Rehabilitation Implementation Toolkit


To facilitate the implementation of the Rehabilitation Model of Care.


The Toolkit assists Rehabilitation Implementation leads and other key LHD  stakeholders to understand the value delivered in current care settings, while identifying the gaps in service delivery. It can also be used to develop and implement additional rehabilitation settings to meet current and projected demand.


The Toolkit focuses on assisting LHDs  to identify opportunities to enhance current rehabilitation services, enabling them to better meet demand by aligning service delivery to the guiding principles outlined in the Model of Care.


The Rehabilitation Implementation Toolkit has been designed to assist Rehabilitation Managers and Clinicians adopt a systematic approach to assessing the current rehabilitation service need and implementing a Model of Care that is appropriate for their local context. The document should be read in conjunction with the NSW Rehabilitation Model of Care, using it as a reference point for implementation planning and delivery of the different care settings.

The toolkit provides an approach to assessing the current care settings and developing implementation action plans. It includes the key information and tools to address the gaps identified between the ‘as is’ service delivery and an enhanced Model of Care.

The toolkit is divided into several phases for implementation with suggested activities within each. The implementation planning and activities will be based on the local focus of implementation – enhancement of a current care setting vs. implementation of a new care setting.

An overview of the sections of the toolkit and phases is below.

  1. Implementation Project establishment: this section provides the framework for carrying out the implementation drawing on project management principles.
  2. Define and assess: this section provides the steps required to review current activity to understand and confirm what you are trying to achieve based on the ‘gaps’ identified against the Rehabilitation Model of Care.
  3. Implement and Monitor: this phase brings together all the findings from the analysis to complete a detailed plan for implementation. This implementation plan will include the key activities, responsible owners, dates for delivery, risks identified, and a communication plan to complement and assist with implementation.

Steps include:

  1. Analysing current and projected activity
  2. Assessing existing tools, processes and guidelines and incorporating the core elements of ‘good practice’ tools.  
  3. Developing new tools and resources as required for the implementation of a new rehabilitation service


The Rehabilitation Implementation Toolkit was developed in consultation with the experts from the rehabilitation and aged care sectors including rehabilitation physicians, geriatricians allied health clinicians, and rehabilitation nurses. Consultation included an online survey of the Rehabilitation Network members as well as site visits to rehabilitation services that had already implemented the Model of Care to inform the formative evaluation and development of the Evaluation and Monitoring Tool.

Key Dates

2010Development of Rehabilitation Model of Care
2011Endorsement by Director General NSW Health of the NSW Rehabilitation Model of Care
2011Gap analysis undertaken by all LHDs across NSW comparing ‘as is’ service with the new model
2012Establishment of ACI Rehabilitation Network
2013Development of Implementation Toolkit and Evaluation and Monitoring Tool
17 July 2013 Rehabilitation Implementation Workshop

Pilot Sites

Hunter New England Local Health DistrictJohn Hunter Hospital
South Eastern Sydney Local Health DistrictPrince of Wales Hospital
St George Hospital
Sutherland Hospital and Community Health Service
Calvary Health Care Sydney
St Vincent's Health NetworkSacred Heart Hospice
Western NSW Local Health DistrictOrange Health Service

Implementation Sites

Hunter New England Local Health DistrictJohn Hunter Hospital
Tamworth Rural Referral Hospital
Murrumbidgee Local Health DistrictWagga Wagga Base Hospital
Nepean Blue Mountains Local Health DistrictNepean Hospital
Northern NSW Local Health DistrictBallina District Hospital


The Rehabilitation Toolkit includes a performance Monitoring and Evaluation Tool which provides guidance as to key performance indicators to evaluate the implementation of the Model of Care.

Related Initiatives

ACI Rehabilitation Model of Care

Further Details

Further information is available on the ACI  Rehabilitation webpage:

Or the ARCHI  website:


Claire O’Connor
Rehabilitation Network Manager
9464 4639

Chris Shipway
Director, Primary Care and Chronic Services
9464 4603

Page Top | Added: 28 October 2013 | Last modified: 16 January 2014

Claire O’Connor
Rehabilitation Network Manager
9464 4639