Project SPLICE - Taranaki District Health Board

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Project SPLICE FINAL - February 2010 Case, there are core functions that require management and coordination that occur at a central level. Whether these activities are grouped across the region or are kept within Taranaki is a subsequent discussion. The Model of Care presented here outlines the approach and this can be configured either as a standalone unit within Taranaki DHB or in partnership with the other Midlands DHBs (Waikato, Tairawhiti and Lakes). Care referral and coordination will focus on five pertinent functions for older people and those with long term conditions: Table 3: Referral and Coordination functionality Function 6 Description 1. Triage Referrals for older people referred for disability support 2. Short term care assessment & coordination: 3. Non-complex assessment 4. Non-complex coordination 5. Administration and interface with national payment systems Access point for clients requiring District Nursing and short term home care Of older people (or like age and interest) using the interRAI Contact tool, via telephone 7 by health professional assessors. Figure 2 illustrates the criteria for categorisation of disability support, using Levels I through to V 8 . Older people assessed within Levels I to III will be managed through the non-complex assessors within Care referral and coordination service and older people assessed as Levels IV or V will be passed to the care clusters for assessment by the care managers using the interRAI MDS-HC. Of older people (or like age and interest) assessed as requiring support (i.e. Home Care) through the interRAI Contact Assessment. For all older people 9 (or like age and interest) receiving disability support services (HBSS, Carer Support or ARC). The administration function will manage provider allocations, payment systems and databases. 6 7 8 9 There are several other services that would lend themselves to inclusion in such an access point such as allied health and disease specific services. However, given the Midland Business Case developments, it is prudent to await the decisions around this proposal prior to investing heavily in further consolidation In those instances when a telephone based assessment is inappropriate, such as when the older person has a hearing loss, or when a face to face assessment is a more culturally appropriate option, the client will be passed to the care manager based within the clusters. This leveling system has been developed from the IN-TOUCH programme, a partnership between ten DHBs, Nurse Maude and The University of Auckland and is discrete from the Support Needs Level and interRAI Contact Acuity Scale. It is currently in operation in Multiple DHBs. Whether non-complex, assessed through the interRAI Contact assessment through the care referral and coordination service or complex assessed using the MDS-HC by the Care Cluster based Care Managers. 22 | P a g e
Project SPLICE FINAL - February 2010 Supporting Allocations Tool (To be used in conjunction with the interRAI Contact assessment tool) Does client require assistance or have difficulty in ANY of the following: Mobility, showering/bathing, dressing, medication management or have some level of cognitive impairment? No Yes Is client assessed as being: socially isolated and requires assistance with shopping? Does client require assistance or have difficulty with ANY of the following: Dressing, medication management and/or has cognitive impairment and/or the carer is reporting significant burden and stress (brittle social support) No Yes No Yes Does the client require assistance with ordinary housework (e.g. cleaning, changing linen, vacuuming)? Continue with goal facilitation process and development of goal ladder using interRAI contact assessment by telephone based assessors Continue assessment using goal facilitation tool using interRAI contact assessment by telephone based assessors Pass through to cluster and assessment to be undertaken using MDS-HC and goal facilitation tool Sign off required by Team Leader prior to commencing package Yes No Yes No Service (Consider alternative community services as required) Allocate care package according to Level II criteria with an automatic discharge at four months unless indicated otherwise through provider three month review Allocate care package according to Level III criteria with an automatic discharge at 12 months unless indicated otherwise through provider three month review Allocate care package according to Level IV criteria with an automatic discharge at 12 months unless indicated otherwise through provider three month review No Does package (including carer support) value less than $XXX per week? No Does total PoC (including carer support) exceed $XXX per week? Medicine (GP or geriatrician) Yes Decision on Level V package allocation, service input or placement in residential care * Case Conference (within 3 months of allocation) Sign off required by DHB Planning & Funding and allocate intermediary (3 month) package according to Level V criteria Care Manager Ax Physio Ax O.T. Ax Figure 2: Assessment process for disability support services (HBSS and ARC) 23 | P a g e
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Project SPLICE - Taranaki District Health Board

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