Output 1.5 Rehabilitation, Aged and Community Care

The provision of an integrated, effective and timely response to rehabilitation, aged care and community care services in inpatient, outpatient, emergency department, sub-acute and community-based settings.

The key strategic priorities for Rehabilitation, Aged and Community Care are:

  • ensuring that older persons in hospital wait the least possible time for access to comprehensive assessment by the Aged Care Assessment Team. This will assist in their safe return home with appropriate support, or access to appropriately supported residential accommodation
  • improving discharge planning to minimise the likelihood of re-admission or inadequate support for independent living, following completion of hospital care
  • ensuring that access, consistent with clinical need, is timely for community-based nursing and allied health services and that community-based services are in place to better provide for the acute and post-acute health care needs of the community.

The Rehabilitation, Aged and Community Care (RACC) division integrates public health system rehabilitation, aged and community and primary care services across the ACT. The division aims to improve the quality and accessibility of services to clients. RACC promotes a continuum of care covering the range of prevention, assessment, diagnosis, treatment, support, rehabilitation and maintenance.

RACC adopts an area-wide approach to client-centred care. To this end, RACC works closely with others to improve the communication between primary, acute, sub-acute and community health care services while fostering professional development and promoting best practice in rehabilitation, aged and community care.

RACC services are delivered at a broad range of sites throughout the ACT, including hospitals, community health centres and the homes of clients. This includes health care and support for people with acute, post-acute, long-term and terminal illnesses.

The provision of these services includes:

  • hospital-based admitted and outpatient geriatric and rehabilitation medicine services, including ortho-geriatrics, at both the Canberra Hospital and Calvary Public Hospital
  • geriatric medicine and rehabilitation medicine outpatient services to regional New South Wales
  • the Rapid Assessment of the Deteriorating and At-Risk Aged (RADAR) Service, providing service to older people in their own homes, including to residents of aged care facilities upon referral from a general practitioner
  • aged care client assessment services
  • residential aged care liaison
  • community nursing and allied health services, such as podiatry, social work, nutrition and weight management, physiotherapy, continence services, occupational therapy and self-management of chronic conditions training courses
  • the Transitional Therapy and Care Program (TTCP), providing allied health services to support clients in the post-hospital discharge period, either in a residential setting or in their own homes. RACC provides this service in partnership with Baptist Community Services
  • falls injury prevention services, including falls assessment clinics, the Stepping On program and related health promotion activities
  • transitional rehabilitation at the Rehabilitation Independent Living Unit (RILU)
  • community-based multi-disciplinary rehabilitation services
  • services provided by exercise physiologists, including programs for rehabilitation, cardiac rehabilitation and hydrotherapy
  • vocational assessment and rehabilitation services
  • driver assessment and rehabilitation services
  • geriatric outpatient speech pathology and neuropsychology services
  • a multi-disciplinary memory assessment service
  • ACT Equipment Scheme
  • Equipment Loan Service
  • Domiciliary Oxygen and Respiratory Support Scheme
  • ACT Continence Support Service
  • Clinical Technology Services
  • a specialised wheelchair and posture seating service
  • prosthetics and orthotics services
  • information and advice on assistive technologies by the Independent Living Centre (ILC).


RACC made improvements to a range of facilities, systems and processes with the aim of improving service provisions, including the following:

  • RACC Prosthetics and Orthotics implemented a triage clinic to better manage client need and wait times. This saw the non-urgent wait time fall from 20 weeks in June 2012 to 13 weeks in June 2013.
  • The Domiciliary Oxygen and Respiratory Support Scheme improved contract arrangements and management of clients. This included annual review of all oxygen clients for the first time in the ACT and the ongoing annual review of all respiratory clients.
  • Following a multi-disciplinary review of how the Spinal Cord Injury Review Clinic was conducted, format changes have allowed for an increase in the number of clients able to attend.
  • Pain management support was introduced in the Rehabilitation Independent Living Unit (RILU) for clients attending the gym for therapy sessions. This has promoted good pain management, allowing the clients to achieve their goals with minimal disruption to their programs.
  • Implementation of multi-disciplinary triage meetings daily has resulted in more timely processing and management of referrals to the Rapid Assessment of the Deteriorating and At-Risk Aged (RADAR) service. Clients referred to RADAR continue to be assessed within the target of one working day.
  • The Exercise Physiology Department implemented a number of service improvements, including the rollout and completion of the Beat It Physical Activity and Lifestyle Program to Health Directorate staff, and the revision and development of standardised testing protocols for exercise tests.
  • RACC strengthened existing initiatives and introduced innovations with the aim of further reducing falls in both community and hospital settings.

RACC introduced the following new services in 2012‑13:

  • Physiotherapy, nutrition, podiatry services and a nursing ambulatory care clinic are now provided at the new Gungahlin Community Health Centre, which opened in the second half of 2012.
  • Additional workshop space at the Village Creek Centre was refurbished and equipped for the implementation of a custom medical-grade footwear service within the Clinical Technology Service.

RACC improved the coordination of geriatric and rehabilitation services across community, outpatient, Emergency Department and inpatient settings:

  • This year saw the successful transition and discharge of the first ventilator-dependent tetraplegic client from inpatient rehabilitation services to the community. This was achieved through comprehensive clinical management, collaboration, and consultation across various health areas and ACT Government departments.
  • RACC Nursing undertook a project aimed at enhancing the experience of elderly clients in the Emergency Department (ED). The project targeted clients either presenting from residential aged care facilities or who were over 85 years. The focus was on improved assessment, diagnosis and treatment of delirium. This project was undertaken collaboratively with the ED. As a result of the project, the average response time by the Department of Geriatric Medicine to the ED showed an improvement of almost 30 minutes. ED staff also report they are now better informed about delirium and dementia.
  • A validated screening tool for malnutrition in the elderly population on 11A, the Acute Care of the Elderly ward at the Canberra Hospital, was introduced. The screen has resulted in more efficient referral to a dietician and timely follow-up.
  • A successful partnership with Goodwin Aged Care Services resulted in an additional eight beds for Canberra Hospital clients approved and waiting for permanent residential aged care placement. This released eight acute beds to assist with access.

RACC undertook considerable learning and development activities, including the following:

  • Sustaining a high level of student placement opportunities across the service, including opportunities for students from the University of Canberra, in a number of allied health professions (such as occupational therapy, clinical psychology, podiatry, physiotherapy, nutrition, prosthetics and speech pathology).
  • A nursing-specific core education course on neurological rehabilitation was developed and delivered. This 12-module course is conducted in a cyclical manner on a fortnightly basis. This format is designed to capture all nursing staff over time, without being dependent on their particular scheduled shifts.
  • The Department of Geriatric Medicine has received a Best Clinical Unit for Teaching nomination from the ANU Medical School for the past three years.
  • Through training and mentoring, a career in geriatric medicine was promoted to junior medical officers and medical students.

In 2012‑13, RACC undertook a number of workforce initiatives, including the following:

  • The successful implementation of a Podiatry Assistant role in the Community Care Podiatry Service in 2011‑12 led to the establishment of a second trainee position, commencing in April 2013.
  • Recruitment was undertaken to a Transitional Therapy and Care Program (TTCP) Access Officer position at the Canberra Hospital. The purpose of the position is to improve access to, and occupancy of, the TTCP and to improve the transition from hospital for clients. The position has been operating since March 2013 and early indications are that there have been improvements in TTCP access.

RACC services, teams and staff members were nominated for or won the following in 2012‑13:

  • The ACT Equipment Scheme (ACTES) Equipment Mobile Repairs and Maintenance Service was evaluated and found to provide a high-quality service, winning an ACT Quality in Healthcare Award in the Innovative Models of Care category.
  • Community Rehabilitation occupational therapy staff were finalists at the ACT Health Quality in Healthcare Awards for Getting on with It—Single Handed, a group designed to look at engagement in functional activities and care of low-function upper limbs.
  • In January 2013, the Rehabilitation Nurse Practitioner was awarded an ACT Health Australia Day
    achievement medallion.
  • In May 2013, the Rehabilitation Nurse Practitioner was awarded the inaugural Nurse Practitioner of the Year award at the ACT Nursing and Midwifery Excellence Awards.
  • The Equipment Loan Service was awarded an ACT Health Australia Day Team achievement medallion for its contribution to clients in the community.
  • At the Health Promotion Awards in June 2013, the Community Care Program was awarded the ACT Medicare Local Award for Outstanding Achievement in a Primary Health Care Setting for its Healthy Communities Outreach Health Program.
  • RACC staff were also nominees and recipients of awards at the 2012‑13 Allied Health Awards for Excellence, nominated for Allied Health Clinical Excellence, Allied Health Management and Leadership Excellence, and winning the Award for Allied Health Assistant Excellence.

RACC published and presented key work in 2012‑13:

  • The Department of Geriatric Medicine published and presented extensive work on:
  • – cardiovascular and neurological diseases in older patients with osteoporotic hip fracture
  • – interactions between serum adipokines and osteocalcin in older patients with hip fracture
  • – hypertension and haemodynamic instability and falls in the elderly
  • – hip fracture in stroke survivors
  • – the impact of malnutrition on co-morbidities, bone metabolism and outcomes in older adults with hip fracture.
  • Other RACC presentations at conferences in 2012‑13 included:
  • – ‘Transition from Clinician to Supervisor—How Do We Develop the Health Professional Supervisors of the Future?’
  • ‘How Do We Know Students Have Positive Clinical Experiences in our Health Service?’
  • – ‘Making Self-Reflection a Reality in Workplace Integrated Learning (WIL): Practical Strategies for Supervisors’
  • – ‘Adult Healthy Weight Service’
  • – ‘Social Inclusion through a Health Coaching Approach to Promoting Healthy Lifestyles in a Disadvantaged Community’—developed in collaboration with the Population Health Division as part of a joint Australian and Territory Government initiative under the National Partnership Agreement on Preventative Health
  • – ‘HWA Aged Care Workforce Reform—Introduction of a Discharge Support Allied Health Assistant Role in the Aged Care Setting’
  • – ‘MS and Driving: A Consideration for All Health Professionals’
  • – ‘DiabExercise: Improving Exercise Physiology Services for the Management of Type 2’.

Issues and challenges

  • The upgrade of the Aged Care Assessment Team (ACAT) national software database to reflect changes to Commonwealth legislation required a significant time commitment, on the part of the ACAT team, to understand the changes and implications for the service in readiness for implementation by August 2013.
  • Increasing demand for ACAT assessment remains a challenge to meeting the key performance indicator for priority 3 referrals. Strategies to improve this over the next six months include the review of intake processes and recruitment of casual and temporary staff to meet demand at peak times.
  • Some specialist New South Wales services are no longer providing orthotics services to ACT clients, placing additional pressure on RACC Prosthetics and Orthotics.
  • The lack of residential aged care facility beds in the community is continuing to impact on the average length of stay and separations in aged care. At 30 June 2013, there were 46 public hospital inpatients awaiting residential aged care facility placement.
  • Significant work continues with the prospective decant of some services based on the Canberra Hospital campus as part of the Health Infrastructure Project. The challenges include providing existing services temporarily in a refurbished area and meeting expected increased demands over the next few years, while the University of Canberra Public Hospital is built.
  • Geriatric staffing remains a challenge. Although three new consultant staff have been recruited since early 2011, there was a resignation in June 2013 and there is a retirement pending in September 2013. Advertising for recruitment to vacant positions and temporary backfill to cover maternity leave are imminent. In 2012‑13, there were three Advanced Trainees in Geriatric Medicine.

Future directions

  • Model of care projects are being finalised to support the expansion of community-based services in community health centres. This includes the provision of services, equipment and facilities to enhance the overall experience of clients and staff. A key focus is to deliver health services that are built around the client, addressing needs at the local level. Consumers and staff are central to the design of all new services and facilities.
  • New nurse-led walk-in centres (WiC) will be located at the Belconnen and Tuggeranong Community Health Centre opening in 2014. The model of care for the new WiCs will be similar to that of the Canberra Hospital WiC, which is available for the one-off treatment of minor illness and injury. No appointment is necessary and the service is provided free to clients.
  • Access to RACC nursing and allied health community-based services in Canberra’s north will be improved as clinics at the new Belconnen Community Health Centre open in late 2013.
  • Work continues with user groups in preparation for the building of the University of Canberra Public Hospital, a stand-alone subacute facility on the north side of Canberra. This exciting project will feature a centre of excellence for subacute care, including inpatient and ambulatory models of care for rehabilitation.
  • There are plans to review the input of Community Geriatrics to have greater input into the assessment and follow-up of elderly clients presenting to ED, especially with falls, to expedite their safe discharge from ED and minimise the likelihood of re-presentation.
  • In collaboration with other ACT Government directorates, including the Community Services Directorate, RACC will participate in the rollout of DisabilityCare Australia in the ACT.