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Community Rehabilitation Services: Supporting Early Discharge & Client Independence

Rhona Smyth, Assistant Manager at the City of Edinburgh's Community Rehabilitation Service, leads a dedicated team since 1998, focusing on early supported discharge to reduce hospital bed days and large care package reliance. Catering to adults over 16, the service includes 3 occupational therapists, 3 physiotherapists, and 12.5 support workers. They conduct joint assessments, set personalized goals, and provide a structured rehabilitation program, including mobility exercises, meal planning, and community mobility training. Effective planning ensures seamless transitions and client independence post-discharge.

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Community Rehabilitation Services: Supporting Early Discharge & Client Independence

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  1. Community Rehabilitation Service Rhona Smyth Assistant Manager

  2. Background • Started in 1998 • Jointly funded by health and social work • Early supported discharge • Reduction in hospital bed days • Reduce the need for large care packages • All adults over 16 years • City of Edinburgh

  3. Staffing • Assistant Manager • 3( WTE) Occupational Therapists • 3 ( WTE) Physiotherapists ( Senior II Vacancy) • 12.5 ( WTE)Community Rehab Support Workers • Clerical

  4. Referral Process • MDT decision - OT/PT Referral • Meeting criteria • AMT 5 + or MMSE 16+ • Motivation • Client and family agreeable • Rehab potential - goal setting

  5. Diagnosis 05/06

  6. Assessment • Joint OT and PT assessment of day of discharge • Clients own goals established • Programme of visits agreed • Provision of equipment /CAS • Weekly Review

  7. Range of Activities • Self Care • Meal planning and preparation • Mobility and exercise • Progression from equipment • Community Mobility/bus practice • Leisure Activities

  8. Medication • Supervision /monitoring • Dosette boxes and refills arranged • Orientation

  9. On discharge from CRS • Referrals made for Home Help ( 12% April - Sept 06) • Discharge letter sent to GP and copy to referring therapist and Hospital Consultant

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