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
