Outpatient Team-based Models to Facilitate Integrated Patient Care

Stroke/head injury survivors often present with difficulties communicating, swallowing, mobility, activities of daily living and reintegration into society. Their complex needs requires integrated, coordinated team approaches. South Africa has approximately 90 stroke survivors daily. Approximately 89000 cases of head injury are reported annually with limited numbers of professionals providing rehabilitation services. Chris Hani Baragwanath Academic Hospital (CHBAH) as a central hospital and the largest in Africa with approximately 3400 beds, deals with a huge number of patients with head injuries. After a median length of hospital stay of nine days, patients transition into out-patient services. Currently 2% of patients are accessing step-down facilities. This was found in a recent research study at the hospital Previously, patients were booked straight into general out-patient appointments resulting in increased waiting times, decreased therapist capacity and poor appointment utilization due to missed initial appointments/patient spontaneous recovery. Patients were booked for three separate appointments on different dates for all disciplines resulting in increased financial and caregiver burden, and poor attendance rates. The hospital therefore implemented a trans-disciplinary screening service and an inter-disciplinary out-patient service developed by the team (speech therapy, occupational therapy, and physiotherapy) at CHBAH to overcome the aforementioned patient and logistical challenges.

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