'iREAP' - integrated Rehabilitation and EnAblement Programme

Introduction : The development of frailty leads to a spiral of decline of increasing frailty, worsening disability, falls, hospitalisation, and death. iREAP addresses the need to provide proactive multidisciplinary, community integrated services for at-risk older people. Practice change : iREAP is an innovative redesign of the traditional Day Rehabilitation Model focusing on pre-crisis early intervention and partnerships with Primary Health Network (PHN) to identify patients in the community. Aim and theory of change : The aim is to provide early, coordinated and integrated, semi-intensive, multidisciplinary rehabilitation to specific patient groups in an outpatient setting. Through an eight week programme combining evidence based falls prevention, education, Physiotherapy, Speech Pathology, Dietetics, Podiatry, Continence Nursing, Geriatric Assessment, Psychology, Social Work, and Occupational Therapy, iREAP aims to achieve: Improved physical function, quality of life and reduced frailty. Provide timely, efficient and effective care to reduce hospital admissions. Improve patient experience and self-management. Targeted population and stakeholders iREAP provides intervention to two distinct high risk older complex patient groups – those at risk of falls and frailty (FF), or those with neurodegenerative conditions (PD). Clients at imminent risk of hospitalisation can be fast-tracked to ensure timely access to care. Stakeholder engagement ensures an integrated approach, including partnerships with the Agency for Clinical Innovation, PHN, Community Transport, local tertiary hospitals and Community Providers. Timeline : iREAP commenced March 2016. Twelve month data for all 76 clients who completed iREAP was collected (35 FF and 41 PD). Successful outcomes ensured continuation of the new model. Highlights : Statistically significant improvements were shown for the following outcomes: Improved function and confidence to self-manage (mean pre and post Timed Up and Go 19.3 to 14.4 seconds (p Mean pre and post Clinical Frailty Scale reduced from 5 to 3 (p Improvement in clients’ quality of life as shown on WHO QOL scale from 78 to 82 (p=0.035) and PDQ-39 49 to 39 (p = 0.001) Ten unnecessary hospital admission were avoided. Patient experience feedback highlight iREAP as a model which is embraced and highly valued by the clients who participate in it. Improvement in clients’ knowledge of their condition 59% to 78% on knowledge test (p Sustainability : Clinical redesign of outpatient services has improved efficiency with non-admitted activity increased in outpatient services by 40%. Further reprioritisation of existing resources along with potential funding opportunities through the PHN will support ongoing expansion of the service. Transferability : Clinical redesign of existing services means this model has potential for replication across different services and could be spread to other complex patient populations. Conclusions : iREAP is an effective integrated interdisciplinary program. Participants improved on both functional measures, quality of life and frailty scores. Discussion : Ongoing evaluation and follow-up is required to assess if these gains are maintained, and if the results translate into reduced falls and hospital admissions in the long term. Lessons learned : Clinical redesign leads to better patient-centred care through co-ordination and goal orientated enablement focus. Partnerships with PHN are crucial in an anticipatory care approach.