Transitional Aged Care Program

Confidently Resuming Fabulous Function After TACP

By

Tracey Craig

Assistant In Nursing

May 2013

Location

• Service of Delivery – Armidale, Guyra and Uralla

Multidisciplinary Team

• Co ordinator/RN – 1FTE

• RN – 0.8

• EEN – 0.8

• EN – 1

• AIN – 0.6

• OT – 0.5

• Physio – 0.8 (currently job sharing)

Client admission to TACP

• After client has been accepted onto TACP, client is allocated a case manager/s.

• Client is seen in the hospital setting prior to discharge and given information.

• Client is taken home by TACP staff and assessed within the home.

• Appointment time given for the next day/week

Case Management Practices

• GP notified of admission to TACP, appointment made within 2weeks for client to see GP

• Medications checked by RN

• Vital call installed at cost to TACP for 3 months, with consent from client.

• To ensure nutrition needs, Meals on Wheels or another organisation providing this service are notified at request of client.

• Client Reviews – client’s goals are reviewed on a Thursday with all staff present, appointments made for the week ahead

• Daily handover for all staff regarding client issues.

• Weekend staff completes detailed hand over of clients seen at the weekend.

Preparing for discharge

• Family conferences arranged at 5-6weeks into the program.

• Follow up appointments are made: client contacted by phone after 1 week, TACP staff attend client’s home 4 weeks after discharge and complete a survey. These can be client centred and are flexible to meet their care.

Challenge Solution

• Client not fully understanding concept of TACP due to focusing on discharge from hospital.

• Information given regarding TACP exercise and social group activities

• Case management appointment made 1 week after admission

• One page document developed summarising all service

Challenges Solutions

• Client receiving best outcomes after discharge from TACP

• Allocation of case manager that co-ordinates care throughout process. This enhances rapport with client, increase acceptance to ongoing care if required

• Effective communication between disciplines within TACP

• Development of SMART goals with client

• Identify ongoing needs and to make suitable referrals

Challenges Solutions

• Family members and friends input into client’s ongoing care

• Maintaining confidentiality and professionalism when staff know client and family and are confronted about care issues outside work hours.

• Client identifies who they wish to be a part of their care

• Staff to follow policy and procedures

• Family conferences

Challenge Solution

• Client acceptance of mobility aides and ongoing services

• Community access for clients

• TACP exercise groups, education sessions.

• Communication skills of staff in regards to developing rapport with client

• Increased knowledge of ongoing service for staff

Challenge Solutions

• Client’s emotional well-being in regards to client’s increase anxiety, decrease confidence and fear of falling after previous fall.

• Provide encouragement and reassurance to client.

• Step by step decrease in need for personal care.

• Installation of vital call.

• Referral to social worker, counsellor if required.

• Establishment of our falls group.

Client centred approach to case management

• Effective Communication skills – build rapport

• Every client is different as they have unique needs.

• Development of client centred goals to empower them to achieve

• Establish and maintain networks that enable effective transition into community setting.

• Identification of client’s strengths.

• Empower client’s to make informed decisions and solutions regarding their care and ongoing health issues.

• These informed decisions enable the client to develop and maintain these ongoing solutions.

• Decisions are developed through collaboration with client to promote sustainable outcome for client.

Goal Setting

• Client included in the decision making of the goals they wish to achieve.

• Staff to put aside own thoughts of goals, unless the goals have the potential to harm client or others.

• Utilise client’s strengths to enable goals to be established.

• Goals to Be Specific Measurable Achievable Realistic Timeframe.

SMART Goals

• Encourage small achievable goals that promotes confidence and empowers clients to achieve other goals.

EXAMPLE: Betty wants to shop independently

• “Betty will resume shopping independently within 3 months” (Long Term)

• “Betty will walk to the mail box aided with her walking stick within 3 weeks”

Case Study

• 94 year old lady who was admitted to TACP after hospitalised for fractured L) NOF

• Client fell whilst walking to the mail box.

• Client was in pain and unable to get up, a passer by assisted client off the ground and walked her into her home.

• Client contacted a friend who then came to the home.

• Client organised her affairs and then pressed Vital call

Short Video

Short Video

• Client presented onto TACP with many challenges.

• Client was anxious and over whelmed by the process, however wanted to get home.

• Client misunderstood the aim of TACP – expected TACP staff to stay the night.

• Client had difficulty accepting the need for a 4ww and being seen in public with a mobility aide

• Quote from client: “Only old people have walking frames”.

• Community access options – client was able to see how many people had mobility aides.

• Returning to social activities as soon as possible.

• Independence with personal care

• Goals were established with client.

• Client became more focused when smaller goals were being achieved.

• Increase in confidence and client became more accepting of mobility aides.

• Client did not feel as old as she was, a lot younger in her mind.

Photos of client

Post TACP

• Currently enjoying all social activities

• Attended Holidays with family, was surprised at the access available for 4ww and other mobility aides.

• Increased confidence in using mobility aides

• Undertaking further education for ipad and computer use

• Walking to complete shopping approximately 700 metres.

• Client did inform that she had a near miss fall after discharge from TACP. After discussion, it was determined that the client had achieved the acquired skills to develop strategies independently to overcome future health issues.

• “The butterfly must push its way through the tiny opening to force the fluid from its body and wings. Only by struggling through the opening can the butterfly's wings be ready for flight once it emerges from the cocoon”.

Journeyofhearts.org

References:

• Summers,N.(2012). Fundermentals of Case Management Practice: Skills for the human services (4th ed). Belmont, CA: Thomas Brooks/cole.

• Arfken,C. Lach,H. Birge,S. Miller,J.Philip(1994). The Prevalence and Correlates of Fear of Falling in Elderly Persons Living in the Community. American Journal of Public Health, Vol.84,No.4 pg565-570.