.

23.1.3 ALLIED HEALTH

The care team at UCPH will include multi-disciplinary Allied Health Professionals. Allied Health is a

term used to describe a range of health professionals who are not doctors, dentists or nurses. This

will include Occupational Therapists, Physiotherapists, Pharmacists, Social Workers, Psychologists,

Speech Pathologists, Prosthetists, Peer Support Works and Dieticians amongst other professions.

RACC Allied Health Professionals will be supported at UCPH by Allied Health Assistants (AHA). AHAs

support and assist the work of Allied Health Professionals by undertaking a range of less complex tasks

so the Allied Health Professionals can focus on more complex clinical work and provide care for a

larger number of patients.


AHAs commonly work with Dieticians, Physiotherapists, Occupational Therapists and Speech

Pathologists in a variety of settings, including acute, rehabilitation, outpatient, community and mental

health. While they work within clearly defined parameters, the role is often very flexible, involving a

mixture of direct patient care and indirect support. The mix of duties is determined by the Model of

Care, scope of practice, the needs of the professional delegating work to the AHA, and the types of

services and programs delivered by the allied health team.

23.1.4 MEDICAL

The Medical staffing profile provides medical cover inclusive of Inpatient, Day Admission Service and

Ambulatory Services. It is proposed for 24 hour medical cover at UCPH. The staffing numbers for

Consultants and Registrars have been benchmarked to the ’Australasian Faculty of Rehabilitation

Medicine (AFRM) Standards for provision of Inpatient Adult Rehabilitation Services in Public and

Private Hospitals 2011’.

General Practitioners will be considered part of the treating team and will be included in the

development and management of the treatment plan.

23.1.5 ADMINISTRATION

The Administration Model for UCPH is proposed to have flexibility with staff working across all clinical

areas. This is proposed to include ward clerks, front reception, support for booking and scheduling of

day admission program as well as general Divisional administrative support. The administration model

will continue to be developed to be an efficient and responsive model.


24 APPENDICES

24.1 CONSULTATION PROCESS UNDERTAKEN TO INFORM THIS DOCUMENT

This document has been developed in consultation with key ACT Health representatives through the

following consultation process:

Two Reference Group (RG) meetings (30 July 2014 and 28 January 2015).

Four rounds of User Group (UG) meetings

o 30-31 July 2014 to profile the current RACC activities

o 1 October 2014 to develop the overarching future Model of Care for RACC at UCPH

o 10-11 December 2014 to develop the overarching future Model of Care for RACC at

UCPH

o 14-15 January 2015 to develop the Model of Service Delivery and Transition Roadmap

for UCPH.

Targeted consultation undertaken by ACT Health to develop the future Model of Care for

UCPH inpatients and ambulatory services (27 October 2014 – 21 November 2014).

Out of session feedback/clarification.

Community Consultation November 2015 to December 2015.

24.2 MEMBERSHIP OF THE REFERENCE GROUPS AND USER GROUPS:

Executive Director, RACC, CHHS

Executive Director, Clinical Support Services, CHHS

Director of Nursing, Clinical Support Services, CHHS

Senior Manager Security Operations, Business and Infrastructure, Strategy and Corporate

Director Logistic Support, Business and Infrastructure, Strategy and Corporate

Executive Director, Mental Health, Justice Health and Alcohol and Drug Services, CHHS

Director Geriatric Medicine, RACC, CHHS

Director Rehabilitation Medicine, RACC, CHHS

Director of Nursing and Assistant Director of Nursing RACC, CHHS

Director Acute Support, Clinical Support Services, CHHS

Director Allied Health, RACC, CHHS


Director Client Support Services, RACC, CHHS

Director Community Care Program, RACC, CHHS

Assistant Director Client Services, Security and Emergency, Business and Infrastructure,

Strategy and Corporate

Clinical Nurse Consultant, 12B, RACC, CHHS

Clinical Nurse Consultant Rehabilitation Independent Living Unit, RACC, CHHS

Clinical Nurse Consultant Acute Care of the Elderly, RACC, CHHS

Rehabilitation Nurse Practitioner, RACC, CHHS

Physiotherapy Clinical Educator, RACC, CHHS

Manager Speech Pathology, RACC, CHHS

Manager Occupational Therapy, RACC, CHHS

Manager Physiotherapy, RACC, CHHS

Manager Community Care Physiotherapy, RACC, CHHS

Manager Psychology and Counselling, RACC, CHHS

Manager Social Work, RACC, CHHS

Manager Exercise Physiology, RACC, CHHS

Manager Aboriginal Liaison Officer Service, Clinical Support Services, CHHS

Manager Pathology Collections; Pathology, CHHS

Rehabilitation Care Coordinator, RACC, CHHS

Manager Transitional Therapy and Care Program, RACC, CHHS

Manager and other nominees, Clinical Support Services, CHHS

Volunteer Manager Client Services, Security and Emergency, Business and Infrastructure,

Strategy and Corporate

Manager E-Health and Clinical Records, E-Health and Clinical Records, Strategy and Corporate

Operational Director ACT-Wide Mental Health Service, Mental Health, Justice Health and

Alcohol and Drug Services, CHHS

Clinical Nurse Consultant, Brian Hennessy Rehabilitation Centre, Mental Health, Justice Health

and Alcohol and Drug Services, CHHS


Consumer representatives, ACT Mental Health Consumer Network

Clinical Director ACT-Wide Mental Health Service, Mental Health, Justice Health and Alcohol

and Drug Services, CHHS

Team Leader Adult Mental Health Day Service, Mental Health, Justice Health and Alcohol and

Drug Services, CHHS

Representatives, Carers ACT

Project Officer, Mental Health, Justice Health and Alcohol and Drug Services, CHHS

Project Officers, Healthcare Consumers Association

Consumer representatives, Healthcare Consumers Association

Project Officers and Manager, Health Services Planning Unit, HIP


24.3 REHABILIATION AND AGED CARE UCPH SERVICE STREAMS

Rehabilitation and Aged Care UCPH Service Streams

INPATIENT UNITS

GENERAL REHABILITATION UNIT OLDER PERSON'S REHABILITATION UNIT SLOW STREAM REHABILITATION UNIT

For pat ients with a range of condit ions

Amputee

Musculoskeletal Disorders Geriat ric Evaluat ion and Management (GEM) Non-weight bearing res t ric t ions

Post orthopaedic surgery Cognit ive impairment

Falls

Medical frac tures

Ortho-geriat ric pat ients

Recondit ioning

Park inson's Disease

Generally tolerate a higher intens ity program Lower intens ity rehab il i tat ion services

Spec ial is t mult i-disc ipl inary team* Spec ial is t mult i-disc ipl inary team* Spec ial is t mult i-disc ipl inary team*

AMBULATORY SERVICES

Recently Acquired Conditions Chronic and Progressive Conditions

CVA Mult iple Sc leros is Amputee Park inson's Disease

ABI Huntington's Disease Multitrauma Dementia

TBI Motor Neurone Disease Orthopaedic Recondit ioning

Newly diagnosed Park inson's Disease Long term SCI management Musculoskeletal GEM

Long term ABI management Decondit ioning Falls

Long term CVA management

Spec ial is t s ingle/ mult i-disc ipl inary team* Spec ial is t s ingle/ mult i-disc ipl inary team* Spec ial is t s ingle/ mult i-disc ipl inary team* Spec ial is t s ingle/ mult i-disc ipl inary team*

NEUROLOGICAL REHABILITATION UNIT

Stroke For pat ients with a range of medical co-

morbidit ies assoc iated with ageing

For pat ients with l imited abil i ty or tolerance to

part ic ipate in rehabil i tat ionAcquired Brain Injury (ABI)

Spec ial is t mult i-disc ipl inary team*

Traumat ic Brain Injury (TBI)

Motor Neurone Disease Maintenance while await ing complet ion of

home modificat ion or res ident ial placementMult iple Sc leros is

Cerebral Palsy

Spina Bifida

Newly diagnosed Park inson's Disease

Late effec ts of Polio

NEUROLOGICALGENERAL OLDER PERSON'S

*Spec ial is t s taf f al igned to service s t reams wil l inc lude: al l ied health ass is tants , medical, nurs ing (inc luding nurs ing ass is tants),nutri t ion, occupat ional therapy, pharmacy, phys iotherapy, psychology & counsell ing, soc ial work , speech pathology and

s tudents . The core c l inical team wil l be determined for each pat ient based on individual c l inical need. Spec ial is t s ingle/ mult i-disc ipl inary teams may inc lude spec ial is t c l inics .

Note: the above diagnoses are indicat ive of the l ik ely condit ions to be appropriate for care within each of the spec ial is t s t reams, the l is ts are not exhaust ive and selec t ion of the appropriate care set t ing and service s t ream wil l be based on individual

c l inical need.

ClinicalServices based off-si te but wi l l provide a service to UCPH patients:Clinical Techno lo g y Wo rksho p (CTW) Serv ice,Driver Assessment and Rehab il i tat io n Serv ice (DARS),Exerc ise Phys io lo g y (EP), Po d iat ry , Prosthet ics and Ortho t ics (P&O), Rap id Assessment o f the Deterio rat ing Aged at Risk (RADAR), Spec ial isedWheelchair and Posture Seat ing (SWAPS) Serv ice, Trans it ional Therapy and Care Prog ram (TTCP), Vocat ional Assessment and Rehab il i tat io n Serv ice (VARS).

Hydrotherapywill be access ib le f o r UCPH inpat ient and ambulato ry pat ients based on ind iv idual c l inical need .


24.4 REFERENCE DOCUMENTS

Reference documents that have informed the development of this report include:

ACT Health Strategy and Corporate, eHealth & Clinical Records, 6/2/13, V1.1.

ACT Health CSP 2014-2018 Draft March 2014.

ACT Health Ambulatory Care Framework 2012.

ACT Health Adult Mental Health Rehabilitation Unit Model of Care, January 2015.

Central Adelaide Local Health Network SABIRS Inpatient Rehabilitation at TQEH Proposed

Model of Care (draft) sourced 2016.

Directions Paper – A Professional Approach to Administration Support to Ambulatory Care

Services, April 2014.

Service Models and Projected Service Demand for Adult Rehabilitation and Aged Care Services

9/10/12, Christopher Poulos.

Subacute Planning Workshop 9/11/12 (dated 4/1/13), Christopher Poulos.

ACT Health Community Health Centres Model of Care Part 1 October 2009, V3.1.

ACT Health Community Health Centres Model of Care Part 2 September 2009, V4.

Towards Culturally Appropriate and Inclusive Services – a Coordinating Framework for ACT

Health 2014-2018.

Health Directorate Reconciliation Action Plan 2012 – 2015.

University of Canberra Public Hospital Services Delivery Plan, 28 August 2013.

ACT Health Workforce innovation in sub-acute care speciality services: a literature review,

November 2013.

ACT Health University of Canberra Public Hospital (UCPH) Workforce Innovation Forum 13

December 2013, Record of Discussion.

University of Canberra Public Hospital (UCPH) workforce planning workshop overview:

Rehabilitation and Aged Care, 6 June 2014, Record of Meeting.

NSW Health Guide to Role Delineation of Health Services, Third Edition 2002, available at

http://www.health.nsw.gov.au/services/Publications/guide-role-delineation-health-

services.pdf

http://www.health.nsw.gov.au/services/Publications/guide-role-delineation-health-services.pdf

http://www.health.nsw.gov.au/services/Publications/guide-role-delineation-health-services.pdf