Community Based Rehabilitation Team (CBRT)

Health professionals

Inclusion criteria

• Consent to receive service, and must have both the desire and ability to participate in a self-directed therapy program (or use carer support), under guidance of the CBRT team
• Be over 18 years of age and must live (or temporarily be staying) in the geographical catchment area of Metro North Hospital and Health Service
• Have a recent health event (past 6 months) with functional change impacting on ability to participate in life roles
• Have functional rehabilitation goals that are achievable with time limited community-based therapy, with a focus on improving independence at home and/or in the community
• Clinical judgement will be applied to all referred clients on a case by case basis

Exclusion criteria

Not appropriate for CBRT

• Immediate risk of hospital admission, ED presentation or harm due to medical instability, acute mental health conditions, or psychosocial reasons (eg; current living situation unsafe or no fixed abode, inadequate care support at home)
• No functional rehabilitation goals identified
• Requiring only a single discipline – including only requiring medical review.
  • Note: If the client requires single discipline rehabilitation, a discussion with the Allied Health Team Leader is required prior to the referral, regarding how the service may be able to accommodate the rehabilitation needs of the client or if another service would be more appropriate.
• Cancer clients who are unable to participate in rehab due to ongoing active medical treatment
• Non or partial weight bearing, awaiting an upgrade to full weight bearing status and/or requires a hoist for transfers.
• Active and untreated substance abuse which inhibits ability to participate and achieve therapy goals
• Deconditioning in the absence of an acute medical event or hospitalization
• Functional symptoms without a confirmed diagnosis (e.g., FND)
• Review of existing or set up of new equipment that is essential for discharge from inpatient environment
• Carer training only required
• Function not adequate for basic needs – e.g., needing 1A to mobilize but limited access to carer support, no functional communication
• Likely to improve current mobility or function without intervention
• Previous rehabilitation with unsuccessful or limited gains
• Client (or NOK) has not consented to referral, or the client does not wish to engage
• Living environment deemed unsafe for CBRT staff to visit (eg; active substance abuse)
• Clients with needs that are better met by an alternative service: eg;
  • Palliative clients who would be more appropriately serviced by Palliative Care Services (i.e., are unable to participate in rehab due to ongoing medical input, or have limited capacity for improvement)
  • Requiring only a single discipline – for example elective surgery or orthopaedic injury that may be better served by outpatient physiotherapy
  • Concurrently accessing other services for rehabilitation in the private or public sector, including eligibility to receive care through work cover, insurance or compensation
  • Recipient of level 3-4 packages or residing in residential aged care facility
  • Maintenance rehabilitation in longer term health conditions which would be eligible for NGO services