Date of Assessment *

Health Professional Completing Report *

Referral Organisation:

Client's Details

Level HCP

Name

Phone Number

Address

Date of birth

Care Managers Name

Care Managers Email *

Initial Barthel Score

Barthel score (out of 100)Please send barthel initial report to CM

Summary and Recommended Plan

Based on today's initial functional and mobility assessment, the following plan and goal/s have been recommended with consent from the client to share this information with their Care Manager / Provider.

Exercise Physiology / Physiotherapy Sessions

AHA Exercise (Weekly)

AHA Exercise (twice a week)

AHA Physio (Weekly)

AHA Physio (Fortnightly)

Falls Prevention Program

Telehealth Group Exercise Program

Care Managers: Below is a brief summary of the ongoing services recommended by our AHP team for your client. Please use the funding section at the bottom of the report to confirm funding for each of these services. With thanks

AHA Physio Exercise Program Recommended

These one to one tailored sessions have a Wellness or Reablement focus for client rehabilitation, post-surgery, falls prevention, improve overall fitness and confidence all within clients home, hydro pool or gym. All sessions are conducted by accredited and approved Allied Health Professionals.

Ongoing Exercise Sessions recommended *

YesNo

Recommended frequency of ongoing exercise sessions *

Once a weekTwo times a weekthree times a weekfour times a week

Clinical reasons for recommending on-going exercise sessions

Additional clinical reasons for ongoing sessions based on today's findings

Recommended amount of AHA Exercise Sessions *

Reason for why exercise program has not been recommended at time of assessment.

Client happy to proceed with on-going exercise sessions *

Yes No

Reasons for why client declined on-going exercise sessions

Equipment Pack Recommended

Is an exercise pack required for this client *

YesNo

Due to COVID-19 we are now adding an initial equipment exercise pack to every client at the start of their first exercise session with us. This will be the clients to use for all ongoing sessions and will not be returned or refunded due to hygiene reasons.

Exercise pack required for this client

Pack 1 - (Ball, Red & Yellow Theraband)Pack 2 - (Green Theraband, 1kg/2kg Dumbell)Pack 3 - (Blue Theraband, 2 x Bean Bags, Slider disks)Pack 4 - Hand Dexterity Pack (Putty, Rubber bands, Tweezer and Pom Poms, Nuts & Bolts)Arm/Leg Pedal Ergo

Reason for exercise pack recommended

Group Exercise Program

Group exercise program recommended for client? *

YesNo

Group exercise programs *

Falls Prevention ProgramDiabetes Management ProgramParkinsons ProgramTelehealth Wellness Exercise Program

Falls Prevention Program Overview

The falls prevention group offers a 12-week program with an initial assessment to evaluate overall function and falls efficacy. Short-term goals are collaboratively set with an allied health professional and the participant. The program includes a personalized home exercise program, education on various falls-related topics, and supervised group exercises led by a physiotherapist or exercise physiologist. After 12 weeks, participants undergo reassessment to track their progress and receive ongoing recommendations. The program aims to provide education, offer exercises, create a supportive environment, and connect members with community resources to empower individuals to reduce the risk of falls and promote safety and independence.

Clinical justifications for Falls Prevention Program

Client has a fear of falling that is limiting their ADLsClient has reduced confidence in their mobilityClient has multiple falls historyTUG >8.5secs indicates a high risk of falls for community dwelling older adultsRecent hospital admission relating to fallsClient exhibits gait abnormalities or unsteadiness during walking

Live Telehealth Wellness Exercise 8-Week Program

The participants are guided through exercises which will engage them for 45minutes targeting strength, cardiovascular, balance and coordination.The sessions are run by an exercise professional which the participants can follow along to via video or telephone supported by the exercise hand outs and equipment provided.

Participants will be offered varying levels of difficulty for each exercise to ensure that they get the most out of the sessions.

This is an ideal program for those clients on lower level funding and for those wishing to increase their weekly exercise expenditure. They can participate in as many times as they like during the 8-week program as we run live sessions on Mond, Wed and Fri at 9:30am.

Clinical recommendations for Group Exercise Program

To meet desired exercise expenditure as per WHO 150mins exercise per weekSocial connection through group exercise at homeClient is primary carer and unable to leave home, this program supports them engaging in exercise whilst still be present at home.Client as a very light exercise tolerance of less than 30mins per week

Client is happy to participate in the group exercise program recommended? *

YesNo

Participants personal email to join the class

How will the client join the telehealth class

Via their own ipad, computer, smart deviceVia their NOK smart deviceWill need to purchase a device to access the programUnsure at this stage

Reasons for declining - Group Exercise Program

Physiotherapy or Exercise Physiologist sessions

Physiotherapy or Exercise Physiology Sessions Recommended *

YesNo

Recommended amount of sessions *

Client is happy proceed with recommended sessions *

YesNo

Plan for sessions

Please note:

Following the recommended sessions the Exercise Physiologist or Physiotherapist shall review your client and consider them ready for sessions with the Allied Health Assistants under their supervison. This will assist in reducing the cost for ongoing sessions.

AHA Physio Program Recommended

These sessions may include but not limited to: hands on AHA Physio and Remedial Massage techniques, aimed at increasing circulation, flexibility, reducing muscle and joint pain, improving joint range, aiding recovery from injury or muscle fatigue and relaxing the nervous system. All the sessions are tailored to the clients need and activities of daily living goals. These sessions are conducted in the clients home or physiotherapy clinic if required by approved and accredited Allied Health therapists.

AHA Physio Program Recommended *

Yes No

Recommended frequency of ongoing AHA Physio sessions *

Once a weekTwice a weekFortnightly

AHA Physio Program - Clinical reason for recommending

Additional Clinical Reasons for AHA Physio Sessions based on todays findings

Recommended sessions of AHA Physio *

Reason why AHA Physio program was not recommended at time of assessment

Client happy to proceed with AHA Physio Program *

YesNo

Reasons for declining - AHA Physio recommendation

Client suitable for

Physio / Massage TableAdapt treatment to suit clients limited mobility

The Allied Health Professional (AHP) completing this assessment has discussed the recommended plan including goals for the ongoing services with the client and NOK. Clinical justifications have been provided in this report to support ongoing programs overseen by the AHP.

At the time of assessment the client and or NOK have provided consent for ongoing services to occur, provided that funding is available from their package.

Client or NOK consents for ongoing services

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Subjective

Reason for referral

Persons Present

Current Social Information

What is your current housing situation?

Are you currently receiving any services at home? What are your social supports?Note days, times and type of services recieving.

Do you care for anyone else?

Are you cared for by anyone else?

Medical History

Medication List Where Relevant

Browse

Regular GP/Practice *

GP Name

Phone of clinic

Vision and Hearing

Notes for therapist:

Objective - Physical function, Mobility and Cognition & ADL's

Mobility

Additional information

Weekly Exercise and Mobility Levels

Mobility Levels

Limited Mobility (0-30 min per week)Light Activity (31-90 min per week)Moderate Activity (91-150 min per week)

Sedentary: Rarely engages in any physical activity.
Minimal Movement: Limited to basic daily activities such as moving around the house or is bed bound

Occasional Light Exercise: Engages in light activities such as short walks or light stretching a few times a week.
Infrequent Structured Exercise: Participates in structured exercise sessions once a week.

Regular Light Exercise: Participates in light to moderate activities such as walking, gardening, or gentle yoga 3-4 times a week.
Moderate Structured Exercise: Engages in structured exercise sessions 2-3 times a week.

Types of movement client enjoys or previously enjoyed.

Activities of Daily Living

Functional Assessments - Baseline Results

Please identify below the areas the client has difficulty independently completing the tasks.

Was the client able to participate in the Functional Assessments below?

YesPartiallyNo

Justification why client did not complete functional assessments

Some tests below were varied to suit the functional ability of the client. These variations will be used in the follow-up review to demonstrate consistency across the assessments.

Strength Assessment

Client states difficulty with following transfers

Getting in and out of bedGetting up and down from a toilet, chairGetting in and out of a carNil difficulty

Strength Ax: Sit to stand (no.)Strength in lower limbs - 30sec test from chair

Table represents below average scores for Sit to Stand

Table represents results which are below average for gender and age.

Test variations or comments

Comments regarding strength and ADL’s

Mobility Assessment

Client states difficulty with lifestyle activities

Mobility Ax: Timed up and go (sec)Mobility: Stand up from chair , walk 2.4m around cone then return to chair. Recorded in seconds.

Scoring: A timed up and go score >8.5 sec is associated with a higher risk of falls in community dwelling older adults

Test variations or comments

Comments regarding Mobility

Static Balance Assessment

Client states some difficulty with ADL's

Difficulty standing and drying or washing selfStanding in queue for long period of timeStanding preparing mealsPulling up trousersStanding to brush teeth or comb hairNil difficulty

Static Balance - Stage One (eyes open)

YesNo

Standing on two feet - hip apart for 10sec

Static Balance - Stage Two (eyes closed)

YesNoNot attempted

Standing feet hip width apart - eyes CLOSED for 10 seconds

Static Balance - Stage Three Left foot forward (10sec)

YesNoNot attempted

Semi tandem - 10sec

Static Balance - Stage Three Right foot forward (10sec)

YesNoNot attempted

Semi tandem - 10sec

Test Comments and or variations

Comments about balance and ADL’s

Manipulative Dexterity Assessment

Manipulative dexterity: Bean Transfer Test (sec) - Right handIndividual moves 10 beans from table to cup (positioned 30cm apart) as fast as possible while being timed.

Manipulative dexterity: Bean Transfer Test (sec) - Left hand

Test Comments and or Variations

Comments regarding dexterity and ADL’s

Falls History

Falls History - Fall in the past 12 weeks

YesNo

A fall is defined as unintentionally coming to the ground or some lower level and other than as a consequence of a sudden onset of paralysis, epileptic seizure or overwhelming external force.

Details about fall and injuries sustained

Has client participated in a Falls prevention program before

YesNo

Where was the falls prevention program

Discussed Falls Prevention and Education program with client available with Summit Health Solutions.

Pain Assessment

Do you have any issues with pain at the moment?

YesNo

Is your pain impacting on daily living?

YesNo

At the time of assessment the client did not report signs of pain and discomfort or pain elicited by movement or activities of daily living.

Pain sites and concern areas

Clear drawing

When did the main pain commence and how?

How does the pain impact them over a 24hr period

Main pain area score (VAS out of 10)

Pain Ax Tool

Clear drawing

Duration of pain

Frequency of pain

Is the client experiencing any pins and needles and or numbness?

Where is the client experiencing PnN and or Numbness?

Any pain medication taken?

YesNo

Details about pain medication taken

Medication list if relevant

Browse

Discussed option for AHA Physio (Massage) with client for pain relief and improved range of movement through joints.

Cognition

Following Instruction

Memory

Comprehension

Additional comments

Language comments

Additional Services Recommended

At the time of assessment and based on the findings the following recommendations are made to support the client. All recommendations were discussed with the client at the time of session.

Nail Care Therapy Recommended

YesNo

Clinical reasons for recommending Nail Care Therapy

Client interested in Nail Care Therapy Service

YesNo

Reason for declining Nail Care Therapy

Podiatrist details and treatments

Occupational Therapy Home Assessment

YesN/A - not recommended at this time

Justification for recommending OT Home Assessment

Reason For OT Home Assessment ? *

Occupational Therapy Equipment Assessment

YesN/A - not recommended at this time

Justification for recommending OT Equipment Assessment

Reason For OT Equipment Assessment ? *

Attachments if required

Drawings/Images

Browse

File attachment

Browse

Please note: Consent was obtained by the client to report medical information discussed and take photos that would support any recommendations made in this report.

Allied Health Professional

This Initial Functional and Mobility Assessment has been peer reviewed by our Allied Health Professional team who have approved the recommendations and clinical justifications for this client.

If you have any questions about this report please contact Admin on 1300 315 315 or email admin@summithealthsolutions.com.au

Thank you for the opportunity to provide this assessment for your client.

Yours sincerely

Peta Weisfelt

Physiotherapist

Summit Health Solutions Australia

Signature *

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Yours sincerely,

Wael Yousef

Physiotherapist

Summit Health Solutions ACT

Image title

Signature *

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Yours sincerely,

Pengfei Li

AHA

Summit Health Solutions ACT

Image title

Signature *

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Yours sincerely,

Raul Naidu

AHA

Summit Health Solutions ACT

Image title

Signature *

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CARE MANAGERS SECTION - Funding request for ongoing & recommended services

The options below have been highlighted as at the time of assessment the client demonstrated an interest in recieving these services.

Please confirm that the client has adquate funding for the following services please.

Physiotherapy / Exercise Physiology sessions

Allied Health Professional Recommends below frequency of sessions for client

This client has adequate funding for 6 Exercise Physiology sessions: Total Cost = $1,217.7 (individual sessions $202.95)

This client has adequate funding for 12 Exercise Physiology sessions: Total Cost = $2,435.4 (individual sessions $202.95)

This client has adequate funding for 6 Physiotherapy sessions Total Cost = $1,217.7 (individual sessions $202.95)

This client has adequate funding for 12 Physiotherapy sessions Total Cost = $2,435.4 (individual sessions $202.95)

The client has limited funds and unable to meet the 6 session minimum of Exercise Physiology or Physiotherapy sessions.

AHA Physio Exercise Sessions Overivew

These one to one tailored sessions have a Wellness or Reablement focus for client rehabilitation, post-surgery, falls prevention, improve overall fitness and confidence all within clients home, hydro pool or gym. All sessions are conducted by accredited and approved Allied Health Professionals.

Allied Health Professional Recommends below frequency of sessions for client

This client has adequate funding for 8 AHA led Exercise Sessions (7 individual sessions $101.50 plus discharge review/report $202.95) Total cost: $913.45

This client has adequate funding for 16 AHA led Exercise Sessions (15 individual sessions $101.50 plus discharge review/report $202.95) Total cost: $1,725.45

The client has limited funds and unable to meet the 8 session minimum of AHA led Exercise Sessions sessions.

Ongoing exercise sessions - weekly

Allied Health Professional Recommends below frequency of sessions for client

This client has adequate funding for 12 exercise sessions (once per week for 12- weeks). Total cost: $1,431.10 (11 individual sessions are $111.65 plus exercise review/report $202.95).

Ongoing exercise sessions - two times per week

Allied Health Professional Recommends below frequency of sessions for client

This client has adequate funding for 24 exercise sessions (twice per week for 12 - weeks). Total cost: $2,770.90 ( 23 individual sessions are $111.65 plus exercise review/report $202.95).

Ongoing exercise sessions - three times per week

Allied Health Professional Recommends below frequency of sessions for client

This client has adequate funding for 36 exercise sessions (three times per week for 12 - weeks). Total cost: $4,110.70 (35 individual sessions are $111.65 plus exercise review/report $202.95).

Ongoing exercise sessions - four times per week

Allied Health Professional Recommends below frequency of sessions for client

This client has adequate funding for 48 exercise sessions (four times per week for 12 - weeks). Total cost: $5,247.55 (47 individual sessions are $111.65 plus exercise review/report $202.95).

Limited funding for Exercise

The client has limited funding available and unable to commence the minimum once a week - 12 weeks of exercise. Will follow-up when funding becomes available.

Additional information where required regarding exercise sessions

Therapy Equipment Pack Recommended Funding Approval

To reduce cross contamination and apply good hygiene processes we are requesting that consumers purchase equipment packs that have been recommended to support their individual programs.

Once approved Summit Health Solutions shall arrange for the equipment to be purchased and delivered to your client.

Pack 1 - (Ball, Red & Yellow Theraband) $25

Pack 2 - (Green Theraband, 1kg or 2kg Dumbell) - $30

Pack 3 - (Blue or Green Theraband, 2 x Bean Bags, Slider disks) - $30

Pack 4 - Hand Dexterity Pack (Putty, Rubber bands, Tweezer and Pom Poms, Nuts & Bolts) - $40

Arm/Leg Pedal Ergo (Professional grade machine with manufacture waranty) - $350 +GST

No funding available at this time for recommended equipment

Group Exercise Program Recommended

Allied Health Professional Recommends

Falls Prevention Program Overview

The 12-week Falls Prevention Program aims to reduce fall risks, increase awareness, and improve confidence in a supportive environment. Conducted in Deakin's studio space, it provides all necessary equipment and materials to promote safety and independence.

Clients will need to attend this Falls Prevention Program in person. They may commence the program at any date however the 12 weeks commences from their first session and paid in full.

This client has adequate funds to participate in the 12 week falls prevention program [Total cost = $360.00] *

YesNo

Live Telehealth Wellness Exercise 8-Week Program

The participants are guided through exercises which will engage them for 45minutes targeting strength, cardiovascular, balance and coordination.The sessions are run by an exercise professional which the participants can follow along to via video or telephone supported by the exercise hand outs and equipment provided.

Participants will be offered varying levels of difficulty for each exercise to ensure that they get the most out of the sessions.

This is an ideal program for those clients on lower level funding and for those wishing to increase their weekly exercise expenditure. They can participate in as many times as they like during the 8-week program as we run live sessions on Mond, Wed and Fri at 9:30am.

This client has adequate funds to participate in the 8 Week Telehealth Exercise program [Total cost = $396.00] *

YesNo

AHA Physio Sessions Overview

These sessions may include but not limited to: hands on AHA Physio and Remedial Massage techniques, aimed at increasing circulation, flexibility, reducing muscle and joint pain, improving joint range, aiding recovery from injury or muscle fatigue and relaxing the nervous system. All the sessions are tailored to the clients need and activities of daily living goals. These sessions are conducted in the clients home or physiotherapy clinic if required by approved and accredited Allied Health therapists.

Allied Health Professional Recommends below frequency of sessions for client

This client has adequate funding for 8 AHA led Physio Sessions (7 individual sessions $146.60 plus discharge review/report $202.95) Total cost: $1,229.15

This client has adequate funding for 16 AHA led Physio Sessions (15 individual sessions $146.60 plus discharge review/report $202.95) Total cost: $2,401.95

The client has limited funds and unable to meet the 8 session minimum of AHA led Physio Sessions sessions.

Ongoing AHA Physio sessions - Massage - weekly

Allied Health Professional Recommends below frequency of sessions for client

Once a Week AHA Physio Services - Massage for 12 weeks: This client has adequate funding. Total cost: $1,896.40 ( 11 individual sessions are $153.95 plus a review at $202.95)

Ongoing AHA Physio sessions Massage - two times per week

Allied Health Professional Recommends below frequency of sessions for client

Twice a Week AHA Physio Services - Massage for 12 weeks: This client has adequate funding. Total cost: $3,743.80 (23 individual sessions are $153.95 plus a review at $202.95)

Ongoing AHA Physio sessions Massage - fortnightly

Allied Health Professional Recommends below frequency of sessions for client

Fortnightly sessions of AHA Physio Services - Massage for 12 weeks: This client has adequate funding. Total cost: $1,896.40 (11 individual sessions are $153.95 plus a review at $202.95)

Limited funding for AHA Physio Massage

The client has limited funding available and unable to commence AHA Physio sessions - Massage for 12 weeks. Will follow-up when funding becomes available.

Additional comments regarding recommended services and funding if required

Thank you for completing this funding section of this report.

Our admin team shall reach out to your client and set up the approved services.

We really appreciate and enjoy working with you and your clients.

I agree that I have confirmed all funding availability for this client in the form above
*

Care Manager Name Confirming Funding *

Signature *

Please click SUBMIT once you have confirmed funding for service and equipment.

You shall recieve a copy of this report in your inbox once you click SUBMIT.

Thank you in advance for supporting us to streamline this process.

Summit Health Solutions

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