Table II.

Key potential barriers and facilitators in rehabilitation service provision

Potential challenges/barriers

Potential facilitators/enablers

Unclear role/responsibilities of rehabilitation professionals within patient flow processes, expected timeframes/KPIs for discharge planning & liaison with external services Limited communication documentation for interdisciplinary input in the care processes for discharge planning Limited pre-admission discharge planning for planned surgical cases for rehabilitation Inadequate complex care planning and care coordination for sub-acute services Limited liaison of subacute services with interdisciplinary teams Limited rehabilitation resources, and coordinated timely referrals to subacute services & follow-up mechanisms Limited prehabilitation and pre-treatment workups prior to admission for some patients Inadequate patient and family communication concerning the discharge plan Limited skilled expertise in rehabilitation & geriatric services Poor integration of AH and rehabilitation physicians within acute cancer care team plans Lack of presence of a designated rehabilitation ward resulting in delay in referral No defined sub-acute referral pathways Acute care consultant-driven decision-making Limited documentation/assessment of patient rehabilitation needs Unplanned admissions from the community Limited robust process to ensure early identification of patient functional complexity & discharge barriers Delayed flagging of patient needs/issues (clinical, functional, social), e.g., NDIS Limited clinical pathways and protocols for rehabilitation treatments Lack of standardized patient assessment screening tool for function

Establishment of an Access and Flow Ward Clinical Group Discharge Coordinator service, introduction of a Discharge Coordinator and Rehabilitation Physician role Implementation of standardized screening and assessment tools to stratify patients’ discharge risk and ensure early and appropriate referrals Suitable discharge pathways available for patients including at home services Support and education to staff regarding rehabilitation needs and assessment Developed communication strategies to involve patients and families in decision-making Use of electronic platform for improved communication amongst team members and improved visibility of patient care across clinical groups Liaison with key stakeholders for improved access to rehabilitation services Refinement of the role and responsibilities of treating staff Daily meetings with discharge coordinators and treating teams Earlier engagement of ambulatory and sub-acute services Building a stronger relationship between cancer services and the subacute care team, including community rehabilitation Increase awareness of in-reach and rehabilitation consultation services for acute cancer patients Rehabilitation medicine involvement in the peri-operative context (functional assessment); peri-operative period to identify risks, suggest risk mitigation strategies, and prepare eventual disposition options Building stronger relationships with external inpatient subacute services Interdisciplinary stakeholder group meetings for resources, infrastructure, workflow, etc. Enhanced support of consumer forums Commencement of a new Rehabilitation Medicine Clinic to support AH staff

AH: allied health; NDIS: National Disability Insurance Scheme.