The Rehab and your GP model of care and resources aim to support the transfer of care for patients and their families from inpatient rehabilitation to community General Practitioner (GP) services.
At times, patients are admitted to inpatient rehabilitation without an identified GP. In addition, GPs may have previously been unaware of their patient’s inpatient rehabilitation admission until the patient presents to their practice after discharge. The Rehab and your GP model of care supports early identification of and communication with an appropriate GP.
One of the strategies is engaging GPs in multidisciplinary case conferencing whilst their patient is still an inpatient. This participation can occur face-face, via phone or telehealth and is billable via Medicare. This multidisciplinary case conferencing maps out a patient’s care plan and treatment options and the roles and responsibilities of all team members. Involving GPs in the patient’s care plan from the very beginning enables a more effective transition of care once the patient is back in the community.