Early Discharge +
Rehabilitation Service


Waitemata has a rapidly growing and aging population, at present 14% (83,720) of our population is aged 65 years or older. This is predicted to reach 115,000 by 2025 and 148,980 by 2033. Combined with a growth in demand, these factors have the potential to place considerable pressure on existing services and facilitates.

The Health and Older Adult service acknowledged that the existing model of rehabilitation care was solely dependant on an inpatient experience. It lacked the opportunity for patients and whānau to participate in the planning and delivery of their rehabilitation, and also rehabilitation was not always in an environment that was most suited to their needs.

EDARS is a short-term intensive rehabilitation programme delivered by an interdisciplinary team in the patient’s home. The at-home programme is similar to that provided in the hospital rehabilitation wards

To create a service that would plan and deliver 'tailor made' rehabilitation therapies based on the client's specific needs and delivered in their home environment with the support of their whānau in order to:

  • improve the patient and whānau experience of rehabilitation and quality of life; with the intention of enabling independent living following stroke, illness or surgery
  • improve patient rehabilitation outcomes through enhanced continuity of care by providing seamless, multi-disciplinary team (MDT) led transition from secondary care to home
  • deliver a community based intensive rehabilitation service, reducing demand for high cost acute and AT&R beds
  • avoid capital expenditure through investment in community services thus reducing demand of acute beds
  • offer an alternative rehabilitation option that will release acute and AT&R bed days

The Early Discharge and Rehabilitation Service (EDARS) proposal provided the opportunity for the DHB to shift focus away from the historical medical model to one that enabled the patient to have a strong influence on what tasks and outcomes mattered to them most for their rehabilitation, it also provided acute rehabilitation staff the opportunity to deliver a model of care with a team composition that was different to anything that had been provided in our region before.

We began a phased roll-out of EDARS at Waitakere Hospital in May 2016, and completed implementation in September 2016. 

The goal of the service is to ensure the programme of rehabilitation delivered at a patient’s home is comparable to the current in-patient treatment delivery in AT&R. This includes care from medical, nursing, the full range of Allied Health therapies (OT, PT, SLT, DT and SW) and multi-disciplinary therapy assistants on a 5 day-a-week basis. The service is intended for patients 65 years and older (55 years and older for Māori and Pacific Island patients), although those close in age who it is believed will benefit will be considered on an individual basis.

The service was implemented at North Shore Hospital in ??? 

We are continuing to work with services to to embed the EDARDS business rules and manage the expectations of the clinicians who have identified long stay patients who would also benefit from an intensive rehabilitation model delivered in the patients' home.

In the first full year of service EDARS accepted 194 referrals from a total of 266 received. Introduction of this service has shown improved outcomes for patients (at October 2017):

  • average length of stay (ALOS) has reduced to 21.6 days (down from 26.4 days)
  • average length of time being seen and treated by service is 31.6 days (target ≤ 42 days)


A review of the patient and whanau’s experience was undertaken with the first 20 patients following the implementation phase; this process was replicated 1 year later. A staff experience review was also carried out, the outcome of these can found in the reviews in the resource section.

The results from both reviews were overwhelmingly positive, with six themes emerging in 2017 – of which five were consistent with the 2016 study.

Two months into the programme a patient experience evaluation was undertaken to determine if the model of care met the patient and whānau’s needs. This in-depth view was used during implementation to shape service development while the remaining team members were recruited and practices and policies were created and embedded. 

We asked patients and their whānau support persons 10 questions as part of the evaluation, and repeated this a year later. Both studies yielded overwhelmingly positive endorsement of the service.

Six clear themes emerged:

EDARS survey results
Patient and whānau feedback about EDARS 1 year on

Project Team

  • Sue French, i3 Innovation + Improvement Project Manager
  • John Svott, HOD Specialist Medicine + Health of Older People
  • Sue Skipper, Operations Manager, MHSOA


  • Gill Fishter, i3 Innovation Research Coordinator
  • Ravina Patel, Assoc Director of Patient Experience


Sue French

Innovation + Improvement Project Manager

Gill Fisher

Innovation Research Coordinator - Person Centred Design