A HORA HABÍA MÁS PIEZAS EN SU LUGAR

The dietician in community rehabilitation assesses a patient’s nutrition-related needs, draws up a nutrition care plan and gives advice on implementation. The primary aim of dietetic management in community rehabilitation is to promote normal

nutritional status, thereby optimising functional status and reducing medical complication rates.

5.4 Summary and Research Directions

Over the past twenty years there has been a move away from a medical model of rehabilitation, which assumed a linear pathway from pathology through impairment to disability and on to handicap, towards a social model, which puts the responsibility back onto society to allow disabled individuals to function to the best of their ability. This is reflected in the World Health Organization's International Classification of Functioning, Disability and Health (ICF; World Health Organisation, 2001). Rehabilitation is the

multi- and inter-disciplinary management of a disabled person’s functioning and health. The goals of rehabilitation are to minimise symptoms and disability through a process of restoration of function or compensatory strategies. The rehabilitation process can be divided into stages: acute, sub-acute, post-acute and community maintenance. However following TBI, patients will have different requirements and each patient will have different needs at different stages of the rehabilitation process. Rehabilitation of TBI patients may be different from rehabilitation in general, due to the influence of specific problems, such as executive and memory deficits. Evidence and expert opinion suggest that rehabilitation is most effectively delivered by a coordinated team of professionals from relevant disciplines.

Rehabilitation services in Tasmania are funded by one of two models: private and public. Patients in the private sector are funded by compensable funds or private insurance. Services in the public sector are provided in the public health system by the DHHS, an agency of the Tasmanian State Government.

The 2003 State-wide Strategic Plan for Rehabilitation Services in Tasmania, in the public sector, addressed many of the recommendations for rehabilitation outlined in this chapter—for example the need for multidisciplinary teams in both acute and community settings with good coordination between them, the need for access to specialist medical and allied health services, and the need for provision of specialist services for patients with TBI. However implementation of these recommendations was inconsistent across the three regions of the state with better provision of services in the south compared with the north and north-west.

During the period of the present study, CRU was the single point of referral for all individuals who required access to public outpatient multidisciplinary rehabilitation in southern Tasmania, and for individuals in the north and north-west of the state

needing input from a multidisciplinary out-patient rehabilitation team. Referrals to CRU were received from medical and allied health professionals working in acute hospitals, from rehabilitation physicians and from GPs and allied health professionals working in the community. During the period of the current research referrals were also accepted from the TNTR research project.

CRU’s clinical services can be best described as outpatient rehabilitation provided in the community by a multidisciplinary team. In multidisciplinary teams health professionals from different disciplines work alongside each other but not

necessarily in close collaboration. Although it was envisioned in the State-wide Plan for Rehabilitation Services in Tasmania that specialist medical physicians would be part of CRU's multidisciplinary team, in practice this was not the case. A specialist physician led case conferences in 2003 when the service was set up, but by 2007, largely due to their unavailability, this role had been passed to a senior allied health clinician.

Although some of the specialist clinics, including the brain injury clinic was held on the CRU premises, and was supported by CRU nursing and allied health staff, the clinics were run separately from CRU’s multidisciplinary team and clinical notes were recorded in the hospital filing system not the CRU clinical files, even for patients who were concurrently receiving treatment at CRU. Referral could be made from the clinics to CRU, but if allied health or nursing clinicians from CRU wanted a patient to be seen by a medical specialist, a referral to one of the clinics had to be made by the patient's GP. It could not be made by the rehabilitation team at CRU.

The outline of current developments in rehabilitation, and the specialist needs of TBI rehabilitation summarised in this chapter suggests that in developing a model of pathways of rehabilitation it will be important to consider the following factors:

 The ICF conceptual model of disability (World Health Organisation, 2001) provides an internationally accepted framework for consideration of the issues relevant to disability and rehabilitation.

 The objectives of rehabilitation are to maximise the injured individual’s

behavioural repertoire, optimise his or her environment and help with emotional stress in both the patient and significant others.

 Although rehabilitation can be thought of in terms of stages, different TBI patients will have different requirements, and the same patient will have different needs at different stages of the process.

 Specific problems, such as executive functioning and memory deficits pose unique challenges in TBI rehabilitation.

 Evidence and expert opinion suggest rehabilitation is most effectively delivered by a coordinated team of professionals with the expertise and skills to undertakes assessment and management of person with TBI at all levels of the ICF model;  Good communication and coordination are essential at multiple levels.

 Although a multidisciplinary team approach to rehabilitation was advocated in the State-wide Plan for Rehabilitation Services for all three regions of Tasmania, in practice implementation of this plan was variable with better provision of services in the south compared with the north and north-west.

 Although it was envisioned that specialist medical staff would be part of the multidisciplinary team operating at CRU and co-ordinated by its manager, in practice specialist physicians had little involvement in service-delivery at CRU.  Several specialist clinics, including a brain injury clinic, were operated on the

same site as CRU and with support from its nursing and allied health staff, but did not constitute part of CRU's clinical service: clinical notes were recorded in the

RHH files not the CRU clinical files, even for patients who were concurrently receiving treatment at CRU.

CHAPTER 6 - Study 1: The Relationship Between Demographic, Injury-related