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Programs & Activities

Inpatient Services

Sub-acute inpatient care is provided through Streams of Care funded by the Department of Human Services. The recognised Streams of Care are:

Geriatric Evaluation and Management (GEM): GEM is sub-acute care of chronic or complex conditions associated with aging, cognitive dysfunction, chronic illness or disability. These conditions require inpatient admission for review, treatment and management by a geriatrician and multidisciplinary team for a defined episode of care.

Rehabilitation:

Rehabilitation is an integral part of a sub-acute service, and is a specialist area of health that aims to:

• maximise independence and quality of life for people with a disabling medical condition, and maximise the likelihood that they will remain or become active and productive members of the community; and
• minimise the long-term care needs and community support needs of these people and so bring about considerable cost savings both in acute health care and in long-term social security, community care and supported accommodation.

Rehabilitation is proactive and goal-orientated. It targets people with loss of function or ability from any cause, either congenital or acquired, and its aim is to improve function and/or prevent deterioration of function to bring about the highest possible level of independence, physically, psychologically, socially and economically.

Sub-acute ambulatory care services

Background

Sub-acute ambulatory care services are available to people of all ages and may follow a hospital stay, hospital day attendance, or may be accessed directly from the community. SACS extend and complement inpatient services. SACS can be delivered in a client’s home or at an ambulatory care centre.

The features of SACS are:

• a flow of care, where therapy in a community setting follows an inpatient hospital stay to assist people in achieving the maximum level of reintegration into their community
• individualised, time-limited, goal-centred episodes of care that aim to improve health outcomes
• the ability to reduce inpatient length of stay and prevent admissions and readmissions to inpatient services by providing people with home-based or centre-based therapeutic interventions, which prevent the deterioration of an existing condition and/or improve a client’s functioning
• an interdisciplinary approach in which team members from different disciplines collectively set goals and share resources and responsibilities.

Target population

The aim of SACS are to help people who have a physical disability, are frail, chronically ill or recovering from traumatic injury or illness to regain and/or maintain optimal function, and to allow people to maximise their independence and return to, or remain in, their usual place of residence. Also, SACS aim to help people with newly emerging and chronic symptoms or concerns that require assessment, diagnosis and treatment, through a range of specialist clinics.

Types of services

Community Rehabilitation: centre-based and home-based

Community rehabilitation services are time-limited and delivered according to a care plan that is based on goals negotiated with the client and their carer(s). The services should form part of an integrated team, working with clients where it best suits their need and preference for treatment and recovery.

To maximise the opportunity for care continuity, community rehabilitation services are delivered in a number of settings including a client’s home (home-based) or at a centre (centre-based).

Specialist clinics

Specialist clinics provide specialist assessment, diagnosis, intervention, management, education, advice and support to clients with specific conditions. Clinics commonly provide time-limited, specialist diagnosis and intervention to the client and referral onto appropriate mainstream services for ongoing management. They also provide consultancy, education and support to carers, relatives and professional service providers. Specialist clinics are delivered in a number of settings including a client’s home and at a centre. Specialist clinics include:

Cognitive dementia and memory services (CDAMS)

For clients with newly emerging cognitive difficulties causing confusion, memory loss or thinking problems. Read more about CDAMS.

Continence clinics

For clients with bladder and/or bowel function difficulties. Continence clinics assess the need for, prescribe, and assist clients to access continence aids and equipment.

Outcome Measurement for Victorian Continence Clinic Services - July 2004 (PDF File 1.1MB)

Service Guidelines for Victorian Continence Clinic Services - July 2004 (PDF File 822KB)

Falls and mobility clinics

For clients with falls, mobility and balance problems. Falls and mobility clinics assess the need for, prescribe and assist clients to access, falls prevention and mobility aids.

Final Report - Evaluation of Falls Clinics and development of a measurement and outcomes framework & Review of Movement Disorder Clinics - October 2002 ( PDF file 3,013KB) ( Word file 2,028KB) ( Zip file 1.144KB)

Evaluation of a Minimum Data Set for Victorian Falls Clinics, National Ageing Research Institute, July 2004 ( PDF file 1187KB)

Pain management clinics

For clients with chronic, non-malignant, persistent and ongoing pain. Management strategies are developed to assist clients.

Polio Services Victoria

A state-wide service for clients with ongoing effects from poliomyelitis.

Movement Disorders clinics

For clients with complex neurological disorders.

Transition of young adults clinics

For clients with complex medical needs transitioning from paediatric to adult care services.

Review of Transition of Young Adults Clinics - Final Report January 2009 (PDF, 141KB)

Review of Transition of Young Adults Clinics - Final Report Attachments (PDF, 982KB)

Review of Transition of Young Adults Clinics review - Response to recommendations February 2009 (PDF, 77KB)

Review of Transition of Young Adults Clinics - Literature Review (PDF, 353KB)

Wound Clinics

For clients with chronic and complex wounds.

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