Abstract:
Aim – The aim of this thesis is to co-design best-practice rehabilitation across the hospital-community continuum for older people following an injury. This research is conducted across five participating District Health Boards (DHBs) and addresses the inefficiencies of the current Non-Acute Rehabilitation (NAR) structure through the development and implementation of a purpose-built case-mix model which is utilised to categorise patients according to social, environmental, functional and diagnostic characteristics to ultimately inform clinical practice. These groupings provide more detail and specificity than is currently available among existing profiling tools. Through participatory action research, clinical service pathways were co-designed to improve service efficiency by streamlining systems with an emphasis on where services are best carried out for any given patient. Complementary to these pathways and predicated on the case-mix model are rehabilitation care bundles, co-designed to ensure patients receive best-practice interventions along the hospital-community continuum. Methods – This project utilises mixed methods research, blending both qualitative and quantitative components through participatory action research and is broken down into three key phases. Phase one ‘Evaluation of the Case-Mix Profiling Tool’ involves the rollout of the clinical profiling tool across partnering district health boards as well as data capture and analysis. Phase two ‘Co-Design and Development’ involves the co-design and development of rehabilitation care bundles and clinical service pathways predicated on case-mix categories established within phase one. Phase three ‘Field Testing and Analysis’ incorporates the rollout of rehabilitation care bundles and clinical service pathways, including a breakdown and analysis of these tools. Findings – The major outputs of this project include the co-design and implementation of clinical service pathways and rehabilitation care bundles which were predicated on the case-mix model. Implementation of these research outputs have influenced a three-day reduction in the average inpatient length of stay for all NAR patients, and has initiated a shift in the utilisation of community rehabilitation services, seeing an eight percent increase in the total number of NAR patients accessing community NAR services, and a reduction of 20% of NAR users accessing inpatient NAR services. Contributions – The case-mix model utilised within this project was a key enabler in the restructuring of the NAR funding mechanism, which has ultimately supported new and more innovative models of care. The case-mix model enables DHBs to put the needs of their patients first and has removed the need for the Accident Compensation Corporation (ACC) administration staff to authorise and monitor funding approvals. This project has enhanced access to NAR services through contractual amendments, revision of the NAR eligibility criteria, and the co-design and implementation of clinical service pathways and rehabilitation care bundles which were based on a purpose-built case-mix model. Service funders, service providers and service users have acknowledged the impact of these changes has improved service efficiency, enhanced access to NAR funding, reduced hospital length of stay and has helped mitigate the impact of the ageing population by redirecting rehabilitation services towards community-based models. The service improvements produced through this project impact thousands of NAR service users within real-world contexts. These changes have the potential to alter the trajectory of rehabilitation delivery and pave the way for further developments.