CHD Living

Care Pathway

To ensure continuity of care and a smooth transition between services we work with patients and their families through each stage of the rehabilitation process. See our care pathway process below.

Stage 1 - Pre-Admission Assessment

  1. Initial enquiry and referral received and discussed by Multidisciplinary Team (MDT)
  2. Pre-admission assessment completed to gain further information, identify needs/risks and to complete proposal of package for funding authorities to gain approval

  3. Patient and/or family to visit chosen rehabilitation centre
  4. Arrange date of admission
  5. Basic Care Planning and Risk Assessments commenced by nursing staff to ensure safe admission

Stage 2 - Admission Initial 2 days

  1. MDT and Nursing Keyworkers Identified and introduce self to Patient
  2. Patient registered with GP Surgery for duration of stay
  3. All initial nursing assessments and Care Planning reviewed/updated to ensure patient safety
  4. Dates for all patient meetings and reports populated and contact made with Case Manager to outline clinical pathway and frequency of reports and meetings
  5. Therapy programme commences

Stage 3 - Within 1 week

  1. MDT review of patient - FIM + FAM and all baseline outcome measures completed
  2. GAS Goal areas set and MDT Goal Planning Meeting arranged for week 2
  3. Therapy timetable (and orientation chart if required) provided to patient
  4. MDT keyworker to discuss with patient their expectations of admission and future rehabilitation goals

Stage 4 - Week 2

  1. MDT Case review Meeting to share assessment results with MDT
  2. MDT Goal Review Meeting held to set therapy goals and care / treatment plans to assist patient to achieve these goals
  3. Care Plan and therapy timetable reviewed and amended if required
  4. Contact made with patient's NOK to discuss case, obtain family objectives and arrange Family Meeting for Week 4

Stage 5 - Week 4

  1. Family Meeting held to discuss progress, rehabilitation goals and future expectations
  2. A full MDT Initial Baseline Report with goals and treatment plan completed (copies) to be sent to funding team, patient's family and Case Manager)
  3. All points from MDT Goal Planning Meeting reviewed

Stage 6 - Week 8

  1. Addendum to initial Baseline Report completed with updated goals and treatment plan (copies to be sent to funding team, patient's family and Case Manager)
  2. CCG invited to attend a Case Review Meeting to discuss extension of rehabilitation period based on clinical reasoning (if required)
Nursing & Residential
Care at home
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