Community Based Rehabilitation(CBR)

(This page is under Construction and Not Complete)

How to refer
A single referral form for a range of services has been designed to decrease the demand on referrers. This form can be used to refer to

All referrals should be faxed to 8345 1134 where they will be triaged to the correct service. The more information that is provided, the easier it will be to prioritise access to each service.

All these services share the same database to ensure the patient does not have to repeat the same information if referred to a range of services. It also allows each service to see which other services are involved and when they will be seeing the client, thus allowing easier co-ordination of care.

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Disciplines involved in CBR

 CBR also offers Hydrotherapy (water based physiotherapy).

While all staff in CBR are operationally accountable to the Sub Acute Ambulatory Care Services (SACS) program, each staff member is professionally responsible to their particular discipline. CBR requires staff to be involved in discipline specific professional development to ensure their ongoing competency and growth. All staff also receive professional supervision and support through their discipline and are encouraged to take students to support the ongoing development of their specialty.


Hours of service
CBR at Sunshine generally treats clients between 9am and 4.00pm Mon to Friday. Staff development, case conference and case planning occurs either side of these hours and earlier or later appointments can be arranged to suit specific client needs.

CBR Williamstown generally treats between 9am and 2pm. Home visits are available in the afternoon and specific appointments can be arranged depending on the availability of the gym (which is a shared facility) and staff time (most staff work across the wards and CBR).

Waiting lists
Waiting lists vary according to demand and priority of need. Every attempt is made to see clients in a timely fashion however, at times demand outstrips our capacity to respond. Patients discharged from a public hospital may be eligible for service through the Post Acute Care (PAC) program if waiting for service would cause a deterioration in function.

Transport
Clients are required to provide their own transport. Where there is significant hardship, please discuss with the relevant CBR Team Leader.



CBR offers a short term, multidisciplinary, goal-oriented service
which aims to assist clients to reach their maximum potential,
to regain their independence where possible and to improve
their quality of life.

Principles
In line with the DHS principles, Western Health SACS aims to:

  • be client centred
  • be flexible
  • maintain continuity of care
  • use an integrated team approach regardless of location
    of care
  • select clients based on objective, accurate and comprehensive assessment
  • determine the location of care by clinical criteria
  • consider centre based care at all points of the sequence
    of care
  • minimise duplication

Client centred flexible care
 CBR sets goals in conjunction with each client and then
designs an individual care plan to meet those goals. The
initial assessment is usually done by a member of the multidisciplinary team who will provide the ongoing care.
Where staff work in the ward as well as CBR (eg Williamstown),
every effort is made to ensure continuity of therapist.

Where will clients be treated?
 Clients can be treated at home, in the centre or in places
such as the local shopping centre, work place or on public
transport. The place of treatment will be determined by the
client goals and treatment needs. Indicators for treatment at
home include if the client is unable to leave the home, is
unable to get into or travel in a car, where the client needs
contextual therapy or where social circumstances indicate
home based treatment would be most beneficial. Frequently,
a client may receive some therapy in the centre where
appropriate equipment is available, eg: physiotherapy, while
other therapy such as occupational therapy is provided at home
to review the environment or provide treatment in the most
appropriate context.

Priority of access
 CBR assists with demand management and throughput of
hospital patients therefore patients who have been recently
discharged or who are at imminent risk of admission will be
prioritised. Additionally, people with falls or swallowing
problems will also be seen as soon as possible. People with
long term chronic conditions will be assessed as a lower
priority.

Exclusions
CBR does not offer maintenance or ongoing therapy, nor
therapy where there are no identifiable rehabilitation goals.
CBR clients must be medically stable.


Catchment area
Community Based Rehab provides service as much as
possible in the area closest to the client's home. Sunshine
and Williamstown CBRs accept referrals for clients who live
in the municipalities of Brimbank, Hobsons Bay, Maribyrnong,
Melton and Wyndham. Clients who live in Melton may now
choose to attend Melton Health which opened in early 2007.
Please contact 9747 7600 to ensure the required service is
available. Clients who live in the Werribee area and need
centre based care can attend the Werribee Community
Rehabilitation Centre (ph: 9742 6711). Home based
service in the Werribee area is still provided through
Sunshine CBR.