TRANSFER OF

CARE CONFERENCE

It’s Not a Bed Problem…It’s a Service Delivery Opportunity

The Changing Health & Wellness

Market

Existing Model of Health

UC-Ageing

DGP

ISLHD

PrimaryHealth

Network

UC-AgeingInspire 1 & 2

ISLHD

Emerging Health & Wellness Market

A dynamic evolving process

Rate of growth of the older population, in absolute terms and relative to the total

population, 1962–63 to 2042–43http://www.health.gov.au/internet/main/publishing.nsf/Content/E0CC456146A997ACCA257494007D9B55/$File/chapter5.pdf

Aged Care – HHH = $200

Crossover of resources

ISLHD & Aged Care BedsCompare Costs / Purchasing Power

= $1200

The Changing Face

of Aged Care

Consumer Directed Care

UnitingCare

Managing a Single Residential & Hospital Bed Base

Illawarra & UnitingCare Bed

Management Strategies

Canterbury Model - NZ

Yesteryear

Yesterday

TodaySchematic Concept Adams & Marsh

Adaptation De Ruyter 2005 revised

2014 Artist G Searle

Uniting Care

Creating a Future

UnitingCare

UnitingCare a Snapshot

ISLHD

ISLHD Snapshot

• The Illawarra Shoalhaven Local Health District is one of the largest employers in our region with a workforce of more than 6,800 staff.

• Nursing staff 47%

• Medical staff 16%

• Allied Health Professionals 7%

• Other 30%

• A total of 1.7% of the ISLHD workforce identifies as Aboriginal or Torres Strait Islander.

Aged Care Health & Wellness supported by

Illawarra

Resident/s

Specialised Care

Clinical, Allied

ACAT & other

referral services

Other

Providers

Medicare Local

(Primary Health Net)

Aged Care

General Care

Clinical, Allied

Diversional

Labour Supply &

Applied Research

Education

UOW & TAFE

The Deteriorating Resident

S - Seems different than usual

T - Talks or communicates less

O - Overall needs more help

P - Pain – new or worsening; Participated less in activities

a - Ate less

n - No bowel movement in three days; or diarrhoea

d - Drank less

W - Weight change

A - Agitated or nervous more than usual

T - Tired, weak, confused or drowsy

C - Change in skin colour or condition

H - Help with walking, transferring, toileting more than usual

Stop & Watch

Residential Aged Care Clinical Advice Line(Integrated Care Partnership with Aged Care Facility (RACF Model)

Resident

Unwell

(Stop & Watch)

Is this an acute

medical

Emergency?

Dial 000 if

appropriateRefer to UC Ageing South Guidelines

(Deteriorating Resident refer to RN)

Problem

Resolved

Additional

Support

Required?

Resident is

managed in RACF

with care of GP

Notify GP

GP

Available?

Resident

receives care in

RACF

Be Prepared…Questions that will be asked:

• Has the GP been contacted?

• Is there an advanced care directive?

• Has the resident been reviewed by

a senior clinician at Elanora?

• What is the residents current condition?

i.e. heart rate, temp, BP Resps rate etc…?

• What is the residents normal physical &

• Cognitive status?

• Has the residents family been contacted?

Contact Illawarra

Residential Aged Care Clinical

Advice Line (M) 0477743538(Operating from Wollongong Hospital)

Plan formulated after ConsultationOption 1:- resident reviewed by GP

Option 2:- Resident offered Rapid Assessment Clinic appointment at

Wollongong or Bulli Geriatric Outpatient Clinic within 24hrs.

Option 3:- resident reviewed in RACF by Aged Care CNC & Geriatric

Advanced Trainee utilising Telehealth within 48 hrs

Option 4:- resident attends the Emergency Dept.

Yes Yes

No

Yes

Yes

Yes

No

No

Ref:- Illawarra Shoalhaven Local Health District August 2014 Amended UC Ageing Elanora Ver1

No

Is this an acute

medical

Emergency?

Acute Emergency response is guided by the Advanced Care

Directive which can inform as to the level of intervention whilst taking into account the

wishes of the Resident .

Example 1

Example 2: Signs of Stroke F.A.S.T.

http://strokefoundation.com.au/what-is-a-stroke/signs-of-stroke/

Call the RN on Duty to assist and review urgently

Refer to UC Ageing South Guidelines

(Deteriorating Resident must be referred to RN)

http://team.unitingcare.local/sites/RHCSSouth/Care%20Forms/Forms/AllItems.aspx

Escalation of

change in

observations is

through the use of

green, amber and

red as a traffic

Light.

Notify GP

Resident

receives care in

RACF

Appropriate care provided specific to this episode

Ensure:-

• Family contacted and followed up with a case conference

Recorded in i-Care:-

• Check documentation reflects Guardianship and up to date

contacts

• Advanced care directive completed up to date and

communicated to appropriate people (Utilise End of Life

Care Pathway) http://team.unitingcare.local/sites/RHCSSouth/Care%20Forms/End%20of%20Life

%20Care%20Pathway%20(EoLCP).pdf

• Ensure all assessments are undertaken

• Amend Care Plan to reflect changes in care needs

• Involve ACFI team.

Resident is managed

in RACF with care of

GP

ED Alternative Data

Total - (service commenced July 2013)

- 256 rapid access geriatric assessments

- 27 next day clinic appointment

- 174 teleconsultation in RACF

- 13 direct admissions, bypassing ED

- 42 RACCAL calls

YTD March 2015

Total - 37 rapid access geriatric assessments

- 5 next day clinic appointment

- 25 teleconsultation in RACF

- 1 direct admission, bypassing ED

- 6 RACCAL calls

Strategic planCommunity Partnerships

Accountability

through clear

reporting lines

Infrastructure

MeasurementEstablish KPI Reports

ImprovementThrough systems changes

Communication1. Committees

2. Meetings

3. Newsletters / Media

4. Project Champions

Training & Development

Alignment

Stakeholders

Governance

Redefining Aged Care & Health Services

Through Community Partnerships

Ref; 2007 Raj Behal MD, MPH Raj_Behal@Rush.edu

21

The Future

The solution is simple;

Use the ‘delegations”

we have within our

respective positions

whilst networking

solutions across

organisations. This is

the key to creating

sustainable and just

communities.