1. Community Rehabilitation Service Rhona Smyth Assistant Manager

2. Background n Started in 1998 n Jointly funded by health and social work n Early supported discharge n Reduction in hospital bed days n Reduce the need for large care packages n All adults over 16 years n City of Edinburgh

3. Staffing n Assistant Manager n 3( WTE) Occupational Therapists n 3 ( WTE) Physiotherapists ( Senior II Vacancy) n 12.5 ( WTE)Community Rehab Support Workers n Clerical

4. Referral Process n MDT decision - OT/PT Referral n Meeting criteria n AMT 5 + or MMSE 16+ n Motivation n Client and family agreeable n Rehab potential - goal setting

5. Diagnosis 05/06

6. Assessment n Joint OT and PT assessment of day of discharge n Clients own goals established n Programme of visits agreed n Provision of equipment /CAS n Weekly Review

7. Range of Activities n Self Care n Meal planning and preparation n Mobility and exercise n Progression from equipment n Community Mobility/bus practice n Leisure Activities

8. Medication n Supervision /monitoring n Dosette boxes and refills arranged n Orientation

9. On discharge from CRS n Referrals made for Home Help ( 12% April - Sept 06) n Discharge letter sent to GP and copy to referring therapist and Hospital Consultant