Community Rehabilitation Program

Clinical service overview

The primary focus is an interdisciplinary team approach towards agreed treatment goals.

Sessions may be held in the client’s home, local community or at our rehabilitation centre at Caulfield Hospital. They may include group and/or individual sessions depending on clinical need.

Groups offered encompass:

• Hip and knee rehabilitation
• Upper limb rehabilitation
• Aquatic physiotherapy
• Community access
• Public transport
• Balance and mobility
• Communication training

Community Rehabilitation has four teams:

• Caulfield home-based
• Caulfield centre-based
• South Melbourne home-based
• South Melbourne centre-based

The Community Rehabilitation team is determined from client geographical location and predominant need for clinical setting at the time of referral.

The Alfred Health Community Rehabilitation Program undertakes clinical research and provides undergraduate education to a range of disciplines.

Referral Criteria

Eligibility criteria

• Must have had an acute illness, injury, surgery, or an exacerbation of a chronic condition resulting in a change in function that is expected to benefit from an episode of rehabilitation
• Goals for realistic functional improvement with rehabilitation episodes should be able to be identified
• Must be willing and able to actively participate in rehabilitation (medically, physically, cognitively, and psychosocially)
• Must be medically stable and should have a GP willing to provide medical support although a rehabilitation specialist is available through the program
• Individuals living independently with low care supports (Home care packages levels 1 & 2, SRS, Low care residential services)
• individuals living independently with high care supports (Home care packages levels 3 & 4), receiving NDIS support or living in a high level residential service will be considered on a case by case basis
• Will accept cardiac or pulmonary diagnoses however appropriateness for specific cardiac or pulmonary rehabilitation services should be considered first

Home-based services

• Must have identified rehabilitation needs which are best or can only be achieved with management predominantly provided in the client’s home environment, for example:
  • The client needs to be in their own environment / local community / specific context to learn and implement skills / strategies (communication / cognitive / physical) that will improve participation in their daily life
  • The client will have difficulty transferring skills / strategies learnt in other contexts into function
• Must have suitable home environment for the provision of therapy (e.g. completion of OT home assessment where indicated, risks including behaviours of concern, violence/aggression, history of drug /alcohol use of client/family/support persons must be satisfactorily managed)
• Unable to access the centre due to health, physical and/or environmental limitations (e.g. fatigue, goals of accessing the community to allow attendance at the centre)

Centre-based services

• Must have rehabilitation needs which are best achieved with management predominantly provided in a centre based facility
• Must be willing and safe to travel into the centre and are able to mobilise (includes wheelchair mobility) sufficiently to access the centre (50 metres)

Exclusion criteria

• Referrals requiring monitoring or maintenance
• Individuals who require an occasional session of therapy post hospital discharge to check safety concerns or equipment
• Referrals for home modifications or equipment prescription in isolation
• Referrals for return to work without associated rehabilitation needs
• Individuals presenting with single issues with little activity limitations who likely require one on one, cubicle based treatment only, for example no gym based management

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