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ACUTE PHASE / TRIAGE 

All Hip # pa	ents  

iden	?ed by Triage early in 

admission  - Enter &amp; track on 

CART 

Triage assessment within 

48Hrs of surgery 

Accept receipt of Triage  

assessments from other  

Networks  

Rehab op?ons, expected 

LOS, requirements on D/C 

discussed with    pa?ent, 

family, carer  

If declined access to 

mee	ng with a  

Rehabilita	on  

Consultant 

Ortho Geri Team Ini	ate 

osteoporosis treatment  

Cogni	ve screen  

For acute delirium (4AT com-

pleted) delirium  

management protocol  im-

plemented 

Pain management  

op	mised 

Handover   transi	on of 

clinical informa	on /  

Triage assessments  (includes 

equipment,  

Bariatric) 

Iden	fy (refer to acute AH 

processes)   home  

safety, social issues,  

barriers to D/C 

Early referrals prompted 

(includes indigenous  

services) 

Pull to Rehab  (aim transfer 

to inpa	ent by day 3 post op) 

Pathway   default  / 1st 

considera	on to  

ambulatory (refer to  

inpa	ent,  home, day  

rehab criteria)   

 

4AZ3 Weighted FIM Mo-

tor 13-18 Age &gt;65                   

LOS TARGET = 32 

4AZ4 Weighted FIM Mo-

tor 13-18 Age &lt;65                  

LOS TARGET = 53 

4AP1 Major Mul	ple 

Trauma                                    

LOS TARGET = 35 

4AH4 Ortho # FIM Motor 

19-37                                           

LOS TARGET = 26 

4AH1 Ortho # FIM Motor 

49-91 Cog 33-35                    

LOS TARGET = 13 

4AH2 Ortho # FIM Motor 

49-91 Cog 5-32                         

LOS TARGET = 15 

4AH3 Ortho # FIM Motor 

38-48                                         

LOS TARGET = 22 

 

 

 

 

 

 

 

 

 

Osteoporosis 

follow up 

Post discharge 

telephone  

review  

At 7 days 

 

 

Community 

Services Day 

Therapy/

External Thera-

py/Support 

providers 

DAY OF REHAB ADMISSION 

Pre arrival handover   a.m. brief 

Key worker assigned (within 24 hrs) 

70% Transfer in before 11.30 

Build on handover / assessments 

received.  Minimise duplica	on 

Assessments include  medical,  

medica	ons, pain, cogni	ve, risk, 

self care, chronic disease  

management 

Diete	cs referral 

Falls risk assessment preventa	ve 

strategies 

Transfer / Mobility assessment 

Preliminary discussion re goals as 

part of assessment: achieve safe 

mobility for discharge 

Seen by Consultant within 24 

Hrs check osteoporosis  

treatment 

Ac?vity / therapy / func?onal  

retraining commenced 

New pa	ent screen 

I-Pad provided (device set up) 

Equipment review and set up  

Up to 72 Hrs POST ARRIVAL 

FIM Assessment 

Establish goals with pa	ent  

(Mul	-D) - maximize func	on and 

ensure  safe discharge to ?nal  

des	na	on 

Care plan / journey document  

ini?ated by Key worker. Therapy 

?me table ini?ated 

Social worker   Consider early 

referral to TCP / DSA. Consider 

family mee	ng 

1st case conference  - FIM review, 

SN Class iden	?ed, D/C plan  

established 

Expected LOS communicated to  

pa?ent  (Consultant) / family 

(KW) / team 

Ac	vity / therapy / func	onal re-

training / hydro / group /  

self directed, aim for no restric	ons 

re level of assistance 

Consider OT home visit 

Early ?ag to ambulatory Rehab and 

Tele-Rehab / other therapy op	ons, 

Iden	fy carer training needs 

Care plan / journey document 

within 24 Hrs 

Seen by medical o?cer within 

48 Hrs (Telehealth) 

Daily visits (up to mul	ple) 

PROGRESSION 

Daily brief   core sta? 

&gt;120 mins therapy daily 

Structured ac	vity   evenings 

Consultant review and Case  

Conference x2 weekly 

Diete	cs bone health educa	on  

6 day a week medical  

ward round (driving discussed) 

Key worker facilitates carer  

training 

Team provide falls  

educa?on  / exercise program 

Other risk factors (e.g. bowel, blad-

der issues) managed 

Team facilitates coaching   self 

management 

Early ?ag to ambulatory Rehab Tele

- Rehab / other therapy op	ons 

Regular goal review    

key worker 

Regular Consultant review as 

required 

7 day interven	ons 

 

 

 

PRIOR to DAY of D/C 

Clear plan   transi?on from  

walking aid and falls preven?on 

strategies 

Bone protec?on treatment (med 

acronym expansion )  refer to 

Fragility # clinic if needed 

Medica	ons ordered /  

Pharmacist educa	on 

Pa?ent experience ques?onnaire 

captured 

Arranged   ongoing therapy,   

support services, follow up  

appointments, equipment, 

an	coagula	on management,  

D/C transport 

D/C summary completed 

End FIM / AROC completed 

DAY of D/C 

Care plan updated. Acute and Re-

habilita?on D/C summaries hand-

ed to pa?ent  

Meds provided 

Informed   post D/C contact.  

10 am D/C 

 

 

 

INPATIENT / HOME REHAB 

DAY REHAB 

REHABILITATION HIP # 

PATHWAY - CHECKLIST  

 

AROC / Lawton s captured 

No formal assessment   handover from other rehab services 

Transport not a barrier to accessing services 

Client centred scheduling 

 

Maximise telehealth 

Push coaching model 

Con	nued falls risk factor modi?ca	on 

Return to baseline mobility 


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