Output 1.5 - Rehabilitation, Aged and Community Care

The aim of Output 1.5 is to provide an integrated, effective and timely response to rehabilitation, aged care and community care services in inpatient, outpatient, Emergency Department, subacute and community-based settings.

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

  • 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

  • improving discharge planning to minimise the likelihood of re-admission or inadequate support for independent living, following completion of hospital care

  • ensuring that hospitalised older persons wait an appropriate time for access to comprehensive assessment by the Aged Care Assessment Team (ACAT), which assist in their:

  • safe return home with appropriate support

  • accessing appropriately supported residential accommodation.


The Exercise Physiology Department commenced input into the School Kids Intervention Program (SKIP), which is a family-centred, multidisciplinary service within the Division of Women, Youth and Children for children aged 4–12 years who are overweight or obese. The program was developed based on the recommendations of the Obesity Service Redesign Project 2012. It has been developed with the aim to support a number of ACT Government’s plans and strategies, including the:

  • Children’s Plan 2010–14

  • Towards Zero Growth Healthy Weight Action Plan.

The program commenced in March 2015 and aims to improve the health and wellbeing of children and their families.

More information: For detailed information about SKIP, see Output 1.6: Early Intervention and Prevention, Early intervention and prevention programs.

The Veteran Liaison Service successfully hosted an ANZAC Day Service to commemorate the 100th Anniversary of the landing at Gallipoli. A representative of the Turkish Embassy attended the service.

The Veteran Liaison Service received a ‘Love Award’ from the Canberra Hospital Foundation to refurbish their lounge and kitchen area.

The RACC Psychology and Counselling service has been restructured to include new graduate and junior positions for clinical psychology and neuropsychology. They, along with the Speech Pathologists, have been responsible for introducing a Cognitive Remediation Program for patients both in hospital and in the community. The aim of this program is to increase and improve the cognitive re-training of patients.

Performance against accountability indicators

The Community Nursing and Allied Health performance exceeded the 2014–15 targets for:

  • number of nursing occasions of service, which was set at 82,000

  • number of allied health regional services, which was set at 22,600.

This was achieved by:

  • recruiting additional allied health and nursing positions, which expanded community-based services

  • implementing changed models of care.

More information: For additional information, see C.6 Statement of performance, Output 1.5: Rehabilitation, Aged and Community Care.


In May 2015, the Rehabilitation and Aged Care Outpatient Clinics relocated to larger premises. The new location in Building 3 of Canberra Hospital provides patients with a more relaxed environment, which assists both the clinician and patient during the assessment or consultative process.

Speech Therapy began using iPads in the inpatient wards (12B and RILU). The aim was to increase therapeutic communication time by introducing innovative activities. This activity has provided the following benefits:

  • assisted when running small communication groups

  • allows patients to practice independently between sessions

  • has indirectly increased social communication between patients on the wards

  • allows interactive language and speech practise using app technology

  • can also be used to assist patients with cognitive communication difficulties in working on cognitive domains such as attention, memory and executive function.

Speech Pathology services use began using telehealth in MDT settings.

Aged care

Reduced access to residential aged care beds has continued to impact on the average length of stay. However, with the opening of new beds across the ACT (in July 2015) this may improve.

Community care

A number of community-based services have reported growth in demand.

Podiatry referrals have increased from by 11.23 per cent from 2013–14 to 2014–15. Physiotherapy referrals increased by 21.5 per cent over the same period.

Referrals for palliative care to the Community Care Nursing service are expected to rise in response to the increased need for primary palliative care services for the ACT community. This will place pressure on the existing capacity of Community Nursing, who will continue to work with Calvary Hospital Home-Based Palliative Care, who provides the specialist component of palliative care services.

The improved Community Nursing performance can be attributed to increased capacity of the service, with growth funding available to the City, Tuggeranong and Belconnen nursing teams. In addition, the foot clinics, which were previously attended by Community Nursing, are now provided by the Podiatry team.

An additional RN was recruited to the Self Management of Chronic Conditions Program in early 2014. This has resulted in increasing the number of chronic conditions group courses by 48 per cent.

The community-based allied health services have also grown, with the Community Podiatry, Nutrition and Physiotherapy teams expanding.

Physiotherapy Assistants review clinics have been implemented in our community team while Occupational Therapy assessment clinics have also been established at the Independent Living Centre (ILC). Our Community Nutrition team has commenced services to renal patients at Belconnen and Tuggeranong Community Health Centres.

The Community Rehabilitation Team (CRT) and Falls Assessment and Prevention Services have also expanded with introduction of additional:

  • Occupational Therapists

  • Physiotherapists

  • Allied Health Assistants.

Dementia care

Canberra Hospital is one of four national hospitals selected to be a national partner with Ballarat Health Services, to implement and evaluate the Dementia Care in Hospital Program (DCHP). This program is funded by the Commonwealth Department of Social Services (DSS). It is an all of hospital education program aimed at improving hospital care of patients with cognitive impairment. ACT Health Human Research Ethics Committee approval is currently being sought. Alzheimer’s Australia is a strong supporter of the project. Its representative and a representative of the Health Care Consumers Association (HCCA) will be involved in the project steering group.

Referrals to the Driver Assessment and Rehabilitation Service (DARS) have increased, especially for older drivers with dementia, which presents an ongoing challenge. An increase of approximately 100 referrals to this service has been recorded over the last two years.

Access to services

The Transitional Therapy and Care Program (TTCP) occupancy continues to increase, with an expected occupancy for 2014–15 of approximately 80 per cent. This has been achieved by altering the service model and improving the staffing profile.

Demand for our equipment services has also increased:

  • As at 30 June 2015, the Domiciliary Oxygen and Respiratory Support Scheme (DORSS) were supporting 1,356 clients compared to 1,228 clients at 30 June 2014. This is an increase of 10 per cent.

  • The Equipment Loan Service (ELS) provided 10,722 items of equipment to clients in the community to facilitate hospital discharges and aid rehabilitation. In 2013–14, 10,222 items were provided. This was an increase of 500 items.

As part of a joint initiative between CRT and the Palliative Care service from Calvary Hospital, the cross-service clinic model for clients with Motor Neurone Disease (MND) was reviewed. Changes were made to improve the continuity of care for clients attending and increase satisfaction of the team.

Video-teleconferencing was also introduced for clients with MND in regional NSW.

RACC continues to actively support student education. Health Workforce Authority (HWA) funding received in 2014–15 was used to provide four staff members with experience in clinical educator positions. This activity was undertaken as a part of a succession planning and retention strategy.

The Coordinator of Community Geriatric Service Rapid Assessment Deteriorating Aged at Risk (RADAR) Service, Geriatric Outpatients and Memory Assessment Service (ROM) commenced within the RACC team in January 2015. This has resulted in a more unified approach to the outpatient-based services provided by RADAR, Geriatric Outpatient Clinics and the Memory Assessment Service.

Hospitalised older persons

In September 2014, the Sub-acute Geriatric Unit (SAGU), ward 11B, was established in Canberra Hospital. This unit is staffed by an MDT and increased the inpatient bed capacity of Canberra Hospital by 18. These 18 beds comprise:

  • 10 subacute geriatric beds

  • eight beds for non-acute patients awaiting residential aged care placement.

This allowed eight inpatients residing at Goodwin Aged Care Service Monash to transfer back to Canberra Hospital.

The falls minimisation rooms in wards 11A and 11B were both highly praised by the surveyors in the May 2015 National Safety and Quality Health Service Standards (NSQHSS) survey.

Awards and presentations

A number of RACC staff received awards during 2014–15:

  • Laura-Jayne Van Alphen was awarded the Allied Health Professional of the Year 2014.

  • Kathryn Pettigrove was nominated for Early Career Excellence Award for 2014 and was awarded with a Recognition of Service.

  • Jaspreet Singh was awarded the Allied Health Assistant of the Year 2014.

  • The RACC Inpatient Leadership Team was nominated for a 2015 ACT Nursing and Midwifery Excellence Award.

A number of RACC staff gave notable presentations during 2014–15:

  • The Physiotherapy Clinical Educator presented at the World Congress of Physical Therapy in Singapore on her PhD research findings on Stroke Rehabilitation.

  • Dr Sarah Walker, Clinical Psychologist, presented at the 2014 Canberra Health Annual Research Meeting on her PhD findings concerning Driving Cessation in Later Life.

  • Mr Yu-Lung Chan and Dr Harriet Downing presented at the 2014 Allied Health Symposium, The Brain That Trains Itself, outlining cognitive remediation and its application in a rehabilitation setting.

  • The Exercise Physiology Department presented a research poster at the ACT Health Allied Health Symposium, demonstrating the value of implementing a behaviour change tool designed to assist patients in self managing their condition.

  • Clinical Technology Services (CTS) presented a paper and a poster at the Australian Rehabilitation and Assistive Technology Association (ARATA) national conference held in Canberra in August 2014.

Future directions

The Australian Government continues to implement significant reforms of the aged care and disability sectors, which present challenges to the:

  • operations and funding of RACC services

  • communications to RACC clients, referrers and the community.


Growth funding received in the 2015–16 budget will be used to establish a new community-based rehabilitation service. This will increase collaboration with inpatient services and increase a seamless transition between services.

A cognitive remediation working group will be developed for patients who have had a stroke or have a traumatic brain injury.

Dementia care

The Dementia Care in Hospitals Program will be implemented from July 2015. The program aims to raise awareness of and support for more dementia-friendly and supportive environments in Canberra Hospital.

Wards 11A, 6A and 5A will be pilot wards for the program.

Access to services

From 1 July 2015, ACT ACAT will transition to the My Aged Care system. The transition period for ACT ACAT is from 1 July 2015 to 1 September 2015, when it is expected the ACAT will be fully operational within the My Aged Care portal.

My Aged Care will become the single mandatory gateway into aged care services, and will:

  • implement a central client record

  • implement a nationally consistent standardised screening and assessment process

  • manage electronic referrals via the My Aged Care online portal

  • strengthen consumer-directed care.

The planning process for moving outpatient clinics to Building 15 will include:

  • determining whether reduced space will impact services

  • determining if some clinics may be better placed in the Community Health Centres

  • using the staging and decanting process to ensure a smooth transition into the new premises.

Occupational Therapy will continue to trial an alternative model of service delivery to ensure equity of service delivery to subacute and chronic neurological caseloads. The goal is to provide a timely, early intervention, interprofessional rehabilitation service to consumers.

RACC continues to be an active participant in a range of Health Infrastructure programs including the establishment of the UCPH. Planning continues for UCPH, which is scheduled for opening in early 2018.

During 2015–16, the Cognitive Remediation Program will be evaluated and quality improvements will be completed.

Lee Silverman Voice Treatment (LSVT) groups will be implemented. Management of the LSVT waiting list will improve, with an extra staff member being trained in the use of the LSVT companion.

In terms of models of care:

  • Service development will continue to examine models of care, service provision and use of allied health assistant (AHA) roles in all clinical areas. For example, CRT is implementing a stream type model within the current Occupational Therapy staffing to provide a more responsive service across the main client groups of subacute and chronic neurological.

  • The Model of Care of the Memory Assessment Service will be reviewed to identify methods for increasing patient flow in the Outpatient Clinic.

In terms of staffing:

  • Active recruitment is progressively filling vacant specialist staff positions in Geriatric Medicine. This will reduce the excessive workload on existing staff and improve streamlining of services. All vacant positions are expected to be filled by end of 2015.

  • Occupational Therapy has experienced staff shortages. While it is anticipated that there will continue to be several staff on temporary contracts in Occupational Therapy, all positions will be filled by August 2015.

The Electronic Medication Management System will be implemented across the RACC inpatient services in early 2016. It will improve medication management and reduce medication errors.

Discharge planning

Statistics indicate 100 patients in the 85 years and older age group will be sent home from the Emergency Department each month. However, approximately 70 per cent of those will return to the Emergency Department and be admitted to hospital. The ROM service is currently developing robust and efficient strategies to reduce hospital admission rates for these patients.