Mobile
Rehabilitation
Team – St
Vincent’s
Style
Dr Shari Parker
Rehabilitation Physician
Drivers for Change
1. Pressure on beds, bed blocks
2. Evidence for Early Rehabilitation
3. The problem of Deconditioning
4. COAG funding
Model of care
• 10-12 patients
• 2 week program
• 7 day / week therapy
– (Evidence suggests ↓ LOS and cost savings1))
•
•
•
•
•
•
Inter-disciplinary rehabilitation care
“We come to you”
Parallel shared care - “hone” and rehab teams
90 mins therapy per day
In addition to usual ward therapy
Case conferences, family meetings
Inclusion Criteria
•
•
•
•
•
LOS > 3 days
LOS likely to be ↓ with MRT input
Impairment with identifiable / realistic goals
Stable – tolerate up to 90 mins therapy per day
Follow commands – if needs interpreter – must
be available during therapy hours
• Willing to participate
• Pre-morbid status –active participant in
community / at home
• Require at least 2 therapies
Exclusion criteria
• Acute CCU, ICU, MAU, Stroke unit,
geriatric ward
• Febrile > 38.5oC in last 24 hours.
• GCS < 13
• LOS < 3 days
• No suitable d/c destination
identified
Staffing
•
•
•
•
•
•
•
Rehabilitation Physician
Rehabilitation Registrar
Clinical Nurse Consultant
Physiotherapist
Occupational Therapist
Social Worker
Clinical Psychologist
0.3
1.0
0.6
1.4
1.4
0.4
0.2
Mobile Rehab Team Process
Identify
suitable
patients
Case
Conference
Liaison with
acute team
Review by
CNC / Reg /
Consultant
InterDisciplinary
Mx
AROC,
M&M
Accepted
into MRT
Team
assessments
Discharge
options
Identify suitable patients
1. Risk of de-conditioning / prolonged LOS
– Complicated patients, prolonged ICU, elderly
– Psychosocial flags
2. Need rehabilitation, medically or surgically
unsuitable for transfer
3. Awaiting rehabilitation
4. “Trial” of Rehabilitation
Direct referrals, case finding
Triage system – aim to get patients directly
home, BUT MRT cannot prolong admission
Team Assessments and Mx
Medical
• Full
admission
• MMSE
• Daily review
PT / OT
• Combined
initial
assessment
• FIM
• GAS
• TUAG
• Daily Rx
SW / Psychol
• Psychosocial
Assessment
• Discharge
planning
• DASS 21
• Psychology
input
Discharge options
Outpatients
Discharge
options
Home
Rehab in the
home
Inpatient
rehabilitation
+/- Services
Results
• Patients 1 Oct 2010 – 30 June 2012 = 412
• Average LOS = 9.8 days
• Discharge Destination 55% directly home
–
–
–
–
–
–
–
–
Usual Accommodation 48%
Interim accommodation 6%
New Accommodation
Return to acute care
Other acute hospital
Rehab unit
Sacred Heart Rehab
Deceased
1%
8%
2%
21%
12%
2%
• Increase annual capacity of Sacred Heart rehab 24%
SNAP Classifications
Re-conditioning / Restorative
46%
Cardiac 18%
Pulmonary 13%
Brain and Neurological 9%
Orthopaedic 6%
SCI 2%
Amputee 2%
Other 4%
Age
30
25
20
% 15
10
5
0
<20
20-29 30-39 40-49 50-59 60-69 70-79 80-89
> 90
Age (years)
MRT filling the gap with the cognitively intact elderly
Referral source
Haematology
Cardiology
Thoracic medicine
Lung Transplant
Neurosurgery
Orthopaedics
Neurology
Vascular surgery
Nephrology
Gastro-Intestinal
Cardiology Heart Failure
Cardiothoracic surgery
Cardiac Transplant
MRT active across entire acute hospital
Majority haematology, cardiac and thoracic
Involvement welcomed by the acute hospital
Functional outcomes
FIM Results
FIM Efficiency: 1.59 points per day
Average Admission FIM = 77
Average discharge FIM = 95
60
Number of Patients
50
40
30
20
10
0
< -10
. -10 to -1
0
1 to 9
10 to 19 20 to 29 30 to 39 40 to 49 50 to 59
FIM Score Change
Sample Size - 184
FIM Results
120
FIM Efficiency:1.59 points per day
Average Admission FIM = 77
Average discharge FIM = 95
Average FIM change = 18
100
Admission
Discharge
FIM Score
80
60
40
20
0
FIM
Motor
Cognitive
GAS Goal Attainment Scale
Goals are client specific and functional
Score
Outcome of Goal
+2
Much more than expected outcome
Mobilise to the bathroom with no aid
+1
More than expected outcome
Mobilise to the bathroom with a walking stick
0
Expected outcome
Mobilise to the bathroom with a rollator Raw score 0 = T-score 50
-1
Less than expected outcome
Mobilise to the bathroom with FASF
-2
Much less than expected outcome
Unable to mobilise to the bathroom with a FASF
GAS Results
Sample Size – 171 patients
Admission Score Distribution
140
No. of Patients
120
100
Admission Score
80
60
40
20
0
26-32
33-39
40-46
47-53
54-60
61-67
68-74
T-Score Distribution Buckets
Discharge Score Distribution
70
No. of Patients
60
50
Discharge Score
40
30
20
10
0
26-32
33-39
40-46
47-53
54-60
T-Score Distribution Buckets
61-67
68-74
Show me the Money!
• 240 patients per annum
• Annual cost of MRT = $527,000
• Break even  $2196 per patient
• Avoided admissions (MRT)
• = sum of annual bed days saved by
avoided admissions x bed day cost
• = 2,622 x $822
• = 2,622 bed day saving (8.0 beds at 90%
occupancy) or $2,155,068
Show me the Money!
Rehabilitation enhancements at SVH have
produced an annual efficiency of
$4,854,247 for an investment of
$1,121,92416
Enhancements have generated an
efficiency equivalent to an increased
capacity by 17.9 beds (at 90% occupancy).
Enablers for success of MRT
• Hospital wide buy in before
commencement
• Close communication with acute medical /
surgical teams – Nursing, Medical, Allied
Health
• Recurrent hospital wide MRT education
• Co-location of RITH / MRT office
• Rehabilitation Fellow = consults coordinator
and MRT
Additional benefits
• Raise profile of rehabilitation in acute
hospital
• Raising awareness of the need for early
mobilisation / discharge planning –
paradigm shirt
• Introducing rehabilitation philosophy early
for patients – arrive in rehab physically and
psychologically prepared for rehab
Barriers and pitfalls
• Patient related
– Reluctance to participate
– “Too many cooks”
 Close liaison, Brochure
• Medical factors – interruptions to care –
Unstable patients, investigations
• Need for short inpatient rehab admission but
hard to achieve - ? How to not lose momentum
• Lack of clarity regarding ongoing funding –
resignations, reduced morale
The Future
• Survival of MRT
• Options for continuity of
care for MRT patients in
subacute
• “ARI” Acute Rehab
initiaive Research – RCT
of MRT in MVA patients
• SERC – MRT inreach into
ICU (Dr Wu)
Thankyou
Dr Shari Parker
[email protected]
0411622122