|Title:||Transition Care for the Older Person|
|Document ID:||Operational Directive OD 0290/10|
|Date of issue:||Tuesday, 6 July 2010|
|Description:||Guidelines developed to provide a standardised foundation for the operation of Transition Care for the older person across all hospitals in the metropolitan area. Amendment proposes the central TCP coordinators manage waitlists to ensure a more effective patient flow and to assist in providing clearer lines of communication between health services and transition care providers.|
|Applicable to:||For all metropolitan public hospitals/health services in Western Australia, especially staff of Aged Care Assessment Teams, social workers and staff involved in discharge planning.|
|Framework:||Clinical Services Planning and Programs Policy Framework|
|Period of effect:||from 1 August 2012 to 31 July 2017|
|Review date:||31 July 2017|
|Authorised by:||Kim Snowball, Director General, Department of Health WA, 27-Jul-2012|
|Print version:||View print version|
Transition Care for the Older Person
The following guidelines have been developed to provide a standardised foundation for the operation of Transition Care for the older person (>65 years) across all hospitals in the metropolitan area. Each hospital has site specific procedures that they follow in regard to Transition Care. The aim of the guideline is to foster consistency in approach whilst enabling site specific procedures to be utilised.
The primary aim of Transition Care is to relocate the older person who is waiting in a public hospital bed and who no longer requires acute or subacute care by discharging them into non-hospital care or where possible to the patient’s own home. This relocation makes available public hospital beds for other patients who require acute medical/surgical or subacute care. Transition Care/Option 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.
In 2007, the Australian Government made a commitment to provide an additional 2000 Transition Care places nationally over the next four years. The new Transition Care Program (TCP) offer WA Health the opportunity to convert Care Awaiting Placement (CAP) beds to Transition Care flexible places, providing funding for therapy and allied health. This model moves from a purely maintenance model (CAP) to an enabling and therapeutic model of care.
All eligible patients and where appropriate, their families/carers are encouraged to accept Transition Care. They also have a right to decline that offer.
3. Accessing Transition Care
From 01 April 2010, all patients in metropolitan hospitals who have been Aged Care Assessment Team approved, have a completed Aged Care Client Record and ARE medically ready for discharge will be classified under one title, Aged Care Services.
Aged Care Services is the umbrella term for the following:
Principles and Minimum Standards
The following principles and minimum standards apply in caring for patients who are eligible for Aged Care Services:
4. Transition Care
Transition Care includes the fully State Government funded program (currently known as CAP) and the joint Australian and State Government funded initiative (currently known as TCP).
Transition Care provides short term flexible care options for the frail older person at the interface of the acute/subacute and residential aged care sectors. Transition Care is a goal oriented therapy/treatment-based program that aims 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.
Following an acute care episode, many frail older 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.
Transition Care will deliver temporary care for those older patients waiting for admission to Aged Care Services, providing further recovery time in a non-acute setting or in the patient’s home which offers the older patient a greater opportunity to optimise their level of independence whilst they and their family and carers make appropriate long term care arrangements.
Access priority to Transition Care, residential places and/or community places is dependent on availability and at the discretion of the Transition Care CENTRAL Coordinator.
First priority - metropolitan Transition Care referrals in the following order:
Admission to all metropolitan Transition Care facilities will be allocated to a central waitlist managed by senior clinical representatives from North Metropolitan Area Health Service (NMAHS) and South Metropolitan Area Health Service (SMAHS).
Patient profile: The elderly patient:
As Transition Care is a through-put model of care, consideration is also given to any potential barriers to discharge to a permanent place. The following actions are a guide to what is required prior to the Transition Care referral/application being considered for those patients who are on the permanent residential aged care pathway.
a. Residential Aged Care uncomplicated referral – where the older person does not have any complex issues:
b. Residential Aged Care complicated referral – where the older person does have complex issues that are likely to be barriers to discharge from Transition Care and consequently increase length of stay:
For the older person who requires Guardianship and/or Administration orders from the State Administrative Tribunal (SAT), the following action is required prior to the Transition Care referral/application being considered:
The following action is required prior to the Transition Care referral/application being considered for those patients who are on a direct pathway to home.
c. Home not requiring permanent residential care referral – where the older person does not have or require an approval for permanent residential aged care:
d. Home including approval for permanent residential referral – where the older person does have an approval for permanent residential aged care:
Target Time frame: Up to 12 weeks.
Those clients admitted to Transition Care, the joint Australian and State Government funded initiative have a possible ONE extension of six (6) weeks available per Transition Care episode with further Aged Care Assessment Team approval.
4.1 Role and Responsibilities
4.1.1 Transferring Hospital
It is the responsibility of the transferring hospital to ensure that:
4.1.2. Admitting Transition Care Facility
It is the responsibility of the admitting Transition Care service provider to ensure that:
5. Evaluation and Reporting
Reporting is used to determine the maintenance and potential expansion of the program. It is 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 Transition Care program; however, as part of the program evaluation, the Aged Care Policy Directorate of the Department of Health requires each hospital to report their Transition Care activity (ie. all those patients medically ready for discharge to Transition Care).
6. Weekly Reporting: Patients Awaiting Aged Care Services
The Department of Health requires the following reporting.
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 Aged Care Services (Permanent residential care - low or high; Flexible care - EACHD; EACH, Transition Care; and Community care – CACP).
Each site collects and reports on individual patients waiting for Aged Care Services, reporting client data as at each Wednesday to the Department of Health, Aged Care Policy Directorate. This provides a snapshot of new and existing patients waiting, the level of care they require and discharge destination. Refer Appendix 1 for reporting instructions and proforma.
This reporting can also provide information about how long a person might wait in a hospital before they are accommodated either in a Transition Care facility, permanent residential care and/or at home. Sites are also able to use this information to determine the throughput of patients over time.
Only inpatients that satisfy both of the following criteria are to be reported on this list.
It is important to note:
The data is collated to give a system wide view of the number of patients in metropolitan public hospitals waiting for Transition Care.
7. Managing Complaints
Care recipients, their family and carers have the right to complain and to have their complaints dealt with promptly and impartially. All hospitals are required to have a complaint’s management process.
Complaints related to a patient’s stay in hospital or to their transfer to a Transition Care facility need to be managed by the transferring hospital.
Complaints regarding Transition Care, residential and/or community need to be initially directed to the Transition Care service provider. If care recipients cannot resolve their dispute with the service provider then the state complaints bodies should be the first point of call; the Department of Health (Aged Care Policy Directorate) as the Transition Care approved provider and/or the Office of Health Review.
Unsatisfied complainants still retain the right to lodge a complaint with the Australian Government Aged Care Investigation Scheme operated by the Department of Health and Ageing.
This circular last updated: Friday, 10 August 2012 at 10:46am