Sub-acute community care

A female therapist sits with a male patient at a dining table in a home setting.Under the REACH program, SMHS manages a number of metropolitan wide sub-acute allied health assessment, rehabilitation and care coordination services to patients who have had a recent hospital admission.

These services are provided in either the patient’s home or in community venues across the metropolitan area.

REACH services are available to patients within the following catchment areas:

Read more about our services below. 

The Complex Needs Coordination Team (CoNeCT) program provides an assessment and time limited care coordination service to patients in their own home.

The program targets patients who present more frequently to hospital and who through a care coordination approach may be able to reduce these hospital presentations. Such patients are often at risk of poor health outcomes due to complex health needs including one or more of the following issues:

  • medical
  • financial
  • psychological
  • social.

To optimise a patient’s linkage to health and care services, CoNeCT staff undertake a comprehensive review of a patient’s situation, including a home visit assessment and care coordination.

CoNeCT is not a crises service and patients whose primary health issue is mental health are not appropriate for the CoNeCT service.

CoNeCT services are provided 8.30am – 5.00pm, Monday to Friday.

CoNeCT referrals

Referrals to CoNeCT are made through public hospital inpatient or outpatient services.

Community Physiotherapy Services (CPS) provides an out-of-hospital discharge option for patients requiring further physiotherapy intervention following inpatient, RITH (see below), or outpatient care.

The program aims to assist patients to regain or optimise function and independence to improve their quality of life and better manage their condition.

The program provides group physiotherapy exercise classes in community venues across the metropolitan area. These short-term, evidence-based classes support the hospital discharge pathway and encourage patients to use self-management strategies.

Classes are located at various recreation centres and halls across the metropolitan area and include:

  • general rehabilitation (land based)
  • gym based rehabilitation
  • oncology gym
  • orthopaedic (post elective surgery)
  • neurology and neurology gym
  • Parkinson’s and Parkinson’s gym
  • cardiac rehabilitation
  • pulmonary rehabilitation
  • hydrotherapy.

Services are provided 8.30am to 5.00pm, Monday to Friday.

CPS referrals

Referrals to the CPS are made through public hospital inpatient or outpatient services.

Rehabilitation in the Home (RITH) program provides short to medium term hospital substitution allied health therapy for patients in their homes. These therapies, supported by medical staff and allied health assistants, include:

  • physiotherapy
  • occupational therapy
  • social work
  • speech pathology
  • dietetics.

The broader RITH program consists of three streams:

  • The RITH program aims to facilitate early supported discharge from hospitals or avoidance of hospital admission for patients by providing them with comprehensive multi-disciplinary allied health therapy in their homes.
  • The Discharge to Assess program aims to reduce the time frail, elderly patients spend in hospital and more appropriately provide a comprehensive multi-disciplinary assessment of patients in their own home to determine care needs.
  • The Elective Joint Replacement pathway assesses and treats patients who have undergone an elective hip or knee replacement as a continuation of hospital care in the patient’s home.

Services provided by RITH are available:

  • 8:30am – 5:00pm, Monday to Friday
  • 8:30am – 5:00pm, Saturday and Sunday.

RITH referrals

Referrals to RITH services are made through public hospital inpatient or outpatient services.

Last Updated: 13/01/2021