The Alfred Health Community Rehabilitation Program provides goal directed rehabilitation for clients following a change in their functional status.
Clinical service overview
Service update – response to COVID-19
1 April 2020
As part of Alfred Health’s response to Coronavirus (COVID-19), we have made changes to the way our services are being delivered, including providing care to our patients in different ways.
While Community Rehabilitation Program will continue to be open, our face-to-face services will be limited to patients who require an urgent assessment or have essential care needs.
If required, our appointments will be conducted via telehealth or in a home-based setting.
Please consider referring your clients to alternative services if they do not have urgent needs.
The primary focus is an interdisciplinary team approach towards agreed treatment goals.
Sessions may be held in the client’s home, local community or at our rehabilitation centre at Caulfield Hospital. They may include group and/or individual sessions depending on clinical need.
Groups offered encompass:
- hip and knee rehabilitation
- upper limb rehabilitation
- aquatic physiotherapy
- community access
- public transport
- balance and mobility
- communication training
Community Rehabilitation has four teams:
- Caulfield home-based
- Caulfield centre-based
- South Melbourne home-based
- South Melbourne centre-based
The Community Rehabilitation team is determined from client geographical location and predominant need for clinical setting at the time of referral.
The Alfred Health Community Rehabilitation Program undertakes clinical research and provides undergraduate education to a range of disciplines.
must have had an acute illness, injury, surgery, or an exacerbation of a chronic condition resulting in a change in function that is expected to benefit from an episode of rehabilitation
goals for realistic functional improvement with rehabilitation episodes should be able to be identified
must be willing and able to actively participate in rehabilitation (medically, physically, cognitively, and psychosocially)
must be medically stable and should have a GP willing to provide medical support although a rehabilitation specialist is available through the program
individuals living independently with low care supports (Home care packages levels 1 & 2, SRS, Low care residential services)
individuals living independently with high care supports (Home care packages levels 3 & 4) or living in a high level residential service will be considered on a case by case basis
will accept cardiac or pulmonary diagnoses however appropriateness for specific cardiac or pulmonary rehabilitation services should be considered first
must have identified rehabilitation needs which are best or can only be achieved with management predominantly provided in the client’s home environment, for example:
- the client needs to be in their own environment / local community / specific context to learn and implement skills / strategies (communication / cognitive / physical) that will improve participation in their daily life
- the client will have difficulty transferring skills / strategies learnt in other contexts into function
- must have suitable home environment for the provision of therapy (e.g. completion of OT home assessment where indicated, risks including behaviours of concern, violence/aggression, history of drug /alcohol use of client/family/support persons must be satisfactorily managed)
- unable to access the centre due to health, physical and/or environmental limitations (e.g. fatigue, goals of accessing the community to allow attendance at the centre)
- must have rehabilitation needs which are best achieved with management predominantly provided in a centre based facility
- must be willing and safe to travel into the centre and are able to mobilise (includes wheelchair mobility) sufficiently to access the centre (50 metres)
- referrals requiring monitoring or maintenance
- individuals who require an occasional session of therapy post hospital discharge to check safety concerns or equipment
- referrals for home modifications or equipment prescription in isolation
- referrals for return to work without associated rehabilitation needs
- individuals presenting with single issues with little activity limitations who likely require one on one, cubicle based treatment only, for example no gym based management
Refer your patient
Fax referral to us
Caulfield Access is responsible for intake, information and referral processing for a wide range of community and ambulatory services.
We accept referrals from GPs, specialists, family, carers, case managers and patients.
We also welcome phone enquiries to discuss potential referrals or an existing referral. Referrals are triaged depending on priority.
Patients requiring immediate assessment should be sent to the Emergency & Trauma Centre.
To refer a patient to a community service either:
- complete the Service Coordination Tool Template (SCTT) and submit electronically, or
- complete and fax your SCTT referral form to Caulfield Access Unit
Consider making referrals for chronic conditions indefinite.
Once a referral has been received, a Care Coordinator will phone the patient to discuss their needs and organise appropriate services. The Care Coordinator will provide the patient with their phone number. Patients are encouraged to contact the Care Coordinator if they have any concerns.
- Referral enquiries (03) 9076 6776
- Referral fax (03) 9076 6773
- Email enquiries email@example.com
|Falls Clinic||Caulfield Hospital||260 Kooyong Rd, Caulfield VIC 3162|