Item | Supporting Evidence | Mean fidelity score (%) |
---|---|---|
Are there any underlying physical issues which may affect or interfere with rehabilitation? | “Atrial fibrillation, previous stroke (left MCA infarct), hypertension, and poor vision. May cause difficulties in different environments.” SP1/PP19 “Hypertension, postural drop currently being investigated so patients’ mobility should improve once management is optimised.” SP4/PP6 | 100 |
Are there any unresolved physical issues which may affect or interfere with rehabilitation? | “Resolving urinary sepsis, functional decline following infection. CT lumbar spine showed L5/4/3 endplate collapse. Pain in lumbar spine limits activities.” SP1/PP25 “Nil of note, medically fit for discharge, no medical follow up.” SP5/PP7 | 100 |
Are there any underlying psychological issues which may affect an individual’s motivation or participation with rehabilitation? | “Mild hypoxic brain injury, patient requires clear step-by-step instructions and struggles with memory.” SP6/PP26 “Nil, very keen to progress.” SP3/PP3 | 100 |
Are there any unresolved psychological issues which may affect an individual’s motivation or participation with rehabilitation? | “Hallucinations settled during admission and had increased mood within inpatient progression.” SP3/PP1 “Nil, very motivated to participate in rehabilitation, nil evidence of delirium.” SP3/PP2 | 100 |
Has the individual been able to demonstrate participation in the rehabilitation assessment or rehabilitation programme during this current episode of care? | “Patient was motivated and engaged in all Occupational Therapy [OT] and physio assessments.” SP2/PP14 “Patient has been keen to participate, clear instructions required due to confusion. Pain has been limiting factor.” SP6/PP26 | 100 |
What are the individual’s current functional abilities and levels of independence? | “Independently mobile with wheeled frame, independent changing stoma. Assistance with washing and dressing, independent with all transfers.” SP4/PP13 “At best had assistance of 2 to mobilise 10m. Mostly handled 2 person step round transfer.” SP3/PP4 | 88.2 |
What were the individual’s pre-morbid (pre-admission) functional abilities and levels of independence? | “Pre-admission (3/52) independently mobile, unlimited exercise tolerance and driving. But 3/52 prior to admission a slow decline due to pain and difficulty with transfers.” SP3/PP3 “Lives alone, no care package. Has cleaner and support from family. Independent with shopping, meals and personal care. Mobilises with walking stick indoors and electric scooter outdoors.” SP4/ PP6 | 88.2 |
Do you have a thorough understanding of an individual’s environment in their usual place of residence? | “Yes, through discussion with patient.” SP1/PP19 “Patient lives in bungalow, 1 step access, all level inside, riser recliner chair, Mowbray toilet frame and double divan bed.” SP2/PP17 | 88.2 |
What support does the individual require to make decisions about their future? | “Wife supports with all ADL’s and decisions. Lacks capacity however, this is variable due to resolving delirium and UTIs.” SP5/PP15 “No concerns regarding capacity, patient has support from family.” SP6/PP23 | 73.5 |
Has the individual been asked, “What’s important to me?” | “I just want to go home [patient]. Go home with the right support and equipment so I can manage as much as I can on my own [husband].” SP5/PP8 “To return to previous baseline function so she is able to toilet independently.” SP3/PP2 | 97 |
Have goals been set and agreed which are SMART? (Short, Medium, Long Term) | “Short – transfer with wheeled frame in 2 days. Medium – go to rehab and mobilise with wheeled frame in 2 weeks. Long – return home independently mobile with wheeled frame in 3 weeks.” SP4/PP1 “To return to independence with personal care and cooking within 4 weeks.” SP6/PP24 | 55.9 |
Has the multi-disciplinary team been involved in the assessment or decision-making process? | “Review by OT, social services, medical review, liaised with daughter.” SP4/PP13 “Nurses report patient is becoming reliant and refusing certain medical interventions but keen for rehab. Integrated Discharge Team to review.” SP4/PP6 | 94 |
Has the individual's rehabilitation potential been assessed over multiple time points? | “Patient assessed every morning with nursing staff, OT and physio reviewed patient daily whilst on ward.” SP2/PP14 “Long admission of 41 days and has reduced motivation, fluctuating cognitive states have been seen.” SP3/PP4 | 88.2 |
Is the proposed rehabilitation programme likely to be effective? | “Given the right amount motivation and improved medical status I think residential rehabilitation would benefit the patient.” SP4/PP5 “Patient has already improved whilst on the ward and this is likely to continue at home with support.” SP6/PP23 | 94 |
Overall impression | “Patient is likely to regain independence and confidence with the reablement team.” SP2/PP14 “Patient has demonstrated determination with little encouragement needed to participate in therapy. Is dependent on medication timing and mental state, however has progressed with each session. I feel that will improve once back at home in familiar environment and once UTI’s and delirium have settled.” SP5/PP15 | 88.2 |