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Table 5 Integrated care pathway for geriatric rehabilitation

From: Process evaluation of an integrated care pathway in geriatric rehabilitation for people with complex health problems

Setting

No.

Care pathway element

Hospital

1

If the main treatment provider believes that the patient is eligible for geriatric rehabilitation, the discharge nurses of the hospital will be consulted. Preferably, this consultation takes place well in advance of discharge.

2

Dismissal from the hospital is preceded by a triage by a discharge nurse. Information about the patient's functional prognosis, endurability, teachability and trainability and the patient’s and informal caregiver’s needs and abilities needs to be gathered to make this triage decision.

3

The triage is always performed under the responsibility of an elderly care physician from the geriatric rehabilitation facility. If the discharge nurse has doubts about eligibility of the patient for geriatric rehabilitation, the elderly care physician should be consulted.

4

Information about functional prognosis, endurability, teachability and trainability and needs and abilities of the patient should be gathered by consulting professionals in the hospital who have been involved in the patient’s care.

5

The patient should always be asked about their needs and abilities and this should explicitly be taken into account when making the triage decision.

6

The informal caregiver should (if applicable) be asked about their ability to provide informal care and this should explicitly be taken into account when making the triage decision.