The Benefits of Seamless Transition Care

A Case Study or Two

Outline

• Seamless Care – What does this mean?

• Brightwater Care Group - our services

• Demonstrate how the Brightwater “Model” supports

seamless care for transition clients through “A case

study or two”

Seamless Care – What is it?

• Seamless care represents the smooth and safe transition of a person through a health system. To be achieved the person’s care must be delivered consistently and without interruption

Brightwater Care Group

• Brightwater was established 110 years ago in Perth

Western Australia, as a not for profit, non-denominational organisation

• Brightwater provides care to over 2000 people and has a staff of over 2100

Brightwater Care Group continued

• Brightwater currently has 23 modern facilities located across the Perth metropolitan area • 13 of these facilities provide accommodation for older

people including 59 Transition Care beds • Two facilities are dedicated to people living with

Huntington’s Disease • The remaining 8 facilities provide a range of

rehabilitation and residential accommodation for younger people with disabilities

Brightwater Care Group continued

Other key services include: • Brightwater At Home Services provides assistance to over

800 clients • Seatec, is a specialist seating and equipment service • An over 55s community (Kingsway Court), commercial

linen and catering businesses that services our own facilities and other organisations such as hotels, mine sites and hospitals in WA

Brightwater Transition Care

Brightwater commenced Transition Care services in 2010

• 44 beds at Brightwater Kingsley

• 15 beds at Brightwater Birralee

• 20 TCC packages

Kingsley

• 66 bed residential aged care facility with 1 dementia specific secure house

• 7 houses single rooms with ensuites, 2 shared rooms

• 5 and 1/2 houses designated to TC

Birralee

• 60 bed residential aged care facility non-dementia specific

• 4 houses with 15 residents. Single rooms with ensuites

• 1 house designated to TC

Brightwater Transition Care Community has 20 Packages

Providing Seamless Care – What We Found Works and a Few Challenges

Transition Care Model

TCP Residential

• TCP Admission’s Coordinator

• TCP Coordinator

TC Community

• TCC Coordinator

Organisational Wide

• Dedicated Admission’s Team

• Monthly Internal Transfer meetings

Transition Care Team (Residential)

AH Team

Nursing

Medical

Care Workers TCP Admissions

CoordinatorCM Kingsley CM Birralee

Medical

Care WorkersNursing

AH Team

TCP

Coordinator

Service Manager

Transition Care Team (Community)

AH TeamNursing

Clients GP

Support

Workers

Transition Care

Community

Coordinator

Service Manager

Systems & Processes

TCP Admission’s Coordinator

• Registered Nurse

• Liaises daily with hospital TCP Coordinator for referrals and discharges

• Triages referrals in discussion with facility teams

• Decisions to admit based on clinical and social needs of client and facility acuity. Will visit in hospital if ? Referral.

• Prior to admission arranges equipment, pharmacy and speaks with hospital nurse for handover

• On day of admission contacts family, meets and greets, provides client with the TCP information pack and emails client summary to TCP staff

TCP Coordinator

• Social Worker

• Arranges family meeting and captures client goal/s

• Social Worker Summary

• Chairs the weekly multidisciplinary team meetings with Geriatrician

• Case manages guardianship applications, liaises with providers (both community packages and residential)

• Attends internal transfer meetings

Clinical Team

• Nursing and Allied Health complete assessments and care plan embedding resident goal/s

• Nurse assesses client competency for self administration of medications

• OT conduct home visits

• Therapy Assistant staff undertake regular therapy interventions under the direction of the therapists and care workers provide care under the guidance of a nurse

Other Things That Work

• House Team Leaders (coordinate care, arrange for follow up external appointments)

• Communication: Group email distribution list

• Regular contact with the BW TCC team

• Attendance at the Internal Transfer meeting

• TCP Team meeting minutes template (team member report on progress against client goal/s)

Birralee TCP team meeting minutes 23/05/2013

1 Name: MJ Pathway:

RESTORATIVE

Admitted: 14/05/13 12 wks 06/08/13 ACAT

Low

PMHx Hypercholesterolemia. # R Ankle, HTN Hearing loss

SERVICES Silver Chain Fortnightly

CLIENT

GOAL

To return home once functioning returns

MINUTES PT: Plaster now dry, non weight bearing, R leg using gutter frame. Ongoing PT

OT: Is socializing, will conduct home visit next Tuesday

SW: Family meeting today, confirms home preference have agreed to referral to BW TCC

Nursing: Skin intact is on daily clexane injection.

2 Name: DM Pathway:

RESTORATIVE

Admitted: 11/04/13 12 wks 04/07/13 ACAT

Low

PMHx #C7, 6TIR Shoulder Replacement 2013, Chronic back pain, Frequent Falls #NOF High Cholesterol OP GORD Anxiety

SERVICES Mercy care, referral made to TCC

CLIENT

GOAL

Return home with services when can ambulate up to 100m and manage meals and drinks

MINUTES PT: independent with walking and can walk up to 30m. Cont with strength and endurance exercise

OT: working with TA’s in meal preparation. Pain is impacting at this point. Home visit when well enough.

SW: Maintaining contact with BW TCC

Nursing: Halo has come off, is now in a semi soft collar, has been assessed for pain and commenced regular meds, has started

steroids for mouth ulcers.

Community Processes

• Process managed throughout by the TCC • Within a day of referral visits client in hospital or

residential TCP to assess and meet with family. • Clinical Nurse and Allied Health arranged to conduct

clinical assessments as required • Distributes a summary of needs to TCC team • TCC team meet 1/14 to discuss progress • Plans discharge with equipment, home meals, ongoing

package as required

Key Challenges

• Communication Communication Communication

• Backfilling key internal staff

• Maintaining strong relationships with multiple hospitals

Case Study - Rose

• Admitted from hospital to TCP following fall resulting in subarachnoid hemorrhage

• STM loss, word finding difficulties, requires supervision ADLs and transferring, ambulates frame up to 50m

• Previous living at home with no services • Family support available. Rose wishes to

discharge home however family concerned about her returning home

• Discharge plan – home with TCC and follow up package

0

20

40

60

80

100

Dec-11

Jan-12

MBIAdmission

MBIDischarge

Case Study - Steve

• Admitted from hospital to TCP following hernia repair

• Hx Parkinson’s Disease with severe dyskinesia

• 67Kg, ambulates frame, Hx over self medicating

• Doubly incontinent, assistance ADLs

• Previous living at home with Brightwater EACH

• Support 1 elderly friend, sister interstate

• Discharge plan – home

0

20

40

60

80

100

Jun-12

Jul-12

Aug-12

MBIAdmission

MBIDischarge

Summary

Key criteria to successful seamless care are:

• The “right” model of care

• Strong systems and processes

• A focus on communication and ;

• Ongoing evaluation and review to identify areas for improvement