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Implementing the Rehabilitation for the Chronic Disease Model of Care

Chronic Disease Rehabilitation Model of Care  (2.3M)		Planning Where are you now?		Preparing Make it happen		Operationalise Make it stick
Governance		Determine the type of Rehabilitation service model Identify Leaders Develop a process map Develop a project timeline Establish a Steering Committee		Develop a Governance Plan Consider the evaluation framework Recruit a project officer See the SESIAHS Lessons Summary - Project Develop Develop Key Performance Indicators (KPIs)		Monitor and evaluate KPI's
Patient Journey How do patients flow through the hospital		Map the patient journey See the correct chronic disease rehabilitation journey in the Model of Care pdf document		Document successful patient stories to show how Rehabilitation can improve quality of life for chronic disease patients.  Include the perspective patients and their carers and/or families.		Monitor the patient journey. Remap the journey to refine and further improve the service.
Policies and Protocols		Identify policies, protocols and guidelines Develop evidence based protocols for Rehabilitation Check these Key Issues Review the Rehabilitation Literature Review Rehabilitation assessment tools in the NSW Chronic Care Program Implementing Rehabilitation for Chronic Disease Vol 2 Review and/or develop agreements with GPs and other community partners		Ensure access is optimised by effective referral systems Identify the care pathways  Develop and establish referral systems. Establish partnerships and agreements with other service providers.		Use protocols and regularly review and update.
People Understand who the staff are, how they function and what role they play in the patient journey		Stakeholder analysis Engage Stakeholders See the ideal staffing for a Chronic Disease Rehablitation Service Develop a staff profile Learn the role of all team members Identify existing teams to build capacity		Develop competencies and position descriptions Encourage multi-skilling and case management training Provide induction training to all staff Mentor staff to understand skills required to provide clinical and educational services to patients		Regularly review and monitor staff workload Ongoing multi-disciplinary case conferences
Resources		Conduct a resource survey to identify what is required for the Rehabilitation service Establish referral processes - see the Key Issues Identify the gaps in existing clinical and non clinical resources that may limit the service establishment.		Use capacity within existing teams Deliver required resources Develop service level agreements for the rehabilitation service		Monitor resource utilisation and modify as required See the SESIAHS Lessons Summary
Communication		Develop a communication plan		Tell people about the program at every opportunity Ensure that systems and capacity are able to manage the demand that the communication plan may generate Implement the communication plan.		Ensure responsive and timely feedback process to Rehabilitation Service providers and referrers Regularly review your communication plan for effectiveness Actively seek feedback on the services you deliver.