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