Overview
Initiative type
Model of Care
Status
Deliver
Published
June 2026
Summary
This project delivers an In-reach Rehabilitation Toolkit, providing a practical, scalable framework to facilitate and support establishment of In-reach Rehabilitation services across the state to address access to rehab.
Dates: January 2025 - April 2026
Implementation sites: Queensland statewide
Partnerships: Healthcare Improvement Unit
This project was presented as a Poster at CEQ Showcase 2026 (PDF 3.5MB).
Aim
To develop and deliver a co designed, evidence informed toolkit that supports consistent, safe, and effective implementation of in reach rehabilitation models across Queensland Health acute care settings.
Outcomes
The project includes the development of:
- a current state analysis of in-reach rehabilitation models throughout the country with literature evidence, benchmarking results and consumer feedback.
- an In-reach Rehabilitation Toolkit, with the following resources published online:
- an established in-reach rehabilitation model of care
- business case resources including alignment with strategic priorities
- pre-implementation reflection tool and implementation process guide
- workflow resources including data management spreadsheets and set-up guides
- a consumer resource that can be adapted to local services
- practical resources including a toolkit user guide and key contact directory.
This project is scheduled to be published in April 2026, and forms part of the broader Queensland Rehabilitation framework.
Background
Timely access to rehabilitation within acute hospital settings is a critical enabler of improved patient outcomes and efficient patient flow. Early rehabilitation intervention supports functional recovery, enhances discharge planning, and reduces the risks associated with prolonged hospital stays (Shiner et al. 2025, Matsui et al, 2010, Wu et al. 2025). In-reach rehabilitation models have been used to address these issues within three Hospital and Health Services (HHSs), in addition to multiple health services interstate. Based on benchmarking of these services, in-reach rehabilitation services across the country have shown marked variation in service models, referral pathways, workforce structures, and governance arrangements. For services looking to implement in-reach rehabilitation in Queensland, similar process and scoping activities were repeatedly undertaken across multiple sites.
State-wide clinical engagement, including Rehabilitation Clinical Network forums, highlighted that while many services recognised the value of in reach rehabilitation, few had access to practical, evidence informed guidance to support implementation. Clinicians and operational leaders consistently reported uncertainty regarding patient selection, referral processes, governance requirements, workforce expectations, and outcome measurement. As a result, existing services varied in scope and maturity, and many HHSs, particularly those in rural and remote areas, lacked viable pathways to establish in-reach rehabilitation teams or deliver rehabilitation within acute wards.
These challenges contributed to avoidable functional decline, delayed discharge, increased pressure on acute beds, and inequitable access to rehabilitation services across the state. Services without local subacute rehabilitation units were particularly impacted, often relying on delayed transfers or fragmented pathways that compromised patient experience and system efficiency.
The existing models currently operate out of Gold Coast University Hospital, Robina Hospital, Princess Alexandra Hospital and Sunshine Coast University Hospital. Ongoing data analysis is being conducted to objectively assess the programs' impact on patient outcomes and service measures. Of the available data, it has been identified that in the 2024-2025 financial year, the existing in-reach services saw a combined total of 1,411 patients, according to the data reported to Australasia Rehabilitation Outcome Centre (AROC) Pathway 2 in-reach data set (2025).
Queensland has successful in-reach rehabilitation models, but without a shared framework to guide consistency, safety, and scalability, they are difficult to replicate, especially in smaller or rural services. This lack of standardised resources and governance limited the system's ability to scale proven models and increase rehabilitation capacity.
In response, the Healthcare Improvement Unit provided funding to support the Queensland Rehabilitation Clinical Network in the development of a statewide in reach rehabilitation toolkit resource. The project aims to translate evidence, frontline clinical expertise, operational insight, and consumer perspectives into a practical resource that could be adopted across diverse hospital contexts. Using the newly established state-wide NSW Rehabilitation Model of Care as a reference, the toolkit provides a consistent yet flexible framework that will improve equity of access, support workforce capability, and strengthen patient journeys from acute admission through to recovery.
Methods
A structured, multistage methodology grounded in codesign, and quality improvement principles was undertaken between October 2025, to be completed in April 2026.
The project commenced with a current state analysis to understand existing in reach rehabilitation activity across Australia. This included consultation with HHSs and review of established in reach models within Queensland and comparable services interstate, to identify variation in service delivery, common enablers, and key barriers to implementation. Evidence synthesis and benchmarking informed the identification of core components required for safe and effective in reach rehabilitation models. These components were translated into a modular toolkit designed to support staged implementation based on local readiness and capacity. Toolkit resources included a minimum standard model of care, clinical governance and safety framework, referral criteria and workflow templates, workforce capability expectations, data and key performance indicator guidance, business case supports, implementation checklists, and consumer facing materials.
Clinical governance and expert oversight were provided through a multidisciplinary Clinical Advisory Group (CAG), comprising representatives from rehabilitation medicine, nursing, physiotherapy, occupational therapy, sub-acute services, clinical network representative and rural and remote services. The CAG met regularly to guide decision making, validate findings, and ensure the toolkit reflected real world clinical and operational contexts.
Draft toolkit components underwent iterative consultation and refinement through the CAG, Rehabilitation Clinical Network co chairs and steering committee. This validation process ensured alignment with state-wide strategic priorities, clinical safety requirements, and frontline feasibility. Final revisions were informed by stakeholder feedback prior to endorsement and publication. Consumer collaboration was embedded in the project, with consumer representatives reviewing patient facing resources and contributing qualitative insights on communication, access, and factors influencing positive rehabilitation experiences. This ensured that the toolkit reflected patient priorities alongside clinical and system considerations. Consumers were recruited from existing in-reach rehabilitation services and provided consent to have their feedback included in project. There is no identifying factors and all insights are anonymous within the publication.
Discussion
The development of the In reach Rehabilitation Toolkit demonstrates the value of a co designed, statewide approach to address variation in care delivery while respecting local context. A key enabler of success was strong clinical leadership through the Clinical Advisory Group, which ensured the toolkit was grounded in frontline experience and operational reality rather than theoretical models.
One of the primary lessons learned was the importance of scalability. Variation between Hospital and Health Services, particularly between metropolitan and rural settings, necessitated a flexible design rather than a prescriptive model of care. Services valued the ability to adopt components incrementally, based on local workforce capacity, patient profiles, and governance arrangements. Business case supports, model of care design and workflow resources, were consistently identified as the most valuable resources.
The project also highlighted the unique challenges faced by rural and remote services, where limited access to subacute rehabilitation beds requires innovative approaches to delivering rehabilitation within acute wards. The toolkit explicitly acknowledges these constraints and provides adaptable guidance to support equitable access to rehabilitation regardless of geography.
While the project will deliver a comprehensive implementation resource, it does not include direct service implementation or evaluation, which remains a limitation. Uptake and impact will depend on local leadership, workforce availability, and resourcing decisions within individual HHSs. However, the inclusion of data guidance and suggested key performance indicators provides a strong foundation for future local and system level evaluation.
The toolkit has clear potential for scale and spread across Queensland, with early interest from services seeking to improve patient flow, standardise practice, and strengthen workforce capability. Beyond rehabilitation, the framework offers a transferable approach for other specialties exploring In reach models of care within acute settings.
References
Gold Coast University Hospital (RRT) AROC All Impairments Report (Inreach - Pathway 2), 1 July 2024 ' 30 June 2025. Australasian Rehabilitation Outcomes Centre (2025).
Matsui H, Hashimoto H, Horiguchi H, Yasunaga H, & Matsuda S. (2010). An exploration of the association between very early rehabilitation and outcome for the patients with acute ischaemic stroke in Japan: a nationwide retrospective cohort survey."¯BMC Health Services Research,"¯10, 213. https://doi.org/10.1186/1472-6963-10-213
Princess Alexandra Hospital (In-reach) AROC All Impairments Report (Inreach ' Pathway 2), 1 July 2024 ' 30 June 2025. Australasian Rehabilitation Outcomes Centre (2025).
Robina Hospital (RRT) AROC All Impairments Report (Inreach - Pathway 2), 1 July 2024 ' 30 June 2025. Australasian Rehabilitation Outcomes Centre (2025).
Shiner, C. T. Olsen, N. Watanabe, Y. Thakkar, S. Faux, S. G. & Wu, J. (2025). Evaluating in-reach rehabilitation: a parallel model of multidisciplinary rehabilitation delivered alongside acute hospital care."¯Disability & Rehabilitation, 1'14. https://doi.org/10.1080/09638288.2025.2534090
Sunshine Coast Hospital (Rehabilitation Response Team) AROC All Impairments Report (Inreach - Pathway 2), 1 July 2024 ' 30 June 2025. Australasian Rehabilitation Outcomes Centre (2025).
Wu, J. Thakkar, S. Shiner, C. T. Watanabe, Y. Muthiah, K. & Faux, S. G. (2025). In-reach rehabilitation is feasible and led to functional gains in selected heart and/or lung transplantation recipients."¯PM & R"¯: The Journal of Injury, Function, and Rehabilitation. https://doi.org/10.1002/pmrj.13433
Key contact
Sally Nicklin
Health Professional Project Lead
Department of Health