Rehabilitate and recover via early intervention

Category: Consumer Directed Care and re-ablement

ACH Group, SA
Milpara Nursing Home
Kapara  Nursing Home
Perry Park Nursing Home
Colton Court Nursing Home
West Park Nursing Home
Yankalilla Centre Nursing Home
VITA Nursing Home
Highercombe Nursing Home

ACH Group’s residential division is home to over 680 older people across eight aged care facilities. All sites have an Early Intervention Working Party (EIWP) that meets regularly to discuss the physical, cognitive and social well being of residents.

The aim of early intervention is to promptly identify decline in health, and work collaboratively to facilitate recovery and rehabilitation. All staff members are trained to report observed changes in resident health for referral to the early intervention working party.

The EIWP is a team of interprofessional health care staff. The team works collaboratively to identify intervention opportunities for residents that experience decline due to illness or injury.

Interventions include tailored goals that are developed in consultation with the resident and incorporate individual choice and preferences. Interventions aim to promote physical activity and/or sensory stimulation while encouraging healthy life choices.

The process to enable residents to remain active and mobile involves a number of people and strategies. The resident, the care team, allied health practitioners, students and volunteers are all involved in planning and participating in the early intervention process. ACH has a clear process in place that identifies residents who require additional support to recover, and to optimise their health status. The type and extent of rehabilitation/recovery depends on the nature and severity of the injury or illness, resident circumstance and identified need. 

A recovery pathway can be initiated by any staff member; observed changes are documented on the Identified Change report. Once an “Identified Change Report” is received the health status of the resident is investigated, with options including referral to the EIWP. Following a referral to the EIWP, a process of clinical review and observation occurs, including comprehensive informed discussion with key stakeholders and health care professionals including customers/representatives, clinical nursing team, registered/enrolled nurses, dementia consultant, GPs, allied health, care staff, fitness instructors and lifestyle coordinators/volunteers/students.

The EIWP then implements an individually tailored and structured program that targets the resident’s rehabilitation needs. It complements goals set by the team in consultation with the resident and/or family representative.

Examples of intervention include:
o        attendance at site gym
o        walking groups
o        exercise classes
o        additional sensory opportunities
o        medication reviews
o        pain and continence reviews
o        dietician and counsellor referrals
o        electric pedals (passive/active peddling) 
o        social groups/lifestyle activities
o        lifestyle outings/active community participation
o        light physical therapy
o        physiotherapy treatments
o        occupational therapy programs.    

Results from the evaluation show that over the last 12 months across all residential sites, 255 residents have been part of a rehabilitation and recovery pathway. Evaluation results show that 89% (n. 227) of residents who have been referred to the EIWP have maintained their mobility.

Feedback from customers indicates that they see involvement in early intervention as a core activity in preventing avoidable decline. Mrs H: “I am enjoying gym, they are going to keep me strong to hold my great grandchild”, and from Mrs B: “Walking daily with the physiotherapist helps me to keep upright”.

For more information on the program, contact Samantha Manoel and Trudy Sutton, email: or, or phone: 0488 504 181.