Rehabilitation at home guidelines

The guidelines should be read in conjunction with the information at Working with the TAC.

What are Rehabilitation at Home services?

Rehabilitation at Home (RAH) is a service that allows our clients, usually requiring hospital inpatient rehabilitation, to undertake part or all their rehabilitation program at home.  RAH is a hospital substitution model that can be offered to clinically independent and medically stable patients who can complete their RAH.

The service is designed to be multidisciplinary, short term, and have time-limited delivery with an approved maximum duration of 8 weeks depending on individual rehabilitation goals. RAH aims to increase the resilience, independence and functional ability of the client and creates an alternative rehabilitation treatment discharge option, reducing unnecessary admission and hospital stay.

RAH services can be delivered by providers who have registered with the TAC and offer a range of services through an integrated and multidisciplinary team of allied health professionals. RAH is designed to give the client an individualised rehabilitation treatment program within their own environment, where professionals work together to achieve the client’s rehabilitation goals.

Who can provide RAH services?

The RAH treatment team must be multidisciplinary and comprised of professionals who can assess and manage clients with active physical and functional rehabilitation needs. The team should consist of the following:

  • At least one clinician who acts as the RAH case coordinator. This role is responsible for the supervision, coordination, and communication of the delivery of RAH services where a multidisciplinary treatment program is established.
  • A physiotherapist, if required, responsible for the delivery of physiotherapy services.
  • An occupational therapist, if required, to provide occupational therapy services beyond those provided by the referring hospital to ensure a safe and effective discharge home.
  • A registered nurse, if required, responsible for the delivery of nursing services.
  • A social worker, if required, responsible for the delivery of support and counselling.
  • A rehabilitation physician, if required.

Each professional must be registered with the Australian Health Practitioner Regulation Agency (AHPRA) without any current restrictions on practice, except for social workers who must be eligible for full membership of the Australian Association of Social Workers (AASW).

All RAH providers must be registered with the TAC and deliver services consistent with the TAC RAH Service Standards.

What services are included in RAH?

We can pay for:

  • RAH case coordination
  • Occupational therapy
  • Physiotherapy
  • Nursing
  • Rehabilitation physician
  • Social work

Treatments and services should be delivered in line with the TAC Clinical Framework and the RAH Service Standards.

The sections below provide descriptions of the services included in the RAH program.

RAH case coordination

The RAH case Coordinator:

  • Has a clinical or allied health background;
  • Takes an active role with the client, working directly with them;
  • Completes an initial telephone conversation with the client to coordinate RAH services;
  • Serves as the touchpoint for the client and as the first contact point from the service to the client; and

The RAH case coordinator undertakes to provide the following:

  • Playing a key role in managing the transfer of information from hospital discharge to the RAH program;
  • Completing the RAH initial assessment formRAH extension request form (if needed) and RAH discharge form;
  • Ensuring the RAH provider dashboard is completed and sent to TAC quarterly (see RAH Service Standards for more information);
  • Providing remote support, education, pain management;
  • Managing the measurement of client satisfaction and complaints;
  • Liaising with the TAC and the client’s GP, employer or other clinicians where required; and
  • Managing and integrating the onward referral to community-based treatment providers at the conclusion of the RAH program where required.

Occupational therapy

Occupational therapy services focus on assisting the client to take part in everyday activities and live a more independent life. The hospital therapist is responsible for a safe discharge to home and assessing for any required equipment in the first 30 days after hospital discharge.

The RAH occupational therapist ensures equipment supplied is set up appropriately and facilitates engagement of the client’s family in the rehabilitation process. See our Equipment guidelines.

Occupational therapy treatment services can include:

  • Evaluation – the abilities of the client are assessed in the context of their work, school, home, leisure, general lifestyle, and family situation.
  • Consultation – having made an assessment, the therapist consults with the client, other professionals and family members who may be closely involved, to develop the treatment program.
  • Treatment – at the person’s home, school, workplace or within the broader community.

Physiotherapy

RAH physiotherapy services cover assessment, diagnosis, treatment and exercise to maximise function and mobility. The physiotherapist includes the client’s family in the rehabilitation process and provides the main physical component of the RAH program.

Physiotherapy services can include:

  • Consultation and treatment sessions (40-60 minutes)
  • Exercise programs, design of gym or hydrotherapy programs.

Nursing

Nursing consultation services can include:

  • General nursing care post hospital discharge
  • Wound management
  • Nursing care after hours if required

Rehabilitation physician

The rehabilitation physician provides medical care to patients with pain, weakness, cognitive impairment and loss of function so they can maximise their physical, psychological, social and vocational potential.

Rehabilitation physician services can include:

  • Central oversight and clinical governance of the treatment plan if required for clients with more complex recovery needs;
  • Assistance with the development of pain management plans;
  • Liaising with hospital specialists/surgeons;
  • Coordination with the treating GP where they lack rehabilitation specific knowledge, and linking back to the primary care GP at the conclusion of RAH; and
  • Provision of services primarily via telehealth.

Social work

Social work services provide support and counselling across a range of issues for clients with more complex biopsychosocial needs so that they can access RAH.

Social work services can include:

  • Crisis, post trauma and mental health support and counselling;
  • Assistance with health literacy;
  • Support with family issues;
  • Advocacy support related to social injustice;
  • Assistance to make linkages with other healthcare professionals or organisations; and
  • Counselling support for mental health issues and referral to primary mental healthcare professionals or GP for assessment for a mental health program.

Additional and concurrent rehabilitation services

Services and treatment not included in the RAH program can still be accessed by the client at the same time as participating in the RAH program. For example, if psychology or dietetics support is deemed appropriate by the treating team and approved by the TAC Claims Manager, access to this service is not limited by the client being in an RAH program.

Access our Medical expenses and supports page for an outline of treatments and services that may be required in addition to the RAH program and our requirements for approval.

It is not expected that rehabilitation services which are included in the RAH program would also be accessed concurrently by the client from another community treatment provider.

Which clients are best suited to Rehabilitation at Home?

RAH is one option suitable for clients who are ready to be discharged from either an acute and/or an in-patient rehabilitation hospital setting. The hospital is responsible for referral to the RAH program where it is identified as an appropriate and safe discharge option in consultation with the client. The discharging hospital should organise and provide any equipment and supports for the client’s safe transition home. The discharging hospital should also provide the RAH provider with a discharge plan outlining the client’s rehabilitation goals and clinical needs where possible.

The pathway for the transition to RAH

Pathway for transitition to RAH

As a RAH provider, you must either accept or reject the RAH referral within the timeframes outlined in the RAH Service Standards. If unable to accept a referral, either based on lack of capacity, geographical coverage or the client is not deemed suitable for RAH, you can reject the referral and liaise with the hospital to arrange an appropriate treatment option for the client.

Clients suited for RAH services:

  • Require coordinated and integrated multidisciplinary rehabilitation following their accident and/or surgery and have a rehabilitation goal.  An exception may be the delivery of single-discipline services where the client is unable to access the community and the home-based therapy is clinically justified.
  • Would otherwise receive care in an inpatient rehabilitation hospital setting, and are safe to go home and not yet ready or fully able to access community rehabilitation services.
  • Present with medically stable conditions involving, but not limited to, hip or knee joints, lower limb orthopaedics, multi-trauma or other physical conditions deemed suitable for an RAH program.
  • Present with biopsychosocial needs where they may require social work support related but not limited to family, anxiety issues, crisis and physical trauma.
  • Are deemed by the discharging hospital to be a client suited to an RAH program.

Clients not suited for RAH services:

  • Under 18 years of age.
  • Are not willing to participate or agree to work towards the goals of the RAH service (i.e. the goals of the client are not consistent with the program goals).
  • Have significant medical, psychiatric, or psychological issues that will impact on their ability to participate in the RAH and should be referred to private or community mental health services.
  • Have a major alcohol, drug or substance abuse issue that interferes with their ability to participate in RAH.
  • Have occupational health and safety risks identified in the discharge process either by the hospital or by the RAH service provider.

What we can pay for

If RAH services begin within the first 90 days of a client’s accident we can pay for the services:

  • without the need to contact us for approval first, and
  • up to a maximum duration of 8 weeks or a fee cap of $3,000, whichever is reached first

The services must be recommended by a health professional or hospital treatment team, related to the client’s accident injuries and delivered in line with the RAH Service Standards. The provider must complete these forms:

If a client needs RAH services to begin 90 days after the date of the client’s accident, we can consider an RAH program. The following steps will apply:

  • If you receive a referral from a health professional or hospital treatment team, you must send us a written request which is to include the RAH initial assessment form from the discharging hospital for approval.
  • After submitting a written request please contact the TAC Claims Manager to discuss timeframes on approval.
  • We will review and assess the request to ensure it is reasonable, clinically justified outcome focused and in line with the RAH Service Standards.
  • We will let you and the client know our decision about what we can or can’t pay for.

RAH services are authorised under Section 23 of the Transport Accident Act 1986.

Initial assessment

You will complete, in conjunction with the client, the RAH initial assessment form. This outlines the patient's rehabilitation goals and the expected outcomes and timeframes. Initial outcome measures and goals are to be outlined as the TAC will be benchmarking outcomes and evaluating the program. More information about this can be found in the RAH Service Standards.

Completion of the RAH initial assessment form will form part of the Rehabilitation Coordination service and its associated fee.

Extension request

In some cases, you may request a program extension and/or an increase to the funding fee cap of $3,000. You can request an extension by submitting a RAH extension request form which will outline the client’s progress to date, the proposed additional services, duration of the treatment extension, expected outcomes and barriers for not meeting current goals. The benefit of the RAH program over a community-based program must also be clearly articulated. This requires approval from the TAC Claims Manager and notification of any request for extension, should be made as early as possible to avoid delays in approvals and any risk to continuity of service for the client.

You should also call the TAC Claims Manager to inform them of your submission of the extension request and to discuss the requirements. Development of the RAH extension request form will form part of the Rehabilitation Coordination service and its associated fee.

The TAC Claims Manager will assess the client’s progress in the program and the request for further services. We will review the extension request to ensure it is reasonable, clinically justified, outcome focused, in line with the RAH Service Standards and let you know our decision.

The RAH Service Standards outline the detailed requirements for service timeframes, required documentation, extension requests, service outcomes and key performance indicators.

Discharge

At the conclusion of the client’s RAH program, you will provide us with a RAH discharge form. A copy of this form should also be sent to the client’s treating practitioner and any other relevant clinicians.

Development of the RAH discharge form will form part of the Rehabilitation Coordination service and its associated fee.

Travel

Travel time can be paid for travel to and from your practice address and the client's residence. Where more than one client is visited in a single travel period, total travel costs should be apportioned equally between clients. Travel should be a reasonable distance from your practice and invoiced in 15-minute increments.

How much we can pay

TAC-registered RAH providers are eligible to invoice as fee per service as stated in the fee schedule agreed to in the registration process, however must not exceed the $3,000 cap. Providers must monitor this spend and request a service extension if they can foresee breeching this cap.

Other things to note

Single discipline rehabilitation services

The TAC will consider the provision of a single-discipline RAH service, where the client would have otherwise received this as an inpatient, where the client is unable to access the community and the home-based therapy is clinically justified. If the client only requires minimal single-discipline treatment from an RAH program and can safely access the community, then the hospital should refer the client to a community provider as the most appropriate treatment option after discharge.

What we cannot pay for

We cannot pay for RAH services while the client is still admitted in hospital, or services that are already included as part of an inpatient rehabilitation program.

We cannot pay for concurrent services that are already part of the client’s RAH program.

For more information

More details can be accessed in our RAH Service Standards and RAH policy.

For the RAH fee schedule and RAH provider registration form, please email health@tac.vic.gov.au.