Home Resources Models of Care Chronic & Complex Chronic Disease Rehabilitation About Rehabilitation for Chronic Disease

About Rehabilitation for Chronic Disease Model of Care

What is Rehabilitation for Chronic Disease?

Rehabilitation for Chronic Disease is defined as ... "the coordinated sum of interventions required to ensure the best physical, psychological and social conditions so that patients with chronic or post-acute disease may, by their own efforts, preserve or resume optimal functioning in society and, through improved health behaviours, slow or reverse progression of disease" (Goble & Worcester, 1999).

Key Elements

Easy and Early Access.

Comprehensive Assessment.

Holistic Goal setting.

Evidence Based, Multi-Disciplinary Interventions.

Maintenance and Support.

Rehabilitation for Chronic Disease services assist people with a chronic disease to achieve optimal physical and psychological function, to self manage their disease and to be active partners with their medical team in decisions about their health care.

Aims

Enhance quality of life by supporting self-management and independence.
Provide education and support to achieve self-management.
Improve functional exercise capacity.
Delay and avoid complications.
Reduce avoidable hospital presentations and admissions.

Key principles

Early and accurate diagnosis.
Supported Management

How does Rehabilitation for Chronic Disease work?

Early and easy access to diagnosis and rehabilitation services. GP referral and collaboration on care planning and management. Prescription of optimal medication regimes, interventions or surgery as indicated. Referrals from all sources including self referrals. Flexible models of service delivery including home, online and telephone support services. Access to the service as soon as the need is identified. Ability to re-enter if appropriate.
Comprehensive assessment. Individual assessment of physical, psychological and functional parameters. Individual assessment of disease(s) management. Planning of care coordination at a variety of levels depending on an individual's and/or carer needs. Medical intervention as indicated including regular checks and assessments, even if well.
Evidence-based multidisciplinary interventions. Evidence-based services that can be delivered in a variety of settings according to individual needs. Multi-disciplinary team interventions designed for each person that take into consideration complex chronic conditions and personal preferences. Planned discharge following evidence of self-management. Optimal medication regimes based on diagnosis. Smoking cessation. Supervised exercise training program. Training and support to self manage exercise routines on a daily basis. Self-management education including disease management, psychological interventions, and early symptom recognition.
Holistic goal setting Goals to improve functional exercise capacity and quality of life through exercise training, information on disease and its management, self-management support, psychological and social support. Patient and/or carer and health professional working to achieve realistic goals. Improvement in skills in self monitoring that increase an individual's knowledge of their disease.
Links to ongoing maintenance and support programs. Maintenance of functional exercise capacity, quality of life an self-management through the individual's own efforts. Delivery in a setting that provides suitable services for people with chronic disease and suits their personal needs. This may be at home or in places that have trained Heartmoves leaders such as at some community centres and local gymnasiums. Support delivered through GPs, rehabilitation teams or community health professionals. Use of exercise diaries and action plans.