This project will develop a model of care, education and resources for both rehabilitation services and General Practitioners to guide ongoing integration, particularly at the difficult points of transition for people with rehabilitation needs. The project will be implemented in three pilot sites with specialised rehabilitation services: a large adult metropolitan site, a regional site and a large paediatric site. The pilot sites will also work closely with GP Liaison Officers to implement communication and transition pathways that are effective for patient care.
Enabling GP integration with rehabilitation services
General Practitioners have a key role in the ongoing care of patients after inpatient rehabilitation and throughout their rehabilitation pathway.
This project aims to identify key points in the rehabilitation pathway where integration with General Practitioners is most beneficial and to describe the best approach in order to maximise outcomes during transition from one phase of rehabilitation to another that is effective for patients, their families, rehabilitation service providers and for General Practitioners.
Strengthen patient care, both during the period of inpatient rehabilitation and on discharge by enabling timely accurate clinical handover, coordination and communication between rehabilitation services and GPs.
Improve support for patients that have complex medical conditions requiring rehabilitation (stroke, acquired brain injury, spinal cord injury/illness, deconditioning, fractures etc.), often accompanied by comorbidities as they return to the community and ongoing medical care with GPs.
Improve support for young people transitioning to adult rehabilitation and health services.
General Practitioners have a vital role in the healthcare and lives of people who require rehabilitation and their families/carers. They hold specialised knowledge of the patient, their family and community that is critical to patient care during the inpatient rehabilitation stay, yet this critical communication may not occur or may not occur in a timely fashion.
Unfortunately, General Practitioners frequently only know that their patient has undertaken rehabilitation at the point of discharge, either having to provide ongoing medical care based on short discharge summaries or having to digest extensive medical and allied health discharge summaries in an initial 15-30minute appointment post inpatient rehabilitation.
General Practitioners are involved with coordinating referrals, ongoing specialist appointments and ongoing medical management of these patients often without having been involved in any discussions with rehabilitation teams. Rehabilitation pathways post discharge have been demonstrated to be complex and diverse and General Practitioners may not be aware of some specialist allied health services or rehabilitation pathways that may be appropriate for their patients. General Practitioners also have a new and emerging role in supporting National Disability Insurance Scheme planning for many of their patients – this is an area where rehabilitation clinicians may provide valuable support. Improved integration would facilitate a safer and smooth transition and journey through ongoing rehabilitation services with improved outcomes.
A key finding from the research, analysing sub-acute and primary health care interfaces (ASPIRE Study) in the elderly population was that despite patients identifying their General Practitioner (GPs) as a highly trusted medical relationship, GPs in fact had peripheral involvement in care transitions and rehabilitation (Strivens et al 2015). The study also found that GPs were overwhelmed by the complex needs and management of services and referral pathways and lacked the central reference point for complicated care transitions and continuity. Integration is impacted by poor quality information exchanges and assumptions post discharge. This study highlights the importance of mutual understanding of the roles and facilitation of active involvement in care transitions when adults (and presumably children) are involved in rehabilitation.
General Practitioners also have a critical role in the transition from paediatric to adult services, a phase of rehabilitation where there are many changes in the care of a young person with complex rehabilitation and health needs. Studies indicate young people with chronic conditions may be doubly disadvantaged when leaving paediatric care as this is a time of vulnerability where a proportion of young people may engage in risk taking behaviors and potentially drop out of health care (Sawyer & Macnee 2010). The Department of Health, United Kingdom, Transition: moving on well, 2008 document states that the “early engagement with adult health services and continuing links with the GP reduces the risk of overdependence as young people and families move on from comprehensive children’s services”.
The project will measure occasions of contact in communication with GPs pre- and post implementation at project sites. It will map the rehabilitation pathway and identify key contact points. The sites will seek feedback on the model and resources for rehabilitation clinicians, GPs and patients and also survey the uptake of the model by rehabilitation services and GPs
Strivens E, Harvey D, Foster M, Quigley R, Wilson M. (2015) Analysing sub-acute and primary health care interfaces – research in the elderly. ASPIRE study. Canberra, Australian Primary Health Care Research Institute
Sawyer S & Macnee S. (2010) Transition to adult health care for adolescents with spina bifida: Developmental Disabilities Research Reviews Vol 16, pgs 60 -65