Aged Care & Rehabilitation Clinical Services Plan 2007 – 2012

Aged Care & Rehabilitation Clinical Service Plan 2007 - 2012RationaleAs improvements in functioning occur, recipients can betransferred to alternative services.ComPacksComPacks provides short term, low level, post acutesupport to patients discharged from acute carehospitals. The availability of ComPacks has beenshown to reduce length of stay.Transitional Aged Care ProgramThe Transitional Aged Care Program (TACP) is jointlyfunded by the Australian and NSW Governments toJune 2008, pending evaluation. It provides shortterm, post acute support and therapy to facilitatefunctional improvement and reduce or delayresidential placement. It facilitates timely dischargeof patients who are medically stable, but require acoordinated program of services for a short term toregain independence.Community Dementia TeamsCommunity Dementia Teams is a new model which hasbeen proposed to assist the Area to respond better tothe increasing incidence and prevalence of dementiaassociated with population ageing. The teams willaddress early, the health and behavioural needs ofpeople with dementia and their carers, with a view toproviding sustained support and reducing avoidablehospital admissions/reducing lengths of stay.Centre Based Day CareCentre Based Day Care (CBDC) provides low levelsupport for older people and respite for carers. Thistype of service is now predominantly funded throughthe HACC program and largely provided by the nongovernmentsector in NSW. There is a need forSSWAHS to review how CBDC services are providedacross the Area and to develop a focus on providingspecialised rather than generalist services.Dementia Advisory ServicesDementia Advisory Services (DAS) play a key role insupporting people with dementia and their carersthrough both direct support and service development.This complementary service is funded by DADHC.Respite and Support ServicesFunding for the range of respite and support servicesprovided by SSWAHS is usually not recurrent, butbased on short/medium term agreements. Theancillary nature of these services and the lack ofcomprehensive availability across SSWAHS, raisequestions about the role of SSWAHS in the provisionof these services.Inpatient Beds – Acute and Sub-Acute Aged Care and RehabilitationDemand for AC&RS inpatient beds, both acute andsub acute, will increase in response to populationgrowth and ageing. In particular the increasingprevalence of dementia (and associated long lengthsof stay) and the impact of falls will be considerable.Additional inpatient capacity is required to respond tothis demand.Recommendation8. As funding permits, expand ComPacks servicesacross the Area, consistent with population growth anddemand9. Monitor Transitional Aged Care Program activity todetermine the most appropriate client mix and servicestructures for ongoing program management10. Pilot two Community Dementia Teams in SSWAHS(at Concord and Liverpool) staffed by RegisteredNurses and Clinical Psychologists, linked with ACAT andthe Specialist Mental Health Service for Older People11. Undertake a comprehensive review of CentreBased Day Care in SSWAHS, including governance,operations, funding, staffing, policies, procedures, clientmix, opportunities for expansion and clinical servicedelivery12. Seek additional HACC funding through DADHC toextend the capacity of the existing Dementia AdvisoryServices and their capacity to service culturally diversecommunities13. Review the role of SSWAHS in the provision ofexternally funded respite and support services14. As funding permits, expand the bed capacity ofAC&RS through the creation of additional units and/orthe colocation of outlier patients to improve inpatientmanagement15. Review issues associated with after hours medicalcoverage at sub-acute/stand alone facilities todetermine appropriate service and staffing models16. Investigate the feasibility of developing specialistinpatient bed capacity, such as transitional living unitsand specialist units for younger people with a disabilityPage 6