Let’s Keep The Positive Momentum:

Achieving client goals throughout a care transfer

Outcomes • Focus on improving the flow of communication with hospitals and utilising social work

and other allied health

• Working with clients to maximise their outcomes/improvements during their time in

Transition Care – and these improvements don’t have to stop when TCP ends

• Continue working towards their goals once they are discharged from TCP, using

Consumer-Directed Care options or flexibility in home care packages to ensure they

have choices which meet their needs and help them maximise independence

• Increased Transition Care occupancy, reduced the longer-term needs of clients and

increased reported job satisfaction of staff

• Case studies and client interviews, of how the program supports clients to make a

smooth transition of their goals through the types of care, so they can continue to

make gains over time.

Brightwater At Home Services -Transition Care in the community

• Brightwater At Home Services is a part of Brightwater Care Group

• Part of the fabric of Western Australia for 114 years

• One of the largest care providers in Australia, with 30 individual locations and 2600

clients, ranging from 16 to 104

• Providing aged care, transition care, home care and care for people with acquired

brain injuries

• Not-for-profit organisation

• Purpose to “Enable Wellbeing”

• Focus on participation and engagement with the community.

Continued…

• Brightwater AHS started in 1990 as pilot program in Perth’s north

• Now covers the entire metropolitan area from Two Rocks in the north to Lake

Clifton in the south

• Coordinators work collaboratively with clients and families to design a service

package that meets their physical and emotional needs

• Strong focus on reablement programs using our allied health and nursing teams

• In the last financial year Brightwater at home staff travelled 1.2 million kms to

provide 150 000 hours of support.

Communication • Work in progress

• Working with changing workforces

• Integral to growth of packages

• Prompt action and clear instructions

• Regular feedback - keeping up

communication even after clients

are discharged

• ‘Squeaky gate syndrome’ to

promote TCC

• Joint allied health visits and sharing

equipment provision

Discharge Checklist

Brightwater Transition Care Program

Contact: Carol van Malsen

Phone: 94008700/0408932327

Fax: 94008799

Email: carol.vanmalsen@brightwatergroup.com

Patient:______________________________________________ Date of Discharge:_____________________________________

Required at time of referral:

TCP referral form

Current TCC ACCR

Allied health referral form

Required at discharge:

Home visit report

Physiotherapy report

Nursing transfer summary (as relevant)

Discharge summary

Social Worker feedback- Hayley Cliff / Senior Social Worker

Glengarry Hospital

“I am a hospital-based Social Worker who works in the aged care and rehabilitation setting. I have referred numerous patients to the Community Transition Care program for support and ongoing therapeutic intervention post discharge from hospital. Liaison with the TCC Coordinator is an essential element of the planning process to ensure services are tailored to meet specific client needs and for continuity of care post discharge.

“I have always found the referral process and communication with the TCC Coordinator to be very positive, timely, responsive and flexible; therefore assisting to ensure open communication with the hospital based allied health team, services targeted to client requirements and timely discharge planning.”

Liz Higham | Senior Social Worker Social Work | Hollywood Private Hospital

“Assessing people in hospital for TCC helps to maintain good communication between TCC and the hospital ward. Having the TCC Coordinator visit the patient in hospital makes the ward more aware of the TCC program, and therefore and makes them more understanding and accountable in the discharge planning process.

“Communication flows well between TCC coordinators and the social workers at the hospital because of their availability via telephone, mobile and email. We all appreciate the timely response from TCC because it allows us to make plans for patients very quickly - for example, when we think that TCC may be an option for the patient you are able to quickly give us an idea of when package may be available for them and we can then determine if that works within our timeframe for discharge.

“You also always contact us to let us know if this timeframe for package availability changes- for example, we may be looking at discharge sooner than a TCC package would be available, and you then let us know if a client then comes off TCC sooner than expected. TCC works well for patients that have been in an inpatient rehab environment because they have had thorough and ongoing assessment and intervention from OT and physiotherapy, and TCC continues the rehabilitation process in the community.”

Consumer Directed Care

• Impact on Transition Care

• Benefit to clients after TCC

• Increased options for clients

Working with clients to maximise their outcomes

Goals and life after TCC

Case Study

Mrs P

74yo female, previously independent with all Personal Activities of Daily

Living (PADL’s), enjoyed walking and Tai Chi

Left CVA resulting in significant right sided weakness (Oct 2014)

Objective Measures

Bed mobility – 1 x assist and bed rail

Transfers – 1 max assist or standing hoist

Ambulation - unable

Physical Mobility Scale= 35/45

Goals

Short term

• Independent bed mobility

• Transfer without standing hoist

Long term

• Walk

• Achieve safe car transfers and access local community

• Kitchen tasks

• Re-commence Tai Chi

Intervention

One session a week with Physio, two sessions a week with Therapy Assistant and home exercise programme assisted by husband

By the end of TCC, Mrs P was able to:

• Transfer with 1 x standby assist

• Walk ~ 5m with quad stick and 1 x standby assist

Options for ongoing allied health intervention

• Community exercises classes

• Outpatient therapy

• HACC

• Enhanced Care Plan (EPC)through GP

• Day therapy

• Consumer Directed Care (CDC) - Level 3, 4 package

Pros and Cons

Pro’s Cons

Day Therapy

• Continue with rehab • Social

• Difficulty accessing due to transport limitations

• Location

Outpatient therapy • Stroke specific intervention • Difficulty accessing due to transport limitations

HACC • Continue with rehab • Not available if receiving High Care Package

EPC • Continue with rehab • Limited to 5 visits a year

Community exercise class

• Exercise therapy • Social

• Difficulty accessing due to transport limitations

Allied Health through CDC Level 4 package

• Continuity of care • MDT – tailor made to suit client

specific goals

• Limitations due tofunding

Best fit for Mrs P

Needs:

• Assistance with showers

• Respite

• Ongoing Allied Health intervention

Outcome

CDC Level 4 Package

• Includes Physio, OT and multi-skilled Therapy Assistant

• Mrs P chose to have Personal Care only 5 days a week , in order to

utilize funds for increased therapy

Work towards attending Stroke specific Outpatient therapy and recommencing modified version of Tai chi, Physio Chi

Goals recap

• Independent bed mobility

• Transfer without standing hoist

• Walk – has begun using quad stick and 1 x standby assist, able to walk 5m

• Achieve safe car transfers and access local community

• Kitchen tasks

Intervention

1 x Physio and 1 x Therapy Assistant visit a week

Increase strength, mobility and balance

Transfer and walking practice

Functional retraining and working towards Mrs P’s own personal goals

Refer to OT for:

Wheelchair assessment and prescription

Bathroom and kitchen assessment / intervention

Achievements after four weeks

Mrs P is now able to:

• walk 10m with wheeled zimmer frame and supervision

• transfer in / out of car with supervision

• has commenced kitchen tasks such as chopping veggies etc.

Achievements after 4 weeks cont…

Mrs P:

• Has also purchased a new wheelchair, so is able to access local

community with much greater ease

• Has used CDC funding to purchase equipment such as rails,

perching stool, chopping board and saving up for further

bathroom modifications

• Is working towards attending Outpatient therapy and Physio Chi

Conclusion

• Goals are priority

• Many options available

• Evaluate all needs to ensure client is provided with holistic care to

achieve best outcome

• Ever changing – flexibility is key

Job Satisfaction

Community Support Workers Deb

“I love the goal setting and progress that comes with Transition care. It is extremely rewarding to see the clients get better and return to as much independence as possible. On a more personal level I love the opportunities to work more closely than you do in mainstream care with the clinical team and the physios and OT’s. I am constantly learning something new.”

Faye “The work itself and the people I get to work with. To see them get most if not all of their independence back. Love the diversity of role - also helping in the office.”

Karen “What I enjoy about my job is the variation of tasks involved and seeing most of the clients improve with time during the TCC period knowing I have contributed to that. I also like being part of a team and working together towards the same goal.”

Job Satisfaction Jacqui Gloyne -Physiotherapist

“I enjoy working with TCC clients on a number of levels. My main motivation is that we are supporting people be the best they can be in their own environment again. With out this a lot of our clients would not be as independent or be able to live in the community. To help someone over come this hurdle is personally very rewarding.

“I enjoy the variety of the work and especially like that one day is never the same as the next. Each client is unique in how an ailment effects them. The way in which you approach that a solution will be something that you have done before but is a challenge as it’s always implemented in a different way. I like that I have to ‘think on my feet’.”

Cont……

Recovery unique to a person essentially begins at home. This is where we see their character, lifestyle and environment as opposed to the more “one size fits all” hospital setting. Working with someone at home allows a very holistic functional approach, which I believe is part of the fundamentals of best health care. Helping someone to achieve goals to make a life easier and more enjoyable is a “win –win” situation on both sides.

Working within a great team means that I come to work each day knowing that we all have a role to play, but can have an outcome that is greater than all of it’s individual parts. I especially like some of the combined assessments I do along side my colleagues because of this. Blending ideas really benefits the client and professionally rewarding.

Client Satisfaction

Interview with Mrs P – our case study

• The transition from hospital back home on Transition Care was excellent.

• With correct equipment and services in place immediately

• The shower assistance and respite made life much easier for me and my husband

• Physiotherapist and Occupational Therapist did such a good job getting movement back into my arms and legs

• Moving onto the high care package was so smooth and I am really benefiting from the ongoing rehabilitation

Mrs G

BACKGROUND: Mrs G is a 80-year-old lady who lives alone and was extremely independent driving/volunteering/making daily welfare phone calls to other elderly people that live alone. She was receiving HACC domestic assistance and gardening. Diagnosed with CVA right hand side weakness and speech loss after CVA.

ON DISCHARGE FROM HOSPITAL: ambulating slowly with a quad stick, suffered verbal dyspraxia. Her speech was severely dysfluent, effortful and characterised by incomplete words and multiple restarts.

MBI – 84

Outcome

• Increased confidence can now walk inside without aids and outside with a walking stick

• Mrs G’s conversational speech now has periods of normal fluency, approximately every third phrase. There is less effort and struggle. She works on her program 3 times a day.

• Returned to HACC services

• Referred to ongoing therapeutic services as still potential to improve

• MBI 95

Therapy Assistant

Use of our Therapy Assistant for regular visits enabled Mrs G to get more out of the TCC program, she noted weekly improvements and when asked Mrs G stated that other people have noticed too. TA reported “Mrs G is motivated and diligent in her practise and this is clearly expressed in her wonderful improvements”.

Client Interview Mrs G

“Initially the transition was hard-because I wasn’t used to it. Had to get into a routine, get used to being on my own and having people coming in all the time.

“Everyone has helped me, made me comfortable with myself-received help in all areas: speech, walking, giving me back my independence.

“TCC ends shortly and Jacqui (physiotherapist) is going to refer me to Joondalup Health Campus for continued physiotherapy. Robin (Speech Therapist) said she would see about the speech side of it.

“I couldn’t find one fault with any of the staff they have all been helpful and supportive.”

Client Satisfaction

Jean and daughter Gail

“We couldn’t have organised it ourselves, we didn’t know where to start. Carol from Brightwater said ‘We’ll look after you’ and they sprang into action.”

“We found transition care a bit like having a fairy godmother,” said Gail. “Everyone is there to help you. Smiling faces every day to greet you and Carol and her team of angels for any help or advice you need.”

Positive results from positive momentum

Increased Occupancy

Reduced long-term needs 2014

Conclusion

Communication

Goals and flexibility

Job and Client Satisfaction

Continuum of care and choices

Increased Occupancy

The beauty of positive transitions