Transition Care ProgramClient information and agreement

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This booklet provides important information about the Transition Care Program and explains what you can expect when you are receiving care.

It explains your rights and responsibilities and the obligations of your Transition Care service.

This booklet is also a formal agreement between you and your Transition Care service provider as required by the Aged Care Act 1997.

Your case manager is:

and may be contacted on:

If you would like to receive this publication in an accessible format please phone 03 9096 0497 using the National Relay Service 13 36 77 if required, or email commission@health.vic.gov.au

This document is available as a PDF on the internet at www.health.vic.gov.au/redesigningcare/

© Copyright, State of Victoria, Department of Health 2014

This publication is copyright, no part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968.

Authorised and published by the Victorian Government, 1 Treasury Place, Melbourne.

Except where otherwise indicated, the images in this publication show models and illustrative settings only, and do not necessarily depict actual services, facilities or recipients of services.

February 2014 (1401025)

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What is TCP? 4

Where will I receive TCP? 4

How long can I stay on the program? 4

What are the care and services available under TCP? 5

What types of services are not included? 5

What is a case manager? 6

What will I need to pay? 6

How much is the fee? 6

How are fees collected? 6

What if my care needs change? 7

What happens if I need to return to hospital during TCP? 7

What are my rights and responsibilities? 8

What quality of service can I expect? 8

Who will be provided with information about me? 9

What if I have a concern or complaint? 9-10

If you have feedback 10

Appendix: Extract of Schedule of Specified Care and Services for 11 Transition Care from the 2011 TCP Guidelines.

My care agreement 24

Contents

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What is TCP?

The Transition Care Program (TCP) provides short-term care and services for older people (or younger persons with aged related conditions) after they leave hospital. By offering low-level therapy and support it allows older people to continue their recovery out of hospital while appropriate long-term care is arranged.

To receive TCP you will need to be assessed and approved by the Aged Care Assessment Service while you are in hospital.

TCP is a joint Victorian–Commonwealth Government program established under the Aged Care Act 1997.

Where will I receive TCP?

TCP can either be provided in a bed-based care setting such as in a nursing home or in your own home. Where you receive care will depend on the type of care you need. Some people may receive care in more than one care setting (but not at the same time, for example, commence in bed based and then move to home based or vice versa) during their time on the program.

How long can I stay on the program?

TCP will start when you leave hospital. Most people will stay on the program for six to eight weeks. The maximum time you can stay on the program is 12 weeks, although in an exceptional circumstance you can be approved for an extension of up to another six weeks. Within this time your case manager will work with you to arrange suitable long-term support.

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What are the care and services available under TCP?

The type of care you receive will depend on what you need and where you receive TCP. For example, the type of help you will need if you are at home may be different from what you will need if you are in a bed-based care setting. The TCP is not a form of rehabilitation. Services may include:

• case management• nursing• domestic home care, such as cleaning

services• meal assistance• help with bathing and showering• organisation of appointments (including

transport)• social activities or diversional therapy• low-level therapy as provided by allied • health staff such as a physiotherapist • continence aids• equipment, as recommended by the

physiotherapist or occupational therapist, such as a shower chair

• in-home respite

It is unlikely you will require all of these services. Hospital and TCP staff will discuss with you what they recommend in consideration of the care goals you (or your representative) have identified, and what can be provided with the available funding. You will be involved in developing a care plan that will outline the services to be provided. Your case manager will review this plan with you regularly.

The full range of specific care and services that can be provided are listed in the national TCP guidelines. This listing is found at the end of this booklet and can be discussed at any time with your case manager.

What types of services are not included?

If you require general medical services such as pathology or radiology services or an appointment with your GP, then TCP staff can help with your appointments. The cost for these services is not covered by the TCP.

Additionally, the cost of pharmacy (prescription) medicines is not included as part of TCP and you will be required to pay for these separately. If you are at your safety net level, please let your case manager know.

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What is a case manager?

You will be allocated a member of the TCP team, known as a case manager, who will help you (and your carer or family) from the time you start on the program to when you finish. Your case manager will help you set goals for what you want to achieve.

You case manager is part of the team of health professionals who are looking after you.

Your case manager will:

• conduct the initial and ongoing assessment of your care needs

• coordinate and monitor your care plan with you

• liaise with service providers to keep them informed of changes required in your care plan

• ensure you have the opportunity to participate in decisions affecting your care

• provide information and education• act as an advocate or supporter on your

behalf if needed• provide emotional support to you and

your carer• develop a discharge plan with you to make

sure the support and services you need are in place when you are discharged.

What will I need to pay?

TCP receives funding from the Victorian and Australian governments, which covers most of the cost of the program; however, you are also asked to pay a fee to contribute to the cost of your care.

TCP is not covered by private health insurance.

Department of Veterans’ Affairs (DVA) recipients are not exempt from the fees unless you were a prisoner of war (PoW).

How much is the fee?

The maximum fee is determined by the Australian Government and is calculated as follows:

• home-based clients – daily rate of 17.5 per cent of current single aged pension

• bed-based clients – daily rate of 85 per cent of current single aged pension

If you are unable to pay the fee, please discuss this with your case manager. If applying for a fee reduction you may be asked to show proof of your income and financial situation.

You cannot be refused a service if you are unable to pay due to financial hardship.

Fees can be reviewed and discussed with your case manager at any time.

How are fees collected?

You will be provided with information about how to pay your fees. Usually you will receive an invoice once you begin on the program.

If you are unable to pay your fees on time please discuss this with your case manager or the TCP manager listed on page 9 of this booklet.

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What if my care needs change?

It is expected that your care needs will change while you are receiving TCP. As your health needs change you may require less or different services. This will be reviewed regularly with your case manager (or care team).

If your care and service needs increase significantly, your case manager will discuss with you whether TCP can provide the care you need. Your case manager will also speak with the people involved in your care to work out how TCP can best assist you. This may include changing from TCP at home to TCP in a bed-based care setting.

If TCP is no longer able to meet your care needs, TCP will finish and your case manager will work with you to make alternative arrangements. These arrangements will be confirmed in writing.

What happens if I need to return to hospital during TCP?

If you are only going to be in hospital for a day or overnight then you can return to TCP when you are discharged from hospital.

If you require a longer hospital stay then your TCP will end.

If you need to return to TCP then the hospital will check whether there is a place available and whether you require re-assessment by the Aged Care Assessment Service.

If your bed-based TCP place is within a hospital setting, then the above will only apply if you need medical help that requires the support of a medical ward.

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What are my rights and responsibilities?

When you are receiving TCP you have the right to:

• be treated as an individual, with dignity and respect

• be supported in decision-making processes and have someone to speak on your behalf if you wish

• information to assist you to make decisions about your care

• take part in the planning and decision making about your care

• talk freely, and in confidence, with your case manager about any aspect of your care requirements

• an interpreter and culturally appropriate services.

You also have the responsibility to:

• actively participate in achieving your care plan goals

• accept personal responsibility for your own actions and choices, even though these may involve an element of risk.

• speak to your case manager about your care needs and any changes that may be needed to your care plan

• respect the rights of the people who are employed to provide your care and treat them with the same dignity with which you wish to be treated

• provide the people who are employed to work in your home with a safe and healthy place to do their work.

(An assessment of your home will be conducted to ensure it is safe and that recommended equipment is installed according to your care needs. If there are ongoing safety concerns, it may not be possible to provide TCP in your home.)

What quality of service can I expect?

You are entitled to receive a high standard of care from TCP, as per State and Commonwealth government quality guidelines.

This will ensure that:

• care is provided by experienced and skilled staff

• the program is provided in a safe, more homely environment (where TCP is provided in a bed- based setting).

• care is provided in a timely, flexible and responsive manner

• the program is regularly reviewed to certify that it is responsive to the needs of its service recipients

• quality is an ongoing focus of TCP, including listening to feedback, reviewing any complaints and complying with the TCP Guidelines.

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Who will be provided with information about me?

Information regarding your health, care needs, and services is required to be shared with your GP, other health professionals, and relevant service providers so your care plan needs are met.

Information is also required by the Commonwealth Department of Health and Ageing and the Victorian Department of Health for funding and evaluation purposes.

When you or your guardian/administrator consent to the TCP agreement, you authorise your TCP service to provide your personal details and information about your health and the care you receive to these people and organisations.

Your personal information will be used and disclosed in accordance with relevant privacy legislation.

Your rights are protected under the:

• Aged Care Act 1997• Aged Care Principles 1997• Victorian Charter of Human Rights and

Responsibilities• Victorian Information Privacy Act 2000• Victorian Health Records Act 2001• Commonwealth Privacy Act 1988

What if I have a concern or complaint?

You have the right to make a complaint and take steps to address any concerns.

If you have a complaint or concern you have the right to:

• raise it without fear of retribution• have the matter resolved in the shortest

possible time• have an advocate of your choice appeal

to senior levels of management.

TCP works to ensure that complaints and concerns are dealt with promptly and confidentially. You are encouraged to discuss these matters with your case manager.

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If you have a complaint:

You will be provided with information about how to address your concerns.

Where possible it is always best to talk to your case manager about your complaint first. However, you may decide that your complaint should be raised with the TCP manager. In both cases your complaint will be dealt with promptly.

The TCP manager at your health service is:

Name:

Phone:

If you are unable to raise your concern with your TCP service or you are dissatisfied with the outcome of your complaint, you may wish to raise the matter with the patient advocate or liaison officer of your health service. If you are still unhappy with the outcome, an external organization may be contacted to address your concern.

In Victoria, the Health Services Commissioner is responsible for receiving and resolving complaints about health service providers. The Commissioner is also responsible for receiving and resolving complaints about TCP.

Office of the Health Services Commissioner - 1800 136 066

As TCP is a partly Commonwealth funded aged care service, you also have the right to access the Aged Care Complaints Scheme with any concerns.

Aged Care Complaints Scheme - 1800 550 552

If you require information, assistance or someone to speak on your behalf, you can contact the National Aged Care Advocacy Line. This is a free and confidential service for people receiving aged care services.

National Aged Care Advocacy Line - 1800 700 600 or if calling from a mobile, contact the Aged Care Information Line on 1800 500 853

If you have feedback:

You will be sent a client satisfaction form at the end of your program. This form gives you an opportunity to tell us about your experience of TCP. We welcome your suggestions on how we could improve the service for you and future clients.

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Schedule 1: Specified care and services for Transition Care services

The Transition Care Payment Agreement provides that the care and services listed in Schedule 1 are to be provided in a way that meets the standards set out in Schedule 2 of the Agreement.

The following lists of care and services are not intended to be exhaustive or to limit the range of care and services provided. They indicate the basic level of care that Transition Care Service Providers must be able to provide, if required by a recipient of Transition Care, for receipt of flexible care subsidy for that recipient. The use of telehealth and telecare devices should be considered where medically indicated and appropriate to the care recipient’s goals. The availability and adoption of this equipment may be subject to adequate infrastructure to support the transmission of data and images.

Note: The current Schedule 1: Specified care and services for Transition Care services under existing Transition Care Payment Agreements will continue to apply until replaced by a Variation to the Payment Agreements which includes the Schedule 1 below.

Part 1 Care and services that must be provided, when required, to Transition Care recipients in a residential setting

Service Content

1.1 Maintenance of all buildings and grounds

Adequately maintained buildings and grounds.

1.2 Accommodation Utilities such as electricity and water.

1.3 Furnishings Bed-side lockers, chairs with arms, containers for personal laundry, dining, lounge and recreational furnishings, draw screens (for shared rooms), resident wardrobe space, towel rails, over-bed tables.

1.4 Bedding materials Beds and mattresses, bed rails, bed linen, blankets and absorbent or waterproof sheeting, incontinence sheets, restrainers, ripple mattresses, sheepskins, tri-pillows, and water and air mattresses appropriate to each resident’s condition.

1.5 Cleaning services, goods and facilities

Cleanliness and tidiness of the entire service.

Excludes: a resident’s personal area if the resident chooses and is able to maintain it himself or herself.

Appendix: Extract from the 2011 TCP Guidelines, pages 68-75

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Service Content

1.6 General laundry Heavy laundry facilities and services, and personal laundry services, including laundering of clothing that can be machine washed.

Excludes: cleaning of clothing requiring dry cleaning or another special cleaning process, and personal laundry if a resident chooses and is able to do this himself or herself.

1.7 Toiletry goods Bath towels, face washers, soap and toilet paper, sanitary pads, tissues, toothpaste, denture cleaning preparations, shampoo and conditioner, and talcum powder.

1.8 Meals and refreshments

Preparing nutritious meals that are culturally appropriate and of adequate variety, quality and quantity for each resident, served each day at times generally acceptable to both residents and management, and generally consisting of 3 meals per day plus morning tea, afternoon tea and supper. Special dietary requirements, having regard to either medical need or religious or cultural observance.

Food should include fruit of adequate variety, quality and quantity, and non-alcoholic beverages, including fruit juice. Assisting care recipients in eating meals.

For care recipients requiring enteral feeding in residential based Transition Care, the Transition Care Service Provider is responsible for providing the enteral feeding formula at no extra cost to the care recipient. See also 3.3 of this Schedule regarding the provision, care and maintenance of tubes for enteral feeding.

1.9 Emergency assistance

At least one responsible person is continuously on call in the facility in which Transition Care is delivered to provide emergency assistance. In a medical emergency, which requires immediate action, appropriate medical assistance must be sought, e.g. by dialling 000.

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Service Content

1.10 Treatments and procedures with respect to ongoing medical management

Treatments and procedures that are carried out according to the instructions of a health professional, such as a GP or a person responsible for assessing a resident’s personal care needs, or undertaken according to the resident’s wishes, including supervision and physical assistance with taking medications, and ordering and reordering medications, subject to requirements of state and territory law.

It is expected that the provision of primary medical care to a Transition Care recipient would be undertaken by a GP.

If the care recipient is a permanent resident of a residential aged care facility, then the care recipient may be eligible for the relevant Chronic Disease Management (CDM) items and associated individual allied health items in the Medicare Benefits Schedule (MBS). If the care recipient is not a permanent resident of a residential aged care facility, then the care recipient may be eligible for the community setting CDM items.

Where GPs are asked to provide different medical services or a higher volume of services than specified in the MBS requirements, then funding of these additional services should occur through the Transition Care Program.

For the purpose of monitoring the care recipient’s health status, telehealth and telecare devices may be used where medically indicated and appropriate to the care recipient’s goals.

1.11 Assistance in obtaining health practitioner services

Arrangements for aural, community health, dental and oral health, medical, psychiatric, optometry and other health professionals to visit residents whether the arrangements are made by residents, relatives or other persons representing the interests of resident’s, or are made direct with the practitioner.

1.12 Goods to assist residents to move themselves

Crutches, quadruped walkers, walking frames, walking sticks, wheelchairs and off-the-shelf aids to assist with upper limb function, should be available as required for the duration of a care recipient’s stay.

Excludes: motorised wheelchairs and custom-made aids.

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Service Content

1.13 Goods to assist staff to move residents

Medical devices for lifting residents, stretchers, trolleys should be provided as required for the duration of a care recipient’s stay.

1.14 Goods to assist with toileting and incontinence management

Includes the provision as required of absorbent aids, commode chairs, disposable bed pans and urinal covers, disposable pads, over toilet chairs, shower chairs, urodomes, catheter and urinary drainage appliances, and disposable enemas.

1.15 Basic medical and pharmaceutical supplies and equipment

Includes analgesia, anti-nausea agents, bandages, creams, dressings, laxatives and aperients, mouthwashes, ointments, saline, skin emollients, swabs, urinary alkalising agents, and anti-diarrheals.

Excludes any goods prescribed by a health practitioner for a particular resident and used only by the resident. In this case, the medication would be covered, as is normal, under the Pharmaceutical Benefits Scheme (PBS).

1.16 Medications Medications subject to requirements of state or territory law.

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Part 2 Care and services that must be provided, when required, to Transition Care recipients in a community setting

Service Content

2.1 Bedding materials Provision of absorbent or waterproof sheeting, incontinence sheets.

2.2 General laundry Assistance with laundry.

2.3 Meals and refreshments

Arrange, where required, transport to help a person shop.

Assistance with nutrition, hydration and preparing and eating meals. The definition of preparing and eating meals assumes that the care recipient is responsible for providing and paying for the food, including enteral feeding formula, if required. See also 3.3 of this Schedule regarding the provision, care and maintenance of tubes for enteral feeding.

However, where Meals on Wheels is required, it is important that the payment arrangements for Meals on Wheels services are clearly described in the care recipient agreement between the service provider and the care recipient. While the Transition Care Service Provider would facilitate access to Meals on Wheels, the cost of the Meals on Wheels would be borne by the care recipient.

Assistance with special dietary requirements, having regard to either medical need or religious or cultural observance.

2.4 Emergency assistance

Having at least one responsible person or agency, approved by the organisation providing the community care, in close proximity and continuously on call to give emergency assistance when needed.

For example, this could be through a personal alert system or a phone number to a mobile or land line which is staffed 24 hours per day.

In a medical emergency, which requires immediate action, appropriate medical assistance must be sought, e.g. by dialling 000.

Each Transition Care Service Provider must develop a protocol for emergency situations and this protocol must be reflected in the service provider’s policies and procedures.

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Service Content

2.5 After hours assistance

As part of each care recipient’s care plan, the service provider must manage the risk of the care recipient requiring after hours assistance. The possible risk factors for each care recipient should be identified and management strategies implemented for these risk factors.

Where the need for after hours assistance has been identified, there should be 24 hour on call access to at least one responsible person or agency in reasonable proximity who is familiar with the care plan and who has given consent to be included in the care plan as contact. The responsible person may be a relative, friend or neighbour who is located close to the care recipient and who will organise after hours assistance or emergency assistance when required. The service provider may also have their own staff on call (i.e. from a nearby aged care service) to go to the care recipient’s home after hours. Should the care recipient not nominate a person as a contact, the Transition Care Service Provider must provide the after hours assistance.

If the care recipient requires 24 hour on call assistance and access to an emergency call system, this must be provided. If a care recipient requires access to an emergency call system on a long-term basis, the care recipient should be given the option of having an emergency call system of their choice installed at their own cost.

2.6 Home help Assistance with home help including domestic assistance. This includes assistance with cleaning or the provision of cleaning services, goods and facilities, if required.

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Service Content

2.7 Home maintenance and functional safety

Home maintenance reasonably required to maintain the home and garden in a condition of functional safety and provide an adequate level of security.

Efforts to ensure functional safety must also include identifying and addressing any Occupational Health and Safety issues that might have an adverse affect on care staff working in the home.

If a care recipient requires home modifications, such as the installation of grab rails, hand rails and ramps to enable the care recipient to continue living at home, service providers, in their role as case manager, should confirm eligibility of the care recipient for home modification services provided under the Home and Community Care (HACC) or Veterans’ Home Care Programs and availability of the required home modifications through these Programs. For care recipients who are not eligible for services under these Programs, the service provider may ask the care recipient to make a contribution to the home modification.

As a follow-up, the prescribing therapist should liaise with the care recipient after the Transition Care episode to ensure that the care recipient’s functional needs have been met once the home modifications are complete or the necessary equipment has been supplied. The follow-up by the relevant therapist could be a home visit or a phone assessment, depending on what type of home modification has been undertaken and the needs of the care recipient.

2.8 Treatments and procedures with respect to ongoing medical management

Control and administration of medication prescribed by a medical practitioner, subject to legal restrictions on providing the medication.

Administration of treatment such as eye drops, pressure care, dressings and urine tests, subject to legal restrictions on providing treatment.

Telehealth and telecare devices may be used where medically indicated and available for monitoring the care recipient’s health status, especially for those who live in rural, remote and outer metropolitan areas.

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Service Content

2.9 Assistance in obtaining health practitioner services

Transport to help a care recipient visit a medical practitioner or assistance in arranging a home visit by a medical practitioner.

2.10 Goods to assist residents to move themselves

Service providers may need equipment to assist in the provision of Transition Care services and meet care recipients’ needs (eg. a wheelchair for assistance with mobility or a personal alert system to provide on-call emergency assistance). Transition Care Service Providers using Australian Government subsidies may purchase such equipment and, where appropriate, this equipment may be loaned temporarily to individual care recipients.

When purchasing equipment for the service, ownership of the equipment vests with the service provider. Any equipment loaned to individual care recipients should be returned to the provider at the conclusion of the Transition Care episode, for use by other care recipients. It is important to note that the provider is purchasing the equipment for use in service provision.

If a care recipient requires aids and equipment on an ongoing basis, service providers should, in their role as case manager, seek equipment from such places as state/territory government equipment schemes or equipment loan services. For care recipients who are not eligible for services under these Programs and the required services are not available, the service provider may ask the care recipient to make a contribution to the purchase of the required equipment.

2.11 Goods to assist with toileting and incontinence management

The provision of continence aids as required without additional charge to the care recipient.

2.12 Other Other services required to maintain the person at home as agreed with the care recipient.

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Part 3 Common care and services that must be provided, when required, to all Transition Care recipients

Service Content

3.1 Administration and care planning

General operation of the Transition Care service, including care recipient documentation and care planning and management. When an older person is in a Transition Care service, initial and ongoing assessment, planning and management of care will be undertaken by appropriately qualified and trained staff members or others (including external practitioners) with expertise in geriatric and/or therapeutic management, with the involvement of the care recipient (or his or her representative), and his or her carer, where appropriate.

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Service Content

3.2 Case management The Transition Care Service Provider should ensure that appropriate case management is available to recipients of Transition Care, to coordinate and monitor all aspects of their care and their movement from hospital, through Transition Care and back into the community or to their normal care arrangements, and act as a central point of contact for everyone involved in the care of the recipient.

This will include:

• ensuring that a comprehensive care plan is available at the time of discharge from hospital;

• ensuring that all aspects of the care plan are carried out, monitoring progress against the care plan goals and adjusting the plan where necessary;

• identifying any changes to a recipient’s care needs that occur during Transition Care and arranging for appropriate adjustments to the services provided;

• liaising with and organising all care requirements provided by external service providers (including GPs and specialists); and

• arranging for appropriate care, if required, following Transition Care or managing the return of the recipient to the community or their normal care arrangements.

Throughout the time spent in Transition Care and with respect to any subsequent arrangements, the case management role includes ensuring that the individual lifestyle choices of the care recipient are taken into account and that everything possible is done to enable social contact between the care recipient and their family and friends.

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Service Content

3.3 Specialised clinical services

Clinical care provided as part of the Transition Care Program, where required, is to be carried out by a registered nurse, or under the direct or indirect supervision of a registered nurse or other professional appropriate to the service delivery and in accordance with professional standards and guidelines. These services may include, but are not limited to, the following:

• assessment for pain and a plan implemented to keep the care recipient as free from pain as possible;

• provision and care and maintenance of tubes, including enteral feeding, naso-gastric and tracheostomy tubes etc;

• establishment, review and maintenance of urinary catheter care and/or stoma care program;

• complex wound management;• enema administration or insertion of suppositories;• suctioning of airways and tracheostomy care;• oxygen therapy requiring ongoing supervision because of

a care recipient’s variable need, including the provision of oxygen and oxygen equipment at no additional cost to the care recipient;

• appropriate medication management; • appropriate nursing services;• taking appropriate action to prevent falls among care

recipients; • on-call access to specialist nursing services, if required; and• specialised swallowing management.

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Service Content

3.4 Therapy services The therapeutic care to be delivered through the Transition Care Program includes low intensity therapy such as physiotherapy, occupational therapy, podiatry, dietetics1, speech pathology, counselling and social work to maintain and improve physical and cognitive functioning and to facilitate improved capacity in activities of daily living. This care is to be provided by appropriately qualified and trained staff or consultants and in accordance with any levels of care specified under the recipient’s care plan, developed as specified in section 3.1.

Recreational activities and diversional therapy are provided that are suited to the care recipient, including lifestyle and general exercise programs. Participation in the activities is encouraged and access to recreational equipment facilitated.

Psychological or counselling services may also be required to provide emotional support and to assist care recipients deal with their psychological and emotional states as they experience changes to their circumstances and confront alterations to their dependency levels, their normal accommodation etc. For example, this may be the case where, following a period in hospital followed by Transition Care, a care recipient requires a higher level of ongoing care than previously.

A key component of the Transition Care Program is the therapeutic services that care recipients can receive. These services are not a substitute for the subacute care delivered through the hospital sector. Hence eligibility for Transition Care includes an ACAT assessment that concludes that, where appropriate, a care recipient has already received hospital based subacute rehabilitation care and/or geriatric evaluation and management where necessary (or will have received it prior to discharge).

The therapy services do not include acupuncture and as such, the cost of the provision of acupuncture is not covered by the Transition Care Program.

1 Day to day diabetes education and management forms part of ‘dietetics’ and is to be undertaken by a qualified diabetes educator who oversees and manages diabetes therapy where clinically appropriate, according to the client’s care needs and care plan .

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Service Content

3.5 Daily living activities assistance

Personal assistance, including individual attention, individual supervision and physical assistance with:

• bathing, showering, personal hygiene and grooming; • maintaining continence or managing incontinence, and

using aids and appliances designed to assist continence management;

• eating and eating aids, and using eating utensils and eating aids (including actual feeding if necessary);

• dressing, undressing and using dressing aids; • moving, walking, wheelchair use and using devices and

appliances designed to aid mobility, including the fitting of artificial limbs and other personal mobility aids; and

• communication, including to address difficulties arising from impaired hearing, sight or speech, or lack of common language (including the fitting of sensory communication aids).

3.6 Social activities Arranging social programs and activities or providing / coordinating transport to socialisation activities/functions at a reasonable frequency. Encouraging Transition Care recipients to take part in social activities. Providing other services that help to prevent social isolation and promote and protect the dignity and well-being of recipients.

3.7 Religious and cultural activities

Provide support to the care recipient in accessing religious and cultural activities.

3.8 Advocacy Advocacy services to help protect the care recipient’s interests.

3.9 Support Support services to maintain personal affairs.

3.10 Waste disposal Safe disposal of organic and inorganic waste material.

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COPY FOR TCP CLIENT HEALTH SERVICE CLIENT FILE HEALTH SERVICE FINANCE DEPARTMENT

TCP Care agreement between the Care Recipient (listed below) and

(TCP service)

1. I, (Care Recipient)

(i) acknowledge that I have read or had explained to me the contents of this TCP information (which includes relevant attachments from the TCP Guidelines) and agreement

agree to receive TCP at Home / Bed based care setting

(ii) authorise TCP to provide my personal details and information about my health and the care I receive under TCP to the Department of Social Services and the Department of Health for funding and evaluation purposes

(iii) authorise TCP staff to discuss my health, care and service needs with my GP, other health professionals, service providers and the following additional persons:

(iv) understand that I will receive a written care plan and discharge plan that details all the services to be provided to me under TCP and the date they start. These plans form part of this agreement. They will be amended over time as necessary and I can also request a review of the plans at any time

(v) understand that TCP is a time-limited program and that my case manager will actively assist me to access long-term care arrangements to best suit my needs

(vi) understand that this agreement can be reviewed at any time and changed with mutual consent. I will be notified in writing of any change.

Signature Verbal Consent (Witnessed by) Date

This agreement is to be signed by the care recipient. In some circumstances an authorised individual may sign on the care recipient’s behalf. If written consent is not practicable to obtain, verbal consent is acceptable, but must be witnessed. Should this be the case, please complete the following:

Why was the care recipient unable to sign?

Name of person who did sign:

Relationship to the TCP care recipient (such as spouse, person responsible)

2. Care Fee – I agree to pay a fee of $ per from the day I start TCP until I am discharged. I understand this fee can be reviewed if requested.

Signature Verbal Consent (Witnessed by) Date

This agreement to pay fees is to be signed by the care recipient or a person acting on their behalf who will be responsible for the receipt and payment of invoices. If written consent is not practicable to obtain, verbal consent is acceptable, but must be witnessed. Should this be the case, please complete the following:

Why was the care recipient unable to sign?

Name of person who did sign:

Relationship to the TCP care recipient (such as spouse, Power of Attorney)

Signed on behalf of Transition Care Program by:

Signature Name Date

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