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

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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