Transfers of care

Rehabilitation medicine (RM) manages patients with complex needs following sudden-onset neurological or musculoskeletal conditions, progressive conditions and long-term disabling conditions. RM services cover a range of healthcare interventions in acute, post-acute and community settings. Timely transfer of care to the appropriate specialist rehabilitation setting is crucial for optimum outcome and there is increasing evidence to support this as best practice. Examples of scenarios follow.

Acute setting

  • Deciding on options for a confused and agitated patient following acute brain injury.
  • Transfer of a brain-injured patient from a busy surgical, medical or neurosurgical ward to a rehabilitation ward – with a calmer, quieter atmosphere and a specialist team familiar with the consequences of brain injury – usually has a beneficial effect, with improvement in attention and cognition, and reduction in agitation.

Post-acute specialist rehabilitation units

  • The RM consultant is responsible for meeting the healthcare needs of the individual, working with the multidisciplinary team to achieve successful discharge home, move the patient to a community rehabilitation setting or provide specialist continuing care.
  • Patients transferred to post-acute rehabilitation are usually medically/surgically stable and require specialist rehabilitation to enable their discharge to either home or care facility.

Community settings

  • Good liaison with community-based rehabilitation teams is essential to continue the rehabilitation process to optimise patients’ activities and social participation, including return to employment or education.
  • The role of the RM consultant in the community varies according to local circumstances, ie whether community rehabilitation is, or is not, commissioned. There are considerable inequities. In ideal situations, RM consultants contribute to the development of teams and the services provided by the team, through their expertise in preventing medical, physical and psychological deterioration, eg development of pressure sores, spasticity management, minimising contractures, osteoporosis prevention, access to appropriate nutritional advice to minimise obesity or malnutrition.
Timely, appropriate planned transfer of care into the most appropriate service for the patient avoids unwarranted length of stay in acute beds, which is detrimental to the patient and to the acute service. For the individual, such delays can significantly impact on crucial motor and cognitive recovery processes, adversely affecting long-term functional outcome. Networked and managed rehabilitation ensures ‘the right patient in the right service at the right time’, improving patient outcomes and family experience, as uncertainties and delays cause patients and families significant distress.

Medical rehabilitation in 2011 and beyond (opens PDF, 525KB, p17) includes an example of poor practice for transfer of care and what should ideally happen.

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