Community Community Rehabilitation and Rehabilitation and

Supported DischargeSupported DischargeNorth Cork North Cork CCommunity ommunity

RRehabilitation and ehabilitation and SSupport upport TTeam eam ((CRSTCRST))

The North Cork Community Rehabilitation and The North Cork Community Rehabilitation and Support Team (CRST) was set up in late 2009. Support Team (CRST) was set up in late 2009.

CRST see clients with acute neurologicalCRST see clients with acute neurologicalconditions or who have had falls with fractures or conditions or who have had falls with fractures or become become deconditioneddeconditioned following prolonged following prolonged hospital stayhospital stay..

CRST TeamCRST Team

The team consists of a physiotherapist, anThe team consists of a physiotherapist, anoccupational therapist and a nurse (all 0.8 occupational therapist and a nurse (all 0.8 WTE), a speech and language therapist (0.5 WTE), a speech and language therapist (0.5 WTE) and two rehabilitation assistants (both 1.0 WTE) and two rehabilitation assistants (both 1.0 WTE).WTE).

Dr Dr CiaraCiara McGladeMcGlade Consultant Geriatrician, Consultant Geriatrician, provides input from Mallow General Hospital. provides input from Mallow General Hospital. She attends team meetings regularly and She attends team meetings regularly and reviews clients in her clinic.reviews clients in her clinic.

The Team are based in the Gilbert Centre in The Team are based in the Gilbert Centre in Mallow, a multipurpose , multi agency building .Mallow, a multipurpose , multi agency building .

CRST rehabilitation gymCRST rehabilitation gym

WHO definition of neuro-rehab is

“a problem solving process in which the person who experiences a neurological impairment or loss of function acquires the knowledge, skills and supports needed for their optimal physical, psychological, social and economic function”

Aims of CRSTAims of CRST

CRST aim to facilitate early supported discharge of CRST aim to facilitate early supported discharge of clients from acute hospitals and continue rehabilitation in clients from acute hospitals and continue rehabilitation in the community.the community.

CRST provide intensive rehabilitation in the home and in CRST provide intensive rehabilitation in the home and in the Gilbert centre.the Gilbert centre.

CRST support the client to regain independence in CRST support the client to regain independence in functional activities.functional activities.

CRST also encourage clients to link into localCRST also encourage clients to link into local

services and/or community groups for socialservices and/or community groups for socialsupport.support.

National Rehabilitation StrategyNational Rehabilitation Strategy Diagram taken from the national policy and strategy for the provDiagram taken from the national policy and strategy for the provision of ision of neuroneuro rehabilitation services in rehabilitation services in

Ireland 2011Ireland 2011--2015 published by the Department of Health in 20112015 published by the Department of Health in 2011

Referral CriteriaReferral Criteria

•• Client must be medically stable and over 18.Client must be medically stable and over 18.•• Be willing and able to participate in a rehabilitationBe willing and able to participate in a rehabilitationprogramme.programme.

•• Require input from two or more disciplines.Require input from two or more disciplines.•• Have insight into personal safety or be supervisedHave insight into personal safety or be supervisedby someone at home.by someone at home.

•• Live in a safe environment.Live in a safe environment.•• Be registered with a local GP.Be registered with a local GP.•• Live within a 15 mile radius of Mallow or be ableLive within a 15 mile radius of Mallow or be abletravel to the rehab gym in the Gilbert Centre intravel to the rehab gym in the Gilbert Centre inMallow.Mallow.

Referring conditions 2012/13Referring conditions 2012/13

Referral SourcesReferral Sources•• Mallow General Hospital (MGH)Mallow General Hospital (MGH)•• Primary Continuing & Community Care (PCCC)Primary Continuing & Community Care (PCCC)•• Cork University Hospital (CUH)Cork University Hospital (CUH)•• St. St. FinbarrFinbarr’’ss Hospital (SFH)Hospital (SFH)•• South Infirmary Victoria University Hospital (SIVUH)South Infirmary Victoria University Hospital (SIVUH)•• National Rehabilitation Hospital (NRH)National Rehabilitation Hospital (NRH)•• Mercy University Hospital (MUH)Mercy University Hospital (MUH)•• Bon Secours Hospital Bon Secours Hospital •• CroomCroom Orthopaedic HospitalOrthopaedic Hospital•• Kerry General Hospital (KGH) Kerry General Hospital (KGH)

Source of Referrals 2012/13Source of Referrals 2012/13

Referral pathwayReferral pathway

On receipt of referral, clients are assessed either inOn receipt of referral, clients are assessed either inthe referring hospital, their own homes or the the referring hospital, their own homes or the rehabilitation gym.rehabilitation gym.

Goals are agreed with the person.Goals are agreed with the person.

A daily home rehabilitation programme is set up by the A daily home rehabilitation programme is set up by the therapists and supervised by the rehab assistants. therapists and supervised by the rehab assistants.

NeuroNeuro clients are also seen twice weekly in the rehab clients are also seen twice weekly in the rehab gym by gym by physiophysio, OT, SALT, and PHN as required., OT, SALT, and PHN as required.

The period of rehab varies from 3 weeks to 3 months The period of rehab varies from 3 weeks to 3 months depending on the clientdepending on the client’’s needs and individual goals.s needs and individual goals.

Referral Pathway

Many clients and their carers need a lot of support during Many clients and their carers need a lot of support during the transition from acute care to home.the transition from acute care to home.

CRST support the individual and their carer to problem CRST support the individual and their carer to problem solve difficulties which arise during the transition home.solve difficulties which arise during the transition home.

A team meeting is held weekly to discussA team meeting is held weekly to discuss

progress and review goals.progress and review goals.

Community IntegrationCommunity Integration

CRST aim to link clients in with local communityCRST aim to link clients in with local communityservices to maintain social contact and reduce theservices to maintain social contact and reduce therisk of isolation. risk of isolation.

Many of the clients live in isolated rural areas with little Many of the clients live in isolated rural areas with little or no public transport. CRST help clients explore options or no public transport. CRST help clients explore options around returning to driving, work with clients and carers around returning to driving, work with clients and carers to improve car transfers and/or accessing community to improve car transfers and/or accessing community transport schemestransport schemes

The Irish Wheelchair Association (IWA), HeadwayThe Irish Wheelchair Association (IWA), Headwayand National Council for the Blind Ireland (NCBI) alland National Council for the Blind Ireland (NCBI) allprovide services in the Gilbert Centre building whereprovide services in the Gilbert Centre building whereCRST are located.CRST are located.

There is also a wheelchair accessible gym in the There is also a wheelchair accessible gym in the building which can be used by former clients on an building which can be used by former clients on an ongoing basis. Access to the ongoing basis. Access to the MotomedMotomed exercise bike is exercise bike is also available by appointment once or twice weekly.also available by appointment once or twice weekly.

CRST support the North Cork Stroke Support Group CRST support the North Cork Stroke Support Group which has monthly meetings in the Gilbert Centre. which has monthly meetings in the Gilbert Centre.

A Social Communication Group is ongoing for clients A Social Communication Group is ongoing for clients with aphasia to practice their communication skills in a with aphasia to practice their communication skills in a safe environment.safe environment.

On discharge clients are referred to their local primary On discharge clients are referred to their local primary care team for ongoing support and rehabilitation as care team for ongoing support and rehabilitation as required.required.

Case Study

Case studyCase study

45 year old female 45 year old female ““MaryMary””

Attended MGH with cardiac symptoms.Attended MGH with cardiac symptoms.

Transferred to CUH for management of Transferred to CUH for management of cardiomyopathycardiomyopathy and and atrialatrial fibrillationfibrillation

Left MCA infarct managed with Left MCA infarct managed with thrombolysisthrombolysis..

Transferred to NRH for inpatient rehabilitation.Transferred to NRH for inpatient rehabilitation.

Referral Pathway Pre DischargeReferral Pathway Pre Discharge

Referred to CRST on admission to NRH.Referred to CRST on admission to NRH.

OT home visit assessment completed to facilitate OT home visit assessment completed to facilitate weekend leave from the NRH.weekend leave from the NRH.

Mary and her family made aware of the CRST service Mary and her family made aware of the CRST service and support available on discharge.and support available on discharge.

OT recommended minor home adaptations and applied OT recommended minor home adaptations and applied for funding to provide adaptive equipment to optimise for funding to provide adaptive equipment to optimise MaryMary’’s independence and safety in her home. s independence and safety in her home.

Mary and her husband attended the rehabilitation gym in Mary and her husband attended the rehabilitation gym in the Gilbert Centre.the Gilbert Centre.

Mary assessed by SALT, Mary assessed by SALT, PhysioPhysio, OT and PHN to identify , OT and PHN to identify rehab goals.rehab goals.

Examples of goals identified: to improve verbal Examples of goals identified: to improve verbal communication, independent outdoor mobility, to cook communication, independent outdoor mobility, to cook family meals, to access local shops, bank etc.family meals, to access local shops, bank etc.

Rehabilitation Pathway post Rehabilitation Pathway post DischargeDischarge

OT setup home programme to facilitate MaryOT setup home programme to facilitate Mary’’s return to s return to independence with personal independence with personal ADLsADLs, cooking and , cooking and household tasks.household tasks.

SALT saw the client twice weekly to work on SALT saw the client twice weekly to work on apraxiaapraxia, , receptive and expressive language skills. She also receptive and expressive language skills. She also requires work on letter formation and spelling. (She is requires work on letter formation and spelling. (She is using her nonusing her non--dominant hand)dominant hand)

Mary attended the CRST gym twice weekly to work on Mary attended the CRST gym twice weekly to work on balance, endurance, strengthening and mobility.balance, endurance, strengthening and mobility.

PHN liaised with the IWA to organise a PA service to PHN liaised with the IWA to organise a PA service to enable her to access shops, the bank, hairdresser etc.enable her to access shops, the bank, hairdresser etc.

Home supportHome support

The MTA visited Mary 5 days per week to supervise The MTA visited Mary 5 days per week to supervise home programme.home programme.

Helped setup of cooking tasks and to support Mary to Helped setup of cooking tasks and to support Mary to use her affected upper limb in functional tasks.use her affected upper limb in functional tasks.

Supervised home exercise programme and practised Supervised home exercise programme and practised outdoor mobility in her local neighbourhood.outdoor mobility in her local neighbourhood.

Practised speech therapy homework. Practised speech therapy homework.

Community IntegrationCommunity Integration

Mary has been linked in to Headway, the IWA and the Mary has been linked in to Headway, the IWA and the North Cork Stroke Support Group and she attends the North Cork Stroke Support Group and she attends the wheelchair accessible gym.wheelchair accessible gym.

MaryMary’’s PA assists her in the community for example they s PA assists her in the community for example they complete the weekly grocery shop, visit the bank etc.complete the weekly grocery shop, visit the bank etc.

Mary has been referred to her local primary care team Mary has been referred to her local primary care team for ongoing rehabilitation and support.for ongoing rehabilitation and support.

Mary has been linked to the return to driving pathway Mary has been linked to the return to driving pathway through the IWA in Blackrock.through the IWA in Blackrock.

How to contact CRSTHow to contact CRST

CRST officeCRST officeThe Gilbert CentreThe Gilbert Centre

Fair StreetFair StreetMallowMallowCo.CorkCo.Cork

Telephone: 076 1084050Telephone: 076 1084050Fax:022 55540Fax:022 55540