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Rehabilitation Services Patient Information

Rehabilitation, Aged and Community Care

Patients Name:

Admission date to Rehabilitation:

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Contents

Welcome 3Rehabilitation journey 4Rehabilitation patient flow 5Your role in your Rehabilitation 6Where does Rehabilitation take place in the hospital 6Directions to RILU 9Rehabilitation team 9Therapy programms 17Meetings 17Discharge 18Rehabilitation Services after discharge 18Useful information 20More information 23Questions 23

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Welcome to the Rehabilitation Service

Rehabilitation is the process of helping a person who has experienced a serious illness or injury restore lost skills and regain maximum independence.

At Canberra Hospital, specialist inpatient rehabilitation services are provided in the Acute Rehabilitation Unit (12B) and at the Rehabilitation Independent Living Unit (RILU).

This booklet provides information about what to expect when you are admitted to either of these Rehabilitation Units: the type of staff you will meet, the services you may use and your role in your rehabilitation process.

This booklet should be read in conjunction with the Guide to Canberra Hospital which outlines other services available on site.

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Your Rehabilitation Journey

After an injury or illness many people require specialist rehabilitation services to enable them to regain lost skills and undertake tasks as independently as possible when they leave hospital.

Before you are admitted to a Rehabilitation Unit at Canberra Hospital you will be seen by a Rehabilitation Doctor who will assess your needs and whether the treatment offered in the unit is going to benefit you or if there is another type of treatment/care that you need. Once you have been accepted for admission, you will be seen by one of the Rehabilitation Care Coordinators who will be your link between your current ward in hospital and the Rehabilitation Unit. You will be transferred to one of the Rehabilitation Units as soon as there is a bed available.

You may be offered a place in a Rehabilitation Unit on a trial basis. Depending upon your progress you will either continue with the rehabilitation program or transfer back to another ward in the hospital.

Once you have reached a stage where the Rehabilitation Team feels that you have gained the maximum possible benefit from inpatient rehabilitation you will be discharged. It is not expected that you will necessarily reach your full potential while an inpatient of the unit. Slow steady progress continues over time with patience and ongoing community based rehabilitation and may continue for many months once you leave hospital.

The usual rehabilitation journey is represented in the Patient Flow diagram on the next page.

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Rehabilitation Patient Flow

Injury/Illness

Emergency Dept

Acute Ward

Accepted for Trial 12B Accepted 12B or RILU

Community Care Program if required

Community Rehab team if required

RILU Day Patient Service if required

Discharged Home/Residential Facility

Seen by Rehab Care Coordinators

Review by Rehab Specialists

Trial 12B stay 12B or RILU stay

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Your Role in Your Rehabilitation

Successful rehabilitation needs a team approach with you, the Rehabilitation staff, your family and carers all working together.

All your treatment and therapy is goal centered. This means that the goals you hope to achieve will be discussed between you and your team at Goal Setting Meetings. A timeframe for achievement of your goals will be discussed and an estimated date for discharge set. A plan will be developed to help you achieve your goals and you will be given a copy to refer to.

Your plan will be reviewed at regular intervals to make sure you are on track, achieving your goals and planning for discharge. If achievement of your goals is not going as well as expected your plan may need to be changed and you can discuss this with the Rehabilitation team.

Full participation in all steps of the program will give you the best chance for improvement. Much of your recovery relies upon your commitment to your exercises, task practise and learning about ways to manage health issues.

It is important to remember that not all your goals will be able to be achieved while you are an inpatient. Ongoing rehabilitation, adaptation to life at home and community based programs will assist you to reach longer term goals.

Where does Rehabilitation take place in the hospital?

At Canberra Hospital there are two rehabilitation units;

Ward 12B provides a specialised rehabilitation service to people who require a high level of assistance to carry out their normal daily activities

Rehabilitation Independent Living Unit is for people who are more independent and provides rehabilitation in a home like environment

After an initial assessment you will be admitted to the most appropriate unit for you.

As part of your rehabilitation journey, as you progress towards increased independence, you may move from Ward 12B to RILU This will further assist in your preparation for discharge home.

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Ward 12B

Ward 12B is a specialised rehabilitation ward where you will be accommodated in either a single or 2 bed room.

Nursing staff are on the ward 24 hours a day to assist if you have any concerns.

Rehabilitation therapy may take place in a number of areas on the ward:

• in your room and the bathroom — to undertake daily tasks of showering and dressing

• in the dining room — to undertake tasks such as eating and drinking• in therapy areas with a specialist therapist• in the rehabilitation gym• in the ward kitchen — cooking tasks

12B Rehabilitation Gym

It is expected that you will participate in activities and exercises as much as possible during gym opening hours, and to attend both morning and afternoon sessions.

You will be taught exercises that you can continue with in your own time in preparation for your discharge. On discharge you will be given a home exercise program.

OPEN HOURS Mon, Weds, Thurs, Fri

9.00 am – 12.00pm 1pm – 3pm

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Rehabilitation Independent Living Unit (RILU)

As you progress with your rehabilitation you may transfer to RILU. Here you will learn to become more independent and practice your daily living skills in a more home-like environment. Some patients may transfer directly to RILU from another acute ward in the hospital.

With your involvement a program will be developed, or your existing program reviewed, to help you reach your optimum level of independence and to support your return to the community.

RILU is designed to be representative of a domestic home with lounge areas, dining room, laundry and kitchen. There are 2 bed and single rooms.

Meals: Breakfast will be set up on the kitchen bench for you to help yourself. Lunch is either ‘help yourself’ or prepared by you as part of a supervised cooking group. Some meals during the week are delivered to the unit from the main hospital kitchens or cooked by staff on site eg BBQ. Staff are always available to assist if required.

Transport: Transport is provided if you need to go to the main hospital for services such as pathology, X-ray, prosthetic department or outpatient services with other specialists. If you need to visit a specialist outside the hospital, we ask that your relatives transport you to the appointment.

Entertainment: There is a television at RILU but you are also able to bring in a personal small sized television, computer or DVD player as long as they are electrically tested and tagged prior to you bringing it into the unit. If you have a radio please use earplugs so that your room mate is not disturbed.

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Directions to RILU

RILU is located in Gaunt Place just near to the hospital campus.

Your Rehabilitation Team

A multi-disciplinary team will be involved in your treatment and care. This is a team of health professionals, all of whom have different skills and knowledge. The makeup of your team will be determined by your individual needs. You may not necessarily need everyone listed here.

Your team will work with you to develop your rehabilitation plan. They will meet regularly with you to review your individual care plan, discussing options and making changes as required.

Rehabilitation Care Coordinators

The Rehabilitation Care Coordinators are registered nurses and health professionals whose role is to assist you to understand and participate in your rehabilitation program. They will keep you informed about your progress and can help to answer any questions you and your family may have about rehabilitation including your discharge and return to the community.

Your Rehabilitation Care Coordinator is:

.............................................................................................

Canberra Hospital RILU

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Nurses

Nursing rehabilitation involves 24 hour care, education, assistance and management of a wide variety of health issues. The primary aim of nursing rehabilitation is to help you learn how to manage everyday activities and functions to enable you to leave hospital (for example management of your bladder and bowel).

Nurses will assess your needs, plan and deliver care whilst respecting your cultural and religious beliefs. They will help you to remember your program and provide extra education as needed but will encourage you to be as independent as you can. Nurses will manage your medications and will advise and assist you with your mobility to help prevent you from having a fall. The Clinical Nurse Consultant (CNC) is the nurse manager of the unit and is available to address any nursing concerns you may have.

Your Clinical Nurse Consultant is:

....................................................................

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Doctors

When you are admitted to the Unit you will be assigned a Rehabilitation Specialist Doctor. This doctor will assess, diagnose and treat your overall condition. You will also see other doctors such as an Intern and Registrar who work closely with the specialist doctor to provide you with optimum rehabilitation and management of medical/health issues.

Your doctors will attend family and case meetings to discuss your progress and treatment.

Your Rehabilitation Specialist Doctor is:

.............................................................................................

Nurse Practitioner

The Rehabilitation Nurse Practitioner is an advanced trained nurse who specialises in the care of patients with complex conditions including spinal cord injuries. The Nurse Practitioner will work with the Rehabilitation Team assisting with the development of care plans, requesting investigations, prescribing medications and referring patients to other health professionals if required.

The Nurse Practitioner also provides outpatient and community based follow up which may be at a home visit, clinic appointment at the Village Creek Centre or one of the ACT Health Community Health Centres.

Your Nurse Practitioner is:

.............................................................................................

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Physiotherapists

Physiotherapists will work with you towards your physical goals such as:

• Getting in and out of bed, • Getting up from a chair• Standing • Walking.You will spend time in the Rehabilitation gym to complete a program of activities and exercises developed with your physiotherapist, to help improve:

• Strength• Coordination• Balance• Muscle stretch• Sensation / feeling• Cardiovascular (heart) fitness.The more time you spend practising these activities and exercises the more likely you are to improve your level of physical function.

Your Physiotherapist is:

.............................................................................................

Occupational Therapist (OT)

The Occupational Therapist (OT) will assist you to maximise your independence and safety in everyday activities such as:

• Personal care (showering, dressing, toileting, grooming)• Domestic / home skills (cooking, home access)• Community (car transfers, transport, driving)• Work skills• Leisure / fun time.Your OT may also assess and work with you to improve:

• Concentration• Memory

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• Problem solving• Planning and organisation.Before you are discharged from hospital your OT may visit your home to assess and advise on:

• Home modifications for safety and access.• Any equipment which may improve safety and independence in the home

and community.Your Occupational Therapist is:

.............................................................................................

Speech Pathologists

Speech Pathologists work with people with a range of communication and swallowing difficulties, as a result of some injury and illness types.

The Speech Pathologist can help you with:

• swallowing difficulties• slurred speech• understanding spoken messages or instructions• difficulties finding the right word• being able to express your thoughts and feelings• communicating with others• problems with reading and/or writing• changes in your voice quality.The frequency of your therapy will be determined after assessment and you and your family will be able to develop a program with your Speech Pathologist to address your individual needs. Education and support to you and your family members is provided throughout the course of your rehabilitation as required.

Your Speech Pathologist is:

.............................................................................................

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Social Worker

Social Work aims to help you and your family to start your rehabilitation and discharge planning. The Social Worker can assist you with different services and support such as:

• Assessment for services and supports that will be required when you are back at home

• Information on practical issues (eg. Centrelink payments, carer agencies and community organisations)

• Counselling to help you and your family with the demands of adjusting and then planning for the future

• Counselling for family members for adjustment difficulties such as, grief reactions, carer stress and self care advice

• Information, referral to and education about community supports such as ongoing community services, groups, activities for both yourself and your carer

• Social workers are also able to provide advocacy within the hospital/healthcare system to help resolve any systemic issues

• Social workers can also refer to services in the community that will enhance your social networks and reduce the risks of social isolation

• Social workers will usually attend your scheduled meetings such as Goal Setting Meetings (GSM) and family meetings

The Social Worker will arrange to meet with you soon after your admission to assess your social situation and assist you with any concerns.

Your Social Worker is:

.............................................................................................

Clinical Psychologist

A Clinical Psychologist has specialist training in the assessment, diagnosis and treatment of psychological and emotional problems and can assist you to manage psychological changes as a result of your illness or injury.

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This might include:

• Anxiety / panic attacks,• Phobias• Depression• Chronic pain.

Clinical Psychology assessment and interventions are aimed at:

• facilitating rehabilitation• treatment planning• goal setting• good mental health• day-to-day functioning through non-drug techniques, strategies and therapies.Your Clinical Psychologist is:

.............................................................................................

Neuropsychologist

Following some illnesses or injuries such as head injury, stroke and chronic neurological conditions, people may experience changes in their thinking skills. This might include problems concentrating or remembering new things. These problems can cause difficulties learning how to do new things, completing everyday tasks (eg cooking, taking medications) or returning to/continuing work, driving and hobbies.

Working with the Neuropsychologist can assist you and your family by:

• understanding your current thinking skills, including any changes in these• understanding how these might impact on daily tasks that are important to

you• discussing strategies to use your strengths and learn ways to reduce the

impact that changes have on everyday tasks.Your Neuropsychologist is:

.............................................................................................

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Disability Counsellor

The Disability Counsellor is available to rehabilitation patients and their families to support adjustment to changes in life as a result of illness or injury. This service can be accessed as an inpatient on 12B or RILU and as an outpatient when you return home.

The Counsellor can assist you and your family with:

• understanding the changes that follow your illness or injury• understanding how you respond to and cope with these changes• working through grief and loss that you may experience as a result of

these changes• making decisions following these changes• increasing self esteem and confidence• managing stress and conflict• enhancing personal relationships• alleviating concerns about your sexual health• reaching your rehabilitation goals• returning home and adjusting to life after hospital.Your Disability Counsellor is:

.............................................................................................

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Therapy Programs

Specialised therapy sessions are provided by occupational and physiotherapists Monday to Friday 9am to 4.30pm (with the exception of Tuesday afternoons). You are expected to attend all planned treatment/ therapy sessions and continue with your independent exercise program and task practice, outside of therapy program operating hours.

Family members and carers may be invited to attend some therapy programs, to see how the treatment is working, and to learn ways of helping you when you leave the hospital. Your family and carers will also have an opportunity to learn how to help you with your independent therapy program. Visitors need to talk to a staff member on the ward if they would like to attend a therapy session.

Therapists will provide feedback to you and your family on progress towards your goals. If progress is not occurring in the given time frame an alternate plan may need to be made.

Meetings

Medical Ward rounds: Are mainly conducted in the morning during the week with medical and nursing staff in attendance.

Nursing Ward rounds: Are conducted in the mornings, on weekdays, with the rehabilitation nurse practitioner, the rehabilitation care coordinator and clinical development nurse.

Goal setting meetings: Are held within two weeks of admission to enable you and your family to meet the team members, discuss and develop goals and to ask any questions about rehabilitation.

Family meetings: May be needed to discuss issues arising in rehabilitation, or for discharge planning. These are coordinated by the therapy team who will arrange a suitable time and venue, and advise your family members.

Case Conference: Occurs each Tuesday afternoon. Therapists, medical, nursing and allied health staff discuss your progress and explore appropriate discharge dates. They will also discuss whether a transfer to RILU may be of benefit in your rehabilitation journey. You will be kept informed of the outcomes of case conference by your Rehabilitation Care Coordinator.

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Discharge

You will be encouraged, with assistance from the team, to start planning for your discharge from the day of your admission. This is to give you the best possible chance of success when you leave hospital.

Discharge from the unit occurs in consultation with the rehabilitation team, with you and your family/carer. Your destination on leaving hospital will be agreed and may follow weekend or trial home leave.

We expect you to be ready for discharge from the ward / unit by 10am on the day you are discharged. If you are from NSW, you can be referred to your local health service. These options will be discussed with you as your discharge date approaches.

If you have been discharged from Rehabilitation services but are unable to return home or to your discharge destination you may need to remain in hospital for a period of time. This might be because you are waiting for a place in a residential facility or for services such as home modifications to be completed. You may be required to pay a fee during this time. This fee is set by the Federal Government. Your Doctor will discuss this with you and you will receive a letter in the mail.

Your Rehabilitation Care Coordinator will keep in contact by phone or home visits (ACT residents only) for up to a year after your discharge. They can assist you with any rehabilitation related issues that you may encounter in the community.

Estimated Date of Discharge: ..............................

Rehabilitation Services after discharge

Your Rehabilitation team may recommend additional outpatient and community services after you have been discharged from hospital.

RILU - Day Patient Service

You may be referred to the RILU Day program as an outpatient (day patient) for specific therapies or prosthetic retraining. You will be living at home or in the community and will attend RILU at appointed times. The days you attend, length of the program and the health professionals you see are determined by your specific needs and goals.

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Multidisciplinary team: Allied Health services you may be eligible for are Physiotherapy, Speech Pathology, Social Work, Occupational Therapy, Clinical Psychology and Neuropsychology. The RILU medical team see outpatients on an “as needs” basis.

Time/Days: 9am – 12pm. Usually a minimum 3 days attendance per week. Sessions in the afternoon or additional days per week may occur as determined by the treating team for required intensity. If you are receiving prosthetics retraining you will need to attend on Monday and Thursdays to be seen by the Prosthetics and Orthotics Service.

Length of program: Is determined by your own goals and therapy needs.

Transport: If you are a ‘day patient’ it is your responsibility to organise your own transport to and from RILU and arrive close to 9.00am and leave soon after 12.00pm. Community Transport services are available and can be organised by calling your local service.

Food: Morning tea is provided to day patients. Breakfast and lunch is not provided with the exception of those participating in the Cooking Group who can eat the meal produced. Attendance at this group is determined by the Occupational Therapist.

Gym: Access to the gym is only when you are working with a therapist on a set program.

Attendance: You must call RILU if you are unable to attend your sessions. Three missed sessions without prior notification will result in cancellation of your rehabilitation program. Please do not attend if you are unwell.

Patient Expectations: As a RILU day patient you have the same healthcare rights as inpatients (as outlined in the Guide to the Canberra Hospital). You are required to follow Canberra Hospital policies and procedures as directed by staff. Acting aggressively towards staff or other patients will result in cancellation of your rehabilitation program.

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Community Rehabilitation Team

If you have sustained neurological impairment due to a stroke, a head injury or a neurological condition and require post discharge therapy you may be referred to the Community Rehabilitation team. This service is for patients who are over 18 years and live in the ACT. The service operates at the Phillip and Belconnen Health Centres, and transport services are available if you require this assistance. If you are a NSW resident you may be referred to a similar program called TACP for continued therapy when you return home.

Community Care

If you do not have a neurological impairment but still require therapy after discharge from 12B or RILU you may be referred to the Community Care program.

Additional Allied Health Services

Additional allied health departments within the Rehabilitation Service:

• Equipment Loans Service (Village Creek Centre)• Vocational Assessment Rehabilitation Service (VARS)• Driver Assessment Rehabilitation Service (DARS)• Prosthetics and Orthotics (Village Creek Centre).

Useful Information

What to bring in• Clothing - The best clothes for you to wear are loose fitting and comfortable

day clothes and sleepwear for the night• Footwear - Therapists and nursing staff may give advice on the best types of

footwear, generally runner/sport type shoes are a good start• Toiletries - these are not supplied by the hospital• Reading material - or something that you would like to do outside of

therapy time.

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What not to bring in• Cigarettes, alcohol and drugs – See page 23 for further information• Electrical equipment which has not been tested and tagged by a

licensed operator• Pot plants as the soil poses a risk of infection.

Rehabilitation Visiting Hours

6am-9pmVisitors should respect your need to attend therapies or for rest periods during the day.

If your condition demands, visiting may be restricted at the discretion of the nursing staff.

Meals (12B)

Menu sheets are delivered daily and you are encouraged to complete your own meal selections; family, nursing staff and nutrition technicians can assist you if you are unable to do this yourself.

The ward dietician can advise on nutritional issues and special dietary needs and meals may need to be changed to suit specific dietary requirements. Fluids may need to be thickened to ensure safe swallowing occurs and a proper fluid intake is maintained.

If you have swallowing difficulties or are on modified diets you will be required to eat in the dining room where supervision from nursing and speech pathologists is available, until you are considered safe to eat independently.

Meals are served at the following times: Breakfast: 8.30am

Lunch: 12.00 midday Dinner: 6.00 pm

Food may be brought in by a family member on a daily basis as long as it is labelled with name and date and it is the correct consistency for the type of diet you are on.

There are a number of options at the hospital to purchase food. Information can be found in the Inpatient guide.

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Personal Property

Please be aware that your personal belongings are your responsibility and the hospital will not be responsible for loss,

theft or breakage of any items.

In the event you are unable to locate your property please speak to your ward staff.

Mail

Mail can be addressed directly to you using the following address:

Name OR Name Rehabilitation Unit: Ward 12B, RILUBuilding 3, Level 2 Canberra HospitalCanberra Hospital PO Box 11PO Box 11 Woden ACT 2606 Woden ACT 2606 A mailbox is located outside the main entrance to the hospital. Stamps can be purchased from the auxiliary shop, also situated in the main foyer.

Weekend and Day Leave

Leave is encouraged for patients who are medically stable and able to transfer safely. It provides a change from the hospital environment and may also allow you to see how you are able to function outside the hospital (e.g. to see if you have any difficulties moving around your house or encounter other issues which you may not have previously considered.)

Please inform the ward staff before leaving the ward at any time. For your safety, we request that you do not leave the hospital

premises without the permission of your doctor.

Laundry

A washing machine and dryer are available for you to use. Your family can also help you with your washing. Nursing staff are not responsible for washing your clothes.

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Smoke Free

Canberra Hospital is SMOKE FREE. Smoking (including electronic cigarettes) is not allowed in any hospital building (including RILU) or on the hospital grounds. Free nicotine patches are available while you are in hospital; please ask staff if you need them.

Alcohol and Illicit Drugs

Alcohol or illicit drugs must NOT be brought into the hospital. This includes the possession and /or smoking of marijuana (cannabis). If you are found drinking alcohol or taking illicit drugs the Rehabilitation Team will consider whether it is appropriate for you to continue as a patient with the Rehabilitation Service. Any visitors found drinking alcohol or taking illicit drugs will be asked to leave by hospital security.

If you have issues with substance abuse and would like assistance to cease this activity please inform the staff so that we can arrange access to support services.

More Information

For further information on:

• Other Facilities and Services at Canberra Hospital • Healthcare Rights• Hand Hygiene• Medication Safety• Preventing Falls• Preventing Pressure Injuriesplease refer to the ACT Health Guide to the Canberra Hospital.

Questions?

Please use the space below to note down any questions you would like to ask a member of your rehabilitation team.

______________________________________________________________________________________________________________________________________________________________________________________________________

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Accessibility

The ACT Government is committed to making its information, services, events and venues as accessible as possible.

If you have difficulty reading a standard printed document and would like to receive this publication in an alternative format such as large print, please phone 13 22 81 or email HealthACT@act.gov.au

If English is not your first language and you require the Translating and Interpreting Service (TIS), please call 13 14 50.

If you are Deaf, or have a speech or hearing impairment and need the teletypewriter service, please phone 13 36 77 and ask for 13 22 81.

For speak and listen users, please phone 1300 555 727 and ask for 13 22 81. For more information on these services visit http://www.relayservice.com.au

© Australian Capital Territory, Canberra, November 2015

This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without written permission from the Territory Records Office, Community and Infrastructure Services, Territory and Municipal Services, ACT Government, GPO Box 158, Canberra City ACT 2601.

Enquiries about this publication should be directed to ACT Health Communications and Marketing Unit, GPO Box 825 Canberra City ACT 2601 or email: HealthACT@act.gov.au

www.health.act.gov.au | www.act.gov.au

Enquiries: Canberra 13ACT1 or 132281 | Publication No XXXXX

Rehabilitation is a goal centred process that enables you to recover independence after illness or injury in a manner that maintains your

dignity and self respect

Your best chance of recovery relies upon your commitment to and participation in your rehabilitation.