|Title:||Care Awaiting Placement Program and other Transition Care Options for the Elderly|
|Document ID:||Operational Circular OP 1882/04|
|Date of issue:||Thursday, 2 December 2004|
|Status:||NO LONGER APPLICABLE|
|Description:||This Operational Circular provides information about existing transition care options including Care Awaiting Placement (CAP) for elderly people in the metropolitan area and informs health service staff of the purpose of the program, its target population, eligibility and evaluation and reporting requirements.|
|Applicable to:||All metropolitan public health service staff|
|Period of effect:||from 1 November 2004|
|Authorised by:||Ms Gail Milner, Director, Rehabilitation, Aged and Continuing Care Directorate, 09-Nov-2004|
|Print version:||View print version|
Care Awaiting Placement Program and other Transition Care Options for the Elderly
Care Awaiting Placement (CAP) has been developed to provide time limited transition care options for aged care patients who are waiting in a public hospital bed for alternative aged care services to become available.
The following guidelines have been developed to provide a standardised foundation for the operation of transition options across all Health Services in the metropolitan area. Each Health Service has site specific procedures that they follow in regard to these transition options. The aim of the guideline is to foster consistency in approach whilst enabling site specific procedures to be utilised.
A number of Transition Care options for the elderly are available in Western Australia. These include:
The primary aim of transition care options is to relocate patients who are waiting in a public hospital bed and who no longer require acute care into non-acute facilities or where possible to the patient's own home. This relocation makes available public hospital beds for other patients who require acute medical or surgical care. This transition care is provided in an environment and with a style of care conducive to the aims of optimising the patient's level of independence whilst smoothing the transition to home or to residential care.
All eligible patients and, where appropriate, their families/carers are encouraged to accept transition care options wherever possible. While the patient and their family/carer are encouraged to accept the offer of transition care they also have a right to decline that offer.
Principles and Minimum Standards
The following principles and minimum standards apply in caring for patients who are considering admission to or are admitted to a CAP service or a Transitional Care Program:
3. Residential CAP
Residential CAP is a fully state funded program designed to temporarily accommodate and care for elderly patients who are in a public hospital and are waiting for permanent residential placement (low or high).
Underlying Philosophy: To provide temporary care for elderly patients waiting for admission to a residential facility whilst allowing beds to be available in a public hospital for other patients requiring acute hospital intervention.
Access priority to CAP residential beds is dependent on bed availability and at the discretion of the Health Service CAP Coordinators.
First priority to residential CAP beds is to be given to patients from public teaching hospitals. Patients from non-teaching public hospitals are the next priority followed by those patients who are at risk of being admitted to a public hospital. In special circumstances other patients can be considered for entry into residential CAP.
Public hospital patients are eligible to access CAP residential beds outside their health region. This option, which depends on bed availability, can be considered if it is appropriate for the patient and their family and carer and is at the discretion of the Health Service CAP Coordinators.
Patient profile: The elderly patient
Target Time frame: to a maximum of 12 weeks
3.1 Role and Responsibilities
3.1.1 Transferring Health Service
It is the responsibility of the transferring Health Service to ensure that:
3.1.2 Admitting CAP Facility
It is the responsibility of the admitting CAP Service to ensure that:
4. Home Care Packages CAP
Home Care Packages (HCP) has been created through the combination of what has previously been referred to as "Home Care Packages (HCP)" and "Elderly Post Acute Services (EPAS)". HCPs are part of the CAP program and as such are fully state funded.
Underlying Philosophy: To allow the frail elderly who have been discharged from a public hospital following an episode of acute illness to return home with the assistance of support services. The service is also targeted at the frail elderly who are at risk of readmission to hospital allowing them to remain in their own home with the assistance of a support network.
The service aims to provide short-term care that is related to improving the health status and independence of the patient. The packages can provide therapy or non therapy based services and post acute care treatment services. It is not a substitute for hospital care. The service may provide a short-term alternative for patients waiting for other services, though all other care options should be explored before the package is activated.
Access priority to HCPs is dependent on the availability of a package and at the discretion of the Health Service HCP Coordinators.
First priority to HCPs is to be given to elderly patients who are ready for discharge from a public hospital. Patients who are at risk of being readmitted to a public hospital following a recent discharge are the next priority.
Public hospital patients are eligible to access HCPs from outside their health region. Often patients are admitted to hospitals outside their home area. In planning an appropriate discharge it may be more appropriate for continuity of care to consider arranging a HCP with the Health Service HCP Coordinator close to the patient's home. If the discharging Health Service provides an HCP to a client outside their region this service is able to request full cost recovery for the HCP from the appropriate Health Service. Sites are encouraged to develop arrangements between them to facilitate this process.
The elderly patient:
Target Time frame: to a maximum of 8 weeks
5. Transitional Care Programs
Transitional Care Programs are joint Commonwealth and State funded initiatives designed to provide short term flexible care options for the frail elderly at the interface of the acute/subacute and residential aged care sectors. They are goal oriented therapy/treatment-based programs that aim to reduce inappropriate extended hospital lengths of stay and reduce premature and inappropriate admission to residential aged care.
The service is provided in a residential facility and/or in a patient's home. In Western Australia, these services include the Transitional Care Service and Intermittent Care Service.
Underlying philosophy: Following an acute care episode, many frail elderly people require more time and less intense therapy and treatment than is provided in an acute hospital setting to return to a higher level of independence. Providing further recovery time in a non acute setting or in the patient's home offers the elderly patient a greater opportunity to optimise their level of independence whilst they and their family and carers make appropriate long term care arrangements.
The elderly patient
Target Time frame: up to 12 weeks residential and/or 12 weeks home based packages.
6. Evaluation and Reporting
CAP reporting is used to determine the maintenance and potential expansion of the program. They are also used to inform the longer term planning strategies especially towards supporting the increase of residential aged care beds/packages with the Australian Government.
It is expected that each site will evaluate its own CAP programs, however, as part of the program evaluation, the Rehabilitation, Aged and Continuing Care Directorate of the Department of Health (DOH) requires that each health service site reports their CAP activity.
The Department of Health requires two distinct CAP reporting mechanisms.
Weekly CAP Reporting: Patients Awaiting Residential Care
The purpose of this data is to identify on a weekly basis the number of inpatients in a public hospital bed who are ready for discharge and awaiting residential care. Each site collects and reports on individual patients waiting for residential placement, reporting client data as at each Wednesday to the Rehabilitation, Aged and Continuing Care Directorate. This provides a snapshot of new and existing patients waiting, the level of care they require and discharge destination. A reporting proforma (Appendix 1) with instructions is provided.
This reporting can also provide information about how long a person might wait in hospital before they are accommodated either in a CAP facility or in a permanent residential facility. Sites are also able to use this information to determine the throughput of patients over time.
Only inpatients who satisfy both of the following criteria are to be reported on this list.
It is also important to note:
These data are collated to give a system wide view of the number of patients waiting for permanent residential accommodation in the metropolitan public hospitals.
Quarterly CAP Reporting Summary
Each site has been provided with CAP software to assist in the financial accountability of CAP funding and to report outcome activity for HCPs and extra site specific residential CAP arrangements, separate to the primary CAP facilities.
The quarterly reports are due within 21 days of the end of each quarter. March 31st (due April 21) June 30th (due July 21) Sept 30th (due Oct 21) Dec 31st (due Jan 21) and need to be forwarded to Rehabilitation, Aged and Continuing Care Directorate either by post or e-mail to the Senior Policy Officer, CAP.
Residential CAP facilities provide weekly data to the Department of Health on the patients admitted, their level of care, length of stay and discharge destination. For full proforma details see Appendix 2. They also report an average length of stay per month which is submitted quarterly.
Transitional Care Programs are reported separately by the responsible organisation. Sites are not required to report on these services.
7. Managing Complaints
Patients and their family and carers have the right to complain and to have their complaints dealt with promptly and impartially. All Health Service sites are required to have a complaint's management process.
Complaints related to a patient's transfer to a CAP residential facility or to a HCP need to be managed by the transferring health service.
Complaints regarding the CAP residential facility need to be initially directed to the CAP facility itself and then to the transferring Health Service if the complaint cannot be resolved by the CAP facility.
Ms Gail Milner
This circular last updated: Thursday, 2 December 2004 at 12:00am