The initial assessment is usually done by the physician. This assessment is aimed to look at the whole person, and after taking a thorough history and examination, it may also be necessary to speak to relevant family members and any health professionals previously involved in the patient’s care. The physician then takes a full functional history starting with premorbid level of function and then current level of function [1].

Multidisciplinary care is the cornerstone of any rehabilitation program. The efficacy of coordinated care is supported by a number of studies [3, 4]. Each discipline will assess the patient independently on arrival to the rehabilitation unit and implement the appropriate assessment tools, outcome measures and management plans. Throughout the program the multidisciplinary team works together in an interdisciplinary manner.

A formal functional tool can be used such as the Barthel [12] or the FIM (functional independence measure) [6, 13]. These assessment tools are usually used within the first 72 h of the patient’s admission and used again within 72 h of discharging the patient. The FIM assessment tool is widely used across the world; it is a common method of assessing basic daily living activities and functional abilities [6]. A cognitive assessment should also be performed on all elderly patients prior to participating in a rehabilitation program [1]. Participation in therapy is dependent on the ability to follow simple one-step commands and to sufficiently recall tasks so that learning is carried over each day [2]. There are a variety of standardised assessment tools but a Mini Mental Status Exam (MMSE) is the one most commonly used. The primary determinant of one’s ability to benefit from a rehabilitation program is one’s pre-existing disability and level of function. However severe cognitive impairment is a risk factor for a poor response to any rehabilitation input [7].

Depression and anxiety is common in the older person. A standardised questionnaire, like the Geriatric Depression Scale (GDS) or the Depression Anxiety Stress Scale (DASS) [14], can be used if there are concerns about whether a patient has any form of mood disturbance, which may affect the ability to participate in a rehabilitation program.

Hearing and vision should also be assessed and corrected as much as possible [1]. Finding out when the patient last had a hearing test or saw an optometrist is a vital part of the assessment. Hearing aids and glasses are often left at home. It is important to remind elderly patients to regularly have their hearing and vision checked.

A fall injury prevention screening tool is commonly used on all patients in the rehabilitation unit.

Underlying medical problems can impact on a patient’s ability to participate and progress in a rehabilitation program; thus it is important to identify and manage these issues promptly. It is essential that underlying medical problems are identified and managed appropriately.

Each rehabilitation patient should have specific rehabilitation goals. These goals are usually patient centred and identified early in the rehabilitation process. Setting functional goals such as to improve mobility or to become independent with self-care tasks is common. The multidisciplinary team often assists the patient in identifying realistic and achievable goals. Rehabilitation therapists often use the pneumonic SMART when setting rehabilitation goals with patients.

An example of a goal is “I want to walk 50 m with my walking stick within one minute”. This goal is ideal because it is specific and it is measurable which enables the patient and the therapist to monitor their progress. Awareness of the goal provides a challenge and enables the patient to be motivated and engaged throughout the program. The goal should also be realistic so that the patient does not become dissatisfied and give up. The goal should be timely so that an endpoint is set and the patient has a clear target to work towards.

The multidisciplinary team usually involves the rehabilitation physician, rehabilitation nurse, physiotherapist, occupational therapist, speech therapist, social worker, dietician, psychologist and podiatrist. The rehabilitation team meets on a weekly basis in a case conference forum. In this meeting each patient is individually discussed. This allows formal coordination of the multidisciplinary plan and documentation of the discharge care plan and follow-up arrangements. The case conference is about reviewing the rehabilitation process including patient-centred goals and progress. Any medical interruptions are discussed.

Family/relative meetings are also important in order to update the patient’s family on the rehabilitation process, provide an open channel for communication and work towards an agreeable and safe discharge plan.