Model of Care

The NCPRM’s Model of Care for the Provision of Specialist Rehabilitation in Ireland was launched by Mr Tony O’Brien, Director General of the HSE in March 2018.

The model of care describes the framework for the development of specialist rehabilitation services in Ireland, and is in line with the National Policy and Strategy for the Provision of Neuro-Rehabilitation Services in Ireland (2011). In researching and developing this model of care, the NCPRM CAG and Working Group examined in detail the current evidence base and existing recommendations for organisation of specialist rehabilitation services across English-speaking OECD countries.

A tiered 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.  For the Irish context, it is proposed that there are three recognised levels of specialist rehabilitation. See Managed clinical rehabilitation networks (PDF, 402 KB, 1 page).

  • 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 (25-33% will have complex needs).
  • Community specialist rehabilitation services: serves a CHO/RHA population (usually ~500,000) and comprises a wide range of therapy services including specialist and generic, statutory and voluntary.

The main premises underpinning all specialist rehabilitation service delivery should be:

  • A person-centred approach to patient care
  • 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), with connected governance and shared processes. 

MCRNs will connect acute and post-acute rehabilitation units, community specialist rehabilitation clinicians & community-based services in a formal way to allow delivery of co-ordinated and integrated rehabilitation for patients.  The NCPRM’s Model of Care acknowledges the fact that different service users need different input and different levels of expertise and specialisation 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.

Model of Care Key Recommendations:

  • A person-centred approach to service delivery
  • Equitable access to services
  • A three-level model of service delivery across Managed Clinical Rehabilitation Networks (MCRNs).
  • Development of appropriately resourced, interdisciplinary inpatient, outpatient and community-based specialist rehabilitation teams across Ireland, supported by education and training
  • Development of systems to facilitate measurement and data collection.

Model of Care (PDF, 7.87 MB, 96 pages)

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 NCPRM 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 (PDF, 2.31 MB, 62 pages). As remaining integrated care pathways are developed, they will also be made available.

Spinal Cord Integrated Care Pathway (PDF, 2.26 MB, 62 pages)