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Model of Care

Model of Care for Specialist Rehabilitation Medicine

The Model of Care of the National Clinical Programme for Rehabilitation Medicine was launched by Mr Tony O’Brien, Director General of the HSE on Thursday 8th March.

 

The model of care describes the framework for the development of specialist Rehabilitation Services in Ireland.

In researching and developing this model of care NCPRM working groups examined in detail the current evidence base and existing recommendations for organisation of specialist rehabilitation services across English-speaking OECD countries.

The three-tier model of complexity-of-need has formed the basis for the commissioning of specialist rehabilitation services in England and Wales since the designation of Brain Injury and Complex Rehabilitation as a specialist service. The model translates to the Irish rehabilitation context with important adaptations.

In the Rehabilitation MOC there are recognised levels of specialist rehabilitation:- 

-       Complex specialist service: serves a national population and manages a high proportion of complex cases (60-70% have complex needs).

-       Local/Regional specialist rehabilitation service: serves a population of up to 1 million and manages fewer complex cases (up to one third or 25-33% will have complex needs).

-       Community rehabilitation services: serves a CHO population (usually ≈500,000) and comprises a wide range of therapy services including specialist and generic, and statutory and voluntary.

Within this framework of specialized rehabilitation care the main premise underpinning all rehabilitation service delivery is

-       Person centered approach to patient care

-       Development of appropriately resourced interdisciplinary inpatient, outpatient and community based specialist rehabilitation teams across Ireland supported by education and training

-       Case management of patients

-       Managed Clinical Rehabilitation Networks (MCRN) 

This Rehabilitation MOC acknowledges the fact that different service users need different input and different levels of expertise and specialization at different stages in their rehabilitation journey. The critical point of this model is that, although service users may need to access different services as they progress, the transition between services should be facilitated by appropriate communication and sharing of information between services so that they progress in a seamless continuum of care through the different stage.

Integrated Care Pathways

The Model of Care includes a number of algorithms outlining pathways of care for particular patient groups. These algorithms were developed by specific workstreams of the Programme and are based on evidence base practice. Each of the algorithms will be developed into full Integrated Care Pathways. The first pathway to be fully developed is the Integrated Care Pathway for Spinal Cord Injury. As remaining integrated care pathways are developed, they will also be made available.

Clinical Strategy and Programmes Division