Community Rehabilitation Best Practice Standards

Question 1

What are the aims of the guidelines?

Answer 1

1. Person centered/needs led approach instead of diagnosis/condition specific approach
2. Lead to clearer pathways for people with disability
3. Enabled supported self-management and goal setting
4. Streamline pathways and allow for early supported discharge from hospital and preventing avoidable readmission

Question 2

2 considerations when thinking about best practice, for involvement of family in rehabilitation

Answer 2

1. A patient’s family will always be made welcome and be involved, provided this is what the patient wants.
2. Information sharing with wider family is only undertaken with explicit consent from the patient.

Question 3

What are the 3 aims of optimisation of the community rehabilitation guidelines

Answer 3

1. Improve function, social participation and health.

Question 4

4 recommendations for the MDT

Answer 4

1. Have a single line management
2. Are locally based
3. Meet regularly in person or virtually
4. Have shared resources or processes

Question 5

List the 7 points in the summary standards.

Answer 5

1. Referral
   processes
   are explicit,
   easy, efficient
   and equitable
2. Rehabilitation
   interventions
   are timely,
   co-ordinated
   and prevent
   avoidable
   disability
3. Rehabilitation
   interventions
   meet peoples’
   needs and
   are delivered
   in appropriate
   formats
4. Rehabilitation
   pathways should
   meet needs and
   be delivered
   locally with access
   to specialist
   services #
5. Rehabilitation
   programmes
   should enable
   optimisation,
   self-management
   and review
6. Rehabilitation
   services are well
   led, adequately
   resourced and
   linked to
   other services
7. Rehabilitation
   services involve
   families

Question 6

Referral
processes
are explicit,
easy, efficient
and equitable - explain the person, clinician and rehabilitation lead roles

Answer 6

PERSON - Knows how
and when to
get help, when
in need of
rehabilitation,
either through
GP or selfreferral
CLINICIAN - Refers people
to the right
services
by using a
rehabilitation
directory of
services
REHABILITATION LEAD - Provides a
rehabilitation
directory, and
ensures equality
of access and
provision of
services

Question 7

Rehabilitation
interventions
are timely,
co-ordinated
and prevent
avoidable
disability - explain the person, clinician and rehabilitation lead roles

Answer 7

PERSON - Gets seen
by the right
person at the
right time, and
knows who
co-ordinates
rehabilitation
CLINICIAN - Undertakes
assessments,
shares
information
across the
network, and
knows local
resources
REHABILITATION LEAD - Recognises and
manages care
co-ordination,
and delivers/
monitors
mandatory
training

Question 8

Rehabilitation
interventions
meet peoples’
needs and
are delivered
in appropriate
formats - explain the person, clinician and rehabilitation lead roles

Answer 8

Knows they
have the best
rehabilitation
option to suit
them
Is trained
to deliver
evidencebased care and
shares decision
making with
people
Maps, develops
and describes
pathways for
people with
different needs

Question 9

Rehabilitation
pathways should
meet needs and
be delivered
locally with access
to specialist
services - explain the person, clinician and rehabilitation lead roles

Answer 9

PERSON - Gets co-ordinated
support for
physical and
mental health,
and can access
the equipment
needed
CLINICIAN - Works with
local services
but refers to
specialist services
if needed to
ensure the best
REHAB LEAD - Ensures
information
can be shared
and provides
resources to
be shared with
people

Question 10

Rehabilitation
programmes
should enable
optimisation,
self-management
and review- explain the person, clinician and rehabilitation lead roles

Answer 10

PERSON - Has the
information,
equipment and
support they
need to look after
their condition
CLINICIAN - Works
independently
with appropriate
workload to
support people
to maintain their
independence
REHAB LEAD - Manages
staffing to
deliver timely
and effective
rehabilitation

Question 11

Rehabilitation
services are well
led, adequately
resourced and
linked to
other services

Answer 11

PERSON - Helps record
rehabilitation
progress and
goals, and
can give
feedback
CLINICIAN - Collects data
including person
goals and service
activity, and
contributes
to audits
REHAB LEAD - Conducts
audits and
benchmarks
services, and
identifies service
priorities

Question 12

Rehabilitation
services involve
families

Answer 12

PERSON - Family members
are made
welcome and
empowered
as important
parts of the
rehabilitation
process
CLINICIAN - Identifies people
relying on carers,
and encourages
families to
take part and
contribute to
care
REHAB LEAD- Develops
pathways to
support families
and monitors
their experience