Allied health professional services (AHPs): Referral, Assessment, Rehabilitation and Transfer of Care

Rehabilitation: habil comes from the Latin meaning to enable

Rehabilitation is a goal directed, time-limited process providing the tools to change life
Rehabilitation is an approach. It needs to be Multi-Disciplinary and Patient-Centred

At all stages there should be early and acitve involvement of colleagues, patients and, with appropriate consent, carers and families.

New episode of acute stroke (suspected or diagnosed)

Hospital / Home
Refer to 'Admission and discharge from the stroke unit' guideline to inform where an indicidual should be treated

Refer patient to appropriate Allied Health Professional
Appropriate referral form and Personal Outcome Plan (POP) should be used

Carry out an appropriate assessment
The MDT will have a daily huddle to discuss admissions, discharges and transfers on the Stroke Unit. A full MDT will be carried out once a week when assessment, goals and outcomes will be recorded.
For patients with a swallowing difficulty refer to 'Dysphagia / stroke swallowing problems' guideline
Refer to 'Management of nutrition (in-patient)' guideline

Set Goals and agree plan for rehabilitation

Transfer of Care
Appropriate referrals should be made to hospital or community-based services (including Day Hospital, Community Rehabilitation Team, CHSS Rehabilitation Support and Stroke Nurse Service, see: 'Admission and discharge from the stroke unit' guideline

Referral Process

•	All adults with a new episode of stroke regardless of age should be referred to a registered Occupational Therapist, Physiotherapist, and as appropriate to Speech & Language Therapist, Dietitian or Clinical Psychologist
•	Referrals should be made on the day of admission following medical assessment
•	The process for onward referrals (eg between and within Hospital and Community Staff (including Multi-Disciplinary Teams), should be guided by Patients' progress but should start as early as possible
•	Referrals may be initiated verbally but the appropriate referral form should be completed and submitted within 48 hours. Personal Outcome Plan (POP) should be used
•	Referrals will be accepted from any appropriate source
•	Cross referrals for assessment, should be made to other members of Multi-Disciplinary Team, Community Allied Health Professionals.

Assessment Process

•	An initial assessment should take place within 48 hours of referral
•	For swallowing/nutrition screening and assessment refer to Protocols for Management of Dysphagia and Nutrition
•	A comprehensive assessment should be carried out, as soon as possible, according to the fitness of the patient
•	Involvement with carers (and as appropriate families), should be made at the earliest opportunity and at least within 7 working days of receipt of referral
•	The recommended Validated Tool and Outcome Measure for Stroke in Highland is FIM/FAM. This should be used by Members of the Multi-Disciplinary Team and findings documented, including: Physiotherapy: Respiratory, functional abilities, positioning and manual handling Occupational Therapy: Positioning and manual handling, Activities of Daily Living, cognitive ability, use of specialist equipment Speech and Language Therapy: Management of Dysphagia and Dysphasia, Supporting Communication

Goal Setting and Rehabilitation

•	Following assessment, rehabilitation plans should be discussed and agreed jointly by Multi-Disciplinary Team, patient, carer(s) and where appropriate with families. Time scales and goals should be explained and agreed
•	Goals set should be realistic, attainable and agreed. Multi-Disciplinary Records should be kept
•	The principles outlined should be the key drivers for the rehabilitation process
•	Therapy MUST start as soon as possible in the patients journey
•	Within stroke unit/hospital setting a formal Multi-Disciplinary Team meeting should be held at least weekly
•	Within dispersed community setting, Multi-Disciplinary Team members should discuss patients weekly and meet at least monthly
•	Goals should be reviewed regularly by each therapist but also by the Team. New goals should be discussed and set, and treatment modified, as appropriate. Each review should provide the basis for informing discharge plan and transfer of care.

Transfer of Care

•	Patients may be transferred from the care of an Allied Healthcare Professional when rehabilitation is complete or when a patient is being transferred to a new setting and appropriate care and rehabilitation is available
•	Typically, a patient will be discharged from rehabilitation when agreed goals have been met OR patient ceases to benefit from active rehab. Rehab will also stop if patient moves out of area or input is refused
•	Where rehabilitation/support needs are ongoing, appropriate and timely referrals should be made including to Community Rehabilitation Teams, CHSS Rehabilitation Support and Stroke Nurse Service, and the Stroke Nurse follow up service
•	Appropriate information should be provided including relevant contact details (eg Stroke Coordinator)
•	For follow-up refer to Multi-Disciplinary Care Pathway.

Editorial Information

Last reviewed: 31 December 2021

Next review: 31 December 2024

Author(s): Stroke Review Group

Approved By: TAM Subgroup of ADTC

Reviewer Name(s): Stroke Co-ordinator

Document Id: TAM402