Output 1.5-Rehabilitation, aged and community care

Output description

The provision of an integrated, effective and timely service 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 readmission or inadequate support for independent living, following completion of hospital care,
  • ensuring that access is 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 healthcare needs of the community.

The Rehabilitation, Aged and Community Care (RACC) Division integrates public health system rehabilitation, aged and community care, 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 healthcare 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 and long-term illnesses.


  • In August 2013, the Aged Care and Assessment Team (ACAT) took back the responsibility of managing all referrals to ACAT from initial point of contact through to assessment end. The changes to the process of referral acceptance, triage and processing have improved the service's capacity to manage referrals in a timely manner. ACAT has met ACT Health requirements to respond to public hospital-based assessments within two working days of acceptance of an appropriate referral. From June 2013 to June 2014, there was a 90 per cent decrease in the number of ACAT priority 3 referrals waiting to be actioned by ACAT.
  • ACAT responded to changes in legislation planned for 1 July 2014 with further upgrades to the national software database and 100 per cent completion of mandatory training as set by the Commonwealth.
  • The Transitional Therapy and Care Program provides goal-focused care to facilitate the transition of elderly clients from hospital to the home. The improved average occupancy rate of 81.81 per cent across the first two quarters of 2013-14, up from 55.42 per cent in 2012-13, can be attributed to improved identification of suitable patients and intake processes with the introduction of the access officer role, coupled with the provision of extensive education to hospital staff about the program.
  • Community Allied Health Services exceeded the established activity target (22,000 occasions of service), providing 24,789 occasions of service. The improvement was made by increasing the staffing levels in podiatry and physiotherapy, which included the establishment of a physiotherapy clinical educator position.
  • Community nursing services were expanded at Belconnen Community Health Centre and Tuggeranong Community Health Centre with the opening of the new and refurbished health centres under the ACT Health Infrastructure Program. Additional ambulatory care clinics, providing mostly wound and continence care, post-chemotherapy monitoring and medication administration, have been established at the health centres and have improved access to care.
  • The community nursing service has also expanded the Self Management Chronic Conditions Program with the implementation of additional Living a Healthy Life with Long-term Conditions courses for community participants across the ACT. This self-management course is patient- and family-centred and empowers the patient to take more responsibility for their health, monitor and manage their symptoms, adhere to treatment regimes and work collaboratively with their health providers. This course educates patients and carers on a variety of self-management strategies, including the management of pain, fatigue, anxiety and depression, healthy eating, exercise, dealing with difficult emotions and working with health professionals to assist in managing conditions optimally.
  • The Exercise Physiology Department is also placing greater emphasis on self-management through behaviour change and goal setting. The department will continue to work with multidisciplinary chronic disease and rehabilitation programs that are already established within the department.
  • A research project aimed at improving services for patients with recurring venous leg ulcers was funded through a Nursing and Midwifery Practice Development Scholarship. As part of the project, monthly compression stocking clinics with a nurse practitioner in wound management commenced at Gungahlin Community Health Centre. Interim results indicate improved outcomes for participants. This clinic provides improved patient assessment for suitability for ongoing compression therapy, prescription of correct pressure gradient stockings, improved monitoring of skin integrity, better support and advice for ongoing care, access to a clinic for ongoing expert advice and monitoring by a nurse practitioner.
  • Stroke education groups within the Community Rehabilitation Team (CRT) were developed and established during 2013-14. A Vestibular Rehabilitation Clinic has also been established at Phillip Health Centre and Belconnen Health Centre (as part of the CRT). The CRT is also now providing services from the expanded Belconnen Community Health Centre.
  • RACC inpatient nursing services successfully introduced assistants in nursing into the Acute Care of the Elderly team (Ward 11A), to improve the quality of service while reducing reliance on short-term agency nurses.
  • In collaboration with food services and nutrition services at the Canberra Hospital, the RACC inpatient nursing services team introduced initiatives to improve the nutritional intake of patients. Initiatives include coloured meal mats to denote which patient requires assistance, monthly themed lunches and a move towards a protected mealtime. Protected mealtimes allow patients to eat their meals without disruptions (for example, a ward round or medication round) and enable staff to focus on providing support and assistance to patients.
  • The Walk-in Centre in Tuggeranong Community Health Centre opened on 26 June 2014 following the closure of the Walk-in Centre at the Canberra Hospital on 25 June 2014. The Walk-in Centre at Belconnen Community Health Centre opened on 1 July 2014.
  • The Prosthetics and Orthotics Service has added the manufacture of custom medical-grade footwear to its range of services. Following necessary recruitment, set-up and training, the service commenced manufacturing custom medical-grade footwear for clients in January 2014.
  • The Domiciliary Oxygen and Respiratory Support Scheme renegotiated the contract with the current supplier and commenced purchasing continuous positive airway pressure (CPAP) machines outright, which has resulted in minimising the rental cost of the scheme. At 30 June 2013, 777 clients were receiving support through this scheme. In 2013-14, 971 clients were receiving assistance, an increase of 25 per cent.
  • A number of RACC staff received awards during 2013-14:
    - Hazel Hurrell, Assistant Director of Nursing, RACC was awarded the 2014 Manager of the Year at the ACT Nursing and Midwifery Excellence Awards; Emma Whitehead, Allied Health Assistant with CRT, was awarded Allied Health Assistant of the Year; and Kerryn Maher, Manager of the RACC Podiatry Service, was awarded Allied Health Professional of the Year and the Allied Health Award for Management and Leadership for Excellence.
    - RACC staff member Margaret Hemsworth was nominated in the 2013 ACT Health Awards for Administrative Excellence, as was the Village Creek Centre administration team.
    - The Community Care quality activity titled 'Improving Documentation of Clinical Interventions' won the 2013 ACT Quality in Healthcare Award, safety category through demonstrating improvement to documentation of clinical intervention.
    - The Community Care Podiatry Team won the Allied Health Award for Excellence.
    - At the Australian Wound Management Association Conference in May 2014, the Nurse Practitioner for Wound Management, Judith Barker, was presented with a fellowship that recognises her outstanding contribution to the Australian Wound Management Association (AWMA) committee activities and her clinical leadership. She is the first AWMA Fellow from the ACT.
  • The Exercise Physiology Department received an allied health funding grant to develop two posters about the multidisciplinary Cardiac Rehabilitation Program and six-minute walk test data.

Issues and challenges

  • A number of RACC services will be impacted by the commencement of the ACT trial of the National Disability Insurance Scheme (NDIS) on 1 July 2014. Preparations for the service delivery, financial, IT and communications issues have been undertaken but work will continue as the trial progresses.
  • RACC is actively involved in the establishment of the University of Canberra Public Hospital (UCPH). The staging and decanting of Building 3, TCH will impact on RACC services.
  • ACAT will need to support the delivery of online assessment and a centralised support system as determined by the Commonwealth through the My Aged Care System. The national framework will ensure a centralised entry point which will make it easier for older people, and their families and carers, to access information on ageing and aged care, have their needs assessed, make referrals and be supported to locate and access services available to them. This will be supported by a central client record.
  • Reduced access to residential aged care beds has continued to impact on the average length of stay and separations in the inpatient wards. In November 2012, RACC contracted eight beds at Goodwin Aged Care Service at Monash for inpatients waiting for permanent placement in a residential aged care facility. The current contract with Goodwin Aged Care Service will cease on 30 September 2014, and these inpatients will be transferred back to Canberra Hospital under the bed realignment project.

Future directions

  • RACC will continue to be heavily involved in the design and development of the new UCPH.
  • RACC is participating in the NDIS pilot, and continues to work closely with Community Service Directorate and the National Disability Insurance Authority locally.
  • Tuggeranong Community Health Centre is expected to expand its weekend nursing clinic services to meet ongoing clinical demand now that more clinic space is available in the new health centre.
  • RACC community-based services are expected to expand its services and increase number of staff positions in 2014-15. This will include additional allied health and nursing services, including the creation of a clinical nurse consultant for stoma therapy to assist with increasing demand in this area.
  • The CRT is expected to provide additional rehabilitation services to community patients with neurological diagnoses as a result of additional funding attached to community health services.
  • The introduction of the community electronic clinical record in 2015 will improve real-time access of clinical information for staff working in domiciliary and clinic settings in the community health centres, including the Walk-in Centres.
  • During 2014-15, ACAT will develop processes to allow for referrals, assessment services, referrals for service delivery from other agencies and maintenance of a central client record.