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Alfred Health Acquired Brain Injury Rehabilitation
Centre http://www.alfredhealthabirehab.org.au/
• Jacqui Morarty • Katrina Neave
Alfred Health ABI Service
• 42 inpatient beds: - 10 TAC/ Work-safe
• ABI Community Rehabilitation Service
• 4 Bed Transitional Living Service
Developing the Model of Care • Prior to the unit opening preliminary development work was undertaken
which included: – a needs analysis of Victorian inpatient rehabilitation opportunities for
the clinical population; – site visits to national and international services; – qualitative research to determine who receives rehabilitation in Victoria
the patient and family perceptions of goal setting, – rehabilitation outcomes – community integration – a systematic review of the features inherent within a model of
rehabilitation care.
Developing the Model of Care • The guideline statements were colour coded according to NOVAK
et al, 2012: – Green GO: High-quality evidence exists supporting the
effectiveness of this intervention—therefore use this approach. – Yellow MEASURE: Low-quality or conflicting evidence exists
supporting the effectiveness of this intervention—therefore measure the outcomes of intervention carefully when using this approach to ensure the goal is met.
– Red STOP: High-quality evidence exists demonstrating this intervention is ineffective—therefore do not use this approach.
Developing the Model of Care • A Model of Care was developed to:
– Guide everyday nursing, medical and allied health clinical care which will improve patient outcomes
– Lead to high patient and family satisfaction
– Maximise interdisciplinary practice.
– The model of care defines the clinical and operational practices within the service that aim to exceed the expectations of all patients and carers by providing outstanding care and service.
Model of Care Principles • Focus on early transfer of patient from acute setting
• Minimise transfers back to acute & disrupting rehab via specialist review in the unit (e.g. trauma, neurosurgical, psychiatry, respiratory)
• Comprehensive interdisciplinary model of care focusing on patient centred rehabilitation to achieve functional “SMART” goals
• Integrated inpatient and community program with inpatient rehabilitation for only as long as it is required for transfer into a community setting
• Community service providing long term management and support in partnership with local services focusing on lifelong, evolving needs
• Extensive family/ carer education and engagement in the process
Patient Directed Goal Setting
• Patient & Family led goals
• All disciplines prescribe and deliver therapy around SMART goals
• Contextual therapy
• Family engagement in care delivery
Referral Pathways • State-wide service
• DH coordinated state wide referral process & forms
• Receipt of referral call within 1 working day
• Outcome within 3 working days
• Face-to-face assessment only where adds value
• Community referrals
• - Typically will have sever to catastrophic, diffuse brain injury (TBI, stroke, hypoxic, other non-progressive causes) - Physiologically stable although may have ongoing acute care - Potential to benefit from interdisciplinary rehab - Long term rehabilitation
Target Patient Population
ABI Community Rehabilitation Service • Provides a specialist ABI Community Rehabilitation Service to
clients and their carers from the Victorian community.
• Will provide allied health and medical support and advice to clinicians working with ABI clients.
• Our service will offer: – Home Based interventions – Centre Based interventions – Remote: Telephone and Telehealth services can be provided
where appropriate – Advice and support to community clinicians
ABI Community Rehabilitation Service
• Periodic review of clients who are residing in a residential facility to establish a plan of care to prevent complications and/or monitor for potential for rehabilitation
• Provide support to local services to transition patients to local services through the provision of specialist and expert secondary consultation, education and advice to these services, who may not have ABI expertise
• The ABI community rehabilitation service will work in close collaboration with existing disability and community support service providers, local rehabilitation services, as well as their patient and family/ carers
Eligibility Criteria • Client has an acquired brain injury of non-progressive pathology
• Clients’ or carers needs cannot be met by another community service
• Continuity of ABI inpatient treatment team is of significance
• Will have potential to benefit from interdisciplinary intervention, by two or more Allied Health disciplines, to improve function, decrease disability, decrease level of care/ caregiver burden
• Must be medically stable and should have a GP willing to provide medical support although a rehabilitation specialist is available through the program.
Referral to ABI Community Service
1. Completed ABI Community referral sent to access unit.
– Referral can be completed by: > Medical > Health Professional > TAC/Workcover
2. Reviewed/assessment by ABI staff 3. Accepted
• Direct from Alfred Health ABI IP unit • Referral from acute hospitals or
subacute rehabilitation • From GP’s or clinicians in the
community • Community therapist requesting
assistance/expertise from ABI community team to manage complex patients with an ABI
Transitional Living Service
• Is a purpose 4 bedroom house which will provide the opportunity for a more extensive transition period and continuation of rehabilitation program
• The rehabilitation program will focus on development of community living skills to facilitate the return to community living
• An interdisciplinary Rehabilitation Team supports the clients and provides individual program development.
• 24 hour support
Transitional Living Service Patients admitted to the Transitional Living Unit will need to:
– An acquired brain injury of non-progressive pathology – Have identified goals to develop independent living skills in community
environment with minimal supports – Be medically stable. – Be able to manage their own personal care and mobility with minimal
prompts and support. – Have no behaviour issues that cannot be managed within the staffing
limitations. – Be able to manage their medications – Agree to the share house rules and actions arising from rule breaking – Have a confirmed discharge destination
Staff Orientation & Education • All staff who commence in the ABI Service participate in a 3-5 day
orientation program that was consistently conducted by the same senior staff
• Staff are introduced and educated on the ABI model of care
• Staff are orientated to the research program, specifically the Service audits
• Staff complete a Questionnaire titled “Acquired Brain injury Rehabilitation: what are your views?
Barriers to Implementing Evidence-Based Practice
• Health care professionals report a number of barriers to implemen4ng evidence-‐based prac4ce including: – lack of 4me
– large caseloads – hospital targets – lack of knowledge to complete searches and appraise ar4cles
Evidence-Based Practice • Evidence-based practice acknowledges that it involves the integration of
the best research evidence with clinical expertise and patients unique values and circumstances.
• An evidence based practitioner doesn’t have to do the research but we must use the outcomes of the research in our clinical practice.
• Importantly we should stop interventions which are found to be ineffective or harmful.
• It can be difficult when asking clinicians to stop a practice that has shown to be ineffective
• A behaviour change is required
Suggestions to overcome barriers
• Provide the support to release staff form their normal roles to enable clinicians to:
– to complete the research – to implement the findings of research through updating guidelines or
providing education – attendance at professional development both course and conferences
Embedded Knowledge Translation Strategies • Initiatives were developed for trial in this funded ABI unit which include:
– In-services from experts in the field
– Interdisciplinary education
– Periodic Service Review > Fortnightly feedback of care delivery measures to ABI clinical team > Evaluation against MOC and clinical guidelines
– Kobo project (KOBO readers loaded with journal articles, clinical practice guidelines and systematic reviews
– Pay slip postcards
ABI Research
• Periodic Service Review – Fortnightly feedback of care
delivery measures to ABI clinical team
– Evaluation against MOC and clinical guidelines
• Patient, staff and family qualitative data collection
Fortnightly Surveys (Periodic Service Review)
• We currently audit against a potential 140 criteria • Behavioural support plans • Careplans • Continuity of care • Discharge planning • Equipment use • Family education • Goal setting • Medical Issues Management • Medical Records • Minimally Conscious Care • Patient Safety • Personal care regimes • PTA management • Roles and responsibilities • Therapy interventions • Ward rounds
Kobo project
• Journal articles, clinical practice guidelines, systematic reviews.
• Designed to be read and taken with clinicians to bedside.
Payslip postcards
Questionnaire • Aim is to identify the best ways to help staff implement evidence-based
rehabilitation guidelines
• Consists of 46 questions
• Results of the questionnaire are used to plan further training and provide support to staff
• The questionnaire is both anonymous and confidential
• Completion of the questionnaire is voluntary
• The same survey is repeated sent out at multiple time points (October 2014, January 2015 and March/April 2015).
FINDINGS – Evidence based practice
• Survey administered at commencement of employment and in March 2015
• Will be administered on two more occasions
• 42% of staff in the ABI unit reported they were aware of the ERABI guidelines (The Evidence based Review of moderate to severe ABI) at commencement of employment
• 71% of staff are aware of ERABI guidelines in March, 2015
Recommendations for Clinical Practice -‐ Delivering interdisciplinary evidenced based prac4ce educa4on, tailored to meet clinician needs, as iden4fied by the clinicians
-‐ Offering different opportuni4es for learning, within work hours
-‐ Provide the support and funds to release staff form their normal roles to enable clinicians to increase their knowledge and the 4me to translate this knowledge into prac4ce
-‐ Making the evidence easily accessible and provide the tools to implement the evidence
-‐ Expec4ng that evidence-‐based prac4ce is used rou4nely in prac4ce
-‐ Monitor & evaluate staff performance against delivering evidence-‐based prac4ce
This project is funded by WorkSafe Victoria and the Transport Accident Commission (TAC), through the Institute for Safety, Compensation and Recovery
Research (ISCRR).!
