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Vanessa Eldridge delivered the presentation at 2014 Transition Care Conference: Improving Outcomes for Older People. The 2014 Transition Care Conference: Improving Outcomes for Older People formed a National account of the consumers' transition care journey within the current aged care environment, highlighted new initiatives to improve TCP access and quality of care, and showcased innovative service delivery models across jurisdictions. For more information about the event, please visit: http://www.informa.com.au/transitioncareconference14
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Vanessa Eldridge Manager Transition Care Program and Restorative Care
Transition Care Program – Case Studies
• How limitations of the model can impact on client pathways
• How TCP could be improved at our health service
TCP at Barwon Health
Originally started in 2006 with: – 19 residential beds – 4 home based packages – In an SRS – Completely brokered model except for Care
Coordination 2.0 EFT – Purchased all allied health, medical (GP), nursing and
personal care
3-fold increase in size
This increased in 2011 to: – 39 residential beds at 2 High Level Care facilities – 18 home based packages – 5 Restorative Care residential beds – Care Coordination EFT of 6.1 – Full time Admin – Full time Manager – Employed Geriatrician at 0.4 EFT + 1.1 EFT Registrar – 0.7 EFT OT – 1.5 EFT Physio – Purchase all other Allied Health
Case Studies
Typical pathway for TCP – 86 yo female – # NOF post mechanical fall ! DHS – PMHx: recurrent UTIs, T2DM, HPT, GORD, stress
incontinence – Previously living alone – HACC services only – Daughter lives nearby and visits 2 x per week – Mild cognitive impairment, but functional – TCP Goal
• aim return home when able to mobilise safely
Case Studies
Typical Pathway – admitted TCP residential • Physio 2x per week plus functional Physio each day (walk
to dining room) • Time to improve confidence (LOS 5 weeks) • OT home assessment ! minor home mods • Transferred TCP Home Based with daily personal care • Discharged after another 6 weeks with increased HACC
services
• Conclusion – a good outcome – goals were met. • This setting was the right setting for this lady. Our
resources were a right match for her needs
Atypical pathway for TCP – 45 yo man – Cerebral palsy, low BMI, non verbal, repeat pneumonia,
epilepsy, anorexia, faecal impaction, hydronephrosis, renal calculi
– Extreme risk of pressure injury – High risk of aspiration pneumonia – Very involved family – no parents, no legal guardian
appointed – Lived in DHS supported accommodation – TCP Goal
• return to supported living accommodation with increased nursing supports, and funding by NDIA/DCA (on waiting list)
Case Studies
Case Studies
Pathway – admitted TCP residential Limitations of the service identified on day 1 • Long medical history – could not be read in one sitting • Medical discharge summary did not capture the full story • High expectations of family • Family not well informed about the setting of TCP • Poor handover received = inadequate pressure care
equipment on arrival • Staff not prepared for clinical needs or equipment needs • Care staff unable to communicate with client due to him
being non-verbal
Case Studies
What happened? • Stayed full 12 weeks • Overnight admission x 2 to ED due to faecal impaction • New pressure injury sustained to sacrum • Manager put in writing to family that he needed to be
discharged by the 84th day • Highly demanding family requiring time ++ of case
management – impact on other clients
• Nursing staff needed to learn new nursing techniques • Physically demanding – 2 to 3 person transfer
Case Studies
• Conclusion – successfully discharged back to supported accommodation, but – At what cost to the other clients and families? – At what cost to my team?
Eligibility ≠ Suitability
Eligibility for TCP as determined by ACAS – What is realistic for the TCP setting? – Consider the model – predominantly PCWs caring for
complex clients – Is moving this person to TCP person-centred? – Does it just meet the hospital’s needs? – Where is the right place for this person? – What are the available resources within TCP? – Does the ACAS assessor fully understand setting they are
recommending?
Context of the Transition Care setting
• Private aged care facility vs PSRACS vs acute/sub-acute setting • A joint vision / partnership model • On-site or off-site • Governance and reporting structure • Accountability of the contractor – watertight contracts • Carer ratio – Personal Care Workers : Div 1 • Environmental limitations eg office space, IT connectivity, private
meeting rooms, shared rooms and bathrooms • Storage of equipment • Availability of resources – physical and human resources • Flexibility of care plans – what can / can’t be expected? • Ongoing education and service improvement
Current state
– Moderate number of ‘inappropriate’ referrals to TCP • E.g. patients requiring IVABs or vac dressings; patients with no
clear goals; patients with a delirium; patients who are still undergoing medical investigations; TCP viewed as the discharge plan
– High number of referrals to TCP who don’t wish to participate in the program
– Moderate number of referrals to TCP who arrive at TCP and self discharge within 48 hours
– General poor understanding within the health service of what TCP can and cannot provide
• E.g. TCP is not a substitute for GEM or rehab; TCP cannot provide daily Physio; TCP is not the final destination
The interface between TCP and ACAS
Bringing eligibility closer to suitability
• How can ACAS and TCP work together better? • How can we understand each other better?
– How do we make sure we understand each other’s roles in the aged care pathway?
• What can we do to prevent conflict between our services? • How can we all achieve client-centred practice? • How do we educate our referrers?
TCP and ACAS working together
• Previously – TCP and ACAS at Barwon Health didn’t work hand-in-hand
• What did I do to improve this? – Asked to meet with the ACAS Manager on a monthly basis – Persisted with communication – Involved her in decision making about TCP referrals and provided
feedback about particular referrals – ‘Meet and Greet’ with the ACAS team – introduced myself and my
team; made myself available for questions via phone or email; provided education about what our TCP could and could not manage
– The health service restructured in 2013 - both ACAS and TCP then reported to the same Directorate
– Managers involved one another in recruitment of new staff – Relied on one another at a personal level – both Managers
managing multi-disciplinary teams
Future Directions for Barwon Health TCP
How could we improve? – Internal model at a Barwon Health public sector aged care
facility – this improves the difficulties around: • Joint vision • Partnership • Governance • Streamlining processes • Access to BH medical records and IT systems • Ideally creates a service wide responsibility for achieving the right care in
the right place at the right time – BUT it costs more!
– Employed allied health • Reduces cost • Increased control over quality and service design • Increased quantity - equivalent or more EFT for the same or less cost • Choice in recruitment
– BUT difficulty with recruitment and retention
Future Directions for Barwon Health TCP
– Clear criteria for TCP (with flexibility) – dependent on other services also having clear criteria
– Updated and clear written information for: – Referrers (including guidelines and procedures) – Potential clients – Families
– Ongoing education of referrers – keep the messages simple and clear
– Increased presence of TCP at the referral source – Physical presence at the hospital and rehab centre – Reallocation of existing EFT and re-prioritising Care Coordinator tasks – Creation of a new position named “TCP Liaison” – working in a team with a
new ACAS Liaison and the Geriatric Consultancy team
Thank you