Continuing Care

In addition to the need for specialist rehabilitation, it has been identified that for a number of patients who have previously been difficult to place, there is a need for appropriate specialist continuing care. St Cyril's Rehabilitation Unit will offer up to 6 specialist continuing care beds for patients who have been assessed within St Cyril's or elsewhere and for whom there are limited rehabilitation goals.

The criteria for admission are the same as that for the Unit as whole with the additional criteria that a rehabilitation plateau has been reached. For these patients MDT assessment will establish that maintenance rehabilitation and ongoing care within an appropriate environment would be beneficial in order to prevent any deterioration and maintain any progress that has been made.

Service Offered

Within the continuing care service patients will receive ongoing nursing care and regular therapy reviews by the Occupational Therapists and Physiotherapists. Patients will be subject to regular MDT and medical review by the Consultant in Rehabilitation Medicine. Commissioners and external care co-ordinators will be invited to regular reviews and families will be supported and kept informed.

It is likely that the specialist continuing care unit will be appropriate for people with challenging behaviours or those who would not be manageable in nursing homes. Uniquely St Cyril's Rehabilitation Unit is placed to have access to Consultant Psychiatrists, Neuro-psychiatrists, RMNs and other professionals with a background in Mental Health. Within St George Healthcare Group there is expertise in working with people with brain injury and staff have access to training opportunities and to consultation with the Head of Neurorehabilitation. The spacious and calm environment is appropriate to these individuals who are often managed best by close attention to the environment and providing a low stimulus milieu.

Discharge

The emphasis within continuing care is on long term placement. However, should the team, via the regular review process with care co-ordinators, feel that St Cyril's is no longer an appropriate environment, then the team will work with the receiving Hospital or Home to create as smooth transition as possible