Aged Care & Rehabilitation Clinical Services Plan 2007 Ã¢Â€Â“ 2012

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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
Aged Care & Rehabilitation Clinical Service Plan 2007 - 2012RationaleAged Care Inpatient ConsultationNot all older patients need to be, or will be able tobe, under the care of AC&RS. However, to ensure themultidimensional needs of the target group are met,additional capacity to provide aged care inpatientconsultation is required.Rehabilitation Inpatient Consultation ServiceGiven the increasing prevalence of disabilityassociated with an ageing population, there will be anincreased demand for rehabilitation inpatientconsultation services. Early delivery of these servicesenhances the patient’s recovery and can assist inreducing length of stay.Dementia and Gerontology Clinical Nurse Consultants (CNCs)Dementia is increasing in prevalence with the ageingof the population. Delirium is also highly prevalent inhospitalised older people. Gerontology/DementiaCNCs will improve the responsiveness of facilities tothe needs of people with dementia and their carers inhospital, potentially decreasing length of stay.Brain Injury RehabilitationBrain Injury Rehabilitation is a state-wide serviceprovided at Liverpool Hospital. The service caters forpeople with a traumatic brain injury; and has limitedcapacity to respond to increasing demands fortertiary services for people with a non-traumatic braininjury.Page 7Recommendation17. Develop the capacity of aged care inpatientconsultation services, consistent with population growthand ageing, whilst strengthening the capacity of non-AC&RS wards to respond to the needs of older people,people with a disability and their carers18. Expand the capacity of inpatient rehabilitationconsultation services consistent with population growthand ageing19. Expand the availability of Dementia and/orGerontology CNC positions, ensuring a presence ineach facility to support inpatient management ofpeople with dementia and/or delirium20. Consistent with state-wide planning for brain injury,develop an additional 10 beds to expand the existingLiverpool Brain Injury Rehabilitation Unit, and tofacilitate provision of services for targeted people witha non-traumatic brain injury, supported by outpatientand community support services, as part of theLiverpool Hospital Stage 2 redevelopmentBurns RehabilitationConcord Hospital operates a state-wide acute burnsservice. Development of specialist burns injuryrehabilitation capabilities would enhance this serviceand facilitate alternatives to inpatient care and an21. Contingent on the outcomes of the state-wideplanning for Burns Services, establish a four bed BurnsStep Down Unit at CRGH in the style of a transitionalliving unit, supported by non-inpatient servicesassociated reduced length of stay in the acute unit.Non-Traumatic Spinal Cord Injury RehabilitationThere is increasing demand for rehabilitation servicesfor people with a non-traumatic spinal cord injury,particularly associated with the ageing of thepopulation. Local delivery of these services wouldsupport patients and carers and enhance the specialistcapacity of rehabilitation services in SSWAHS.22. Subject to the outcomes of state-wide planning forSpinal Cord Injury Services, investigate thedevelopment of a 14 bed non-traumatic spinal cordinjury/post-acute injury rehabilitation unit withinSSWAHS, supported by outpatient and non-inpatienttherapy servicesPartnership/Associated ServicesPartnership/associated services are integral to theprovision of a comprehensive care and support systemto meet the needs of AC&RS clients. AC&RS and23. AC&RS participate in the implementation of theFalls Prevention and Management Program and otherrelevant Health Promotion initiativespartner/associated services working collaboratively, 24. Establish collaborative processes to improve thewill improve the service system, in relation tocoordination and integration of Aged Care andresponsiveness, flexibility and capacity to meet ever Specialist Mental Health Services for Older People,increasing demand. Services include:particularly in the management of people with− Health Promotion;behavioural and psychological symptoms of dementia− Mental Health;25. Implement a range of initiatives to improve the− Other Sub-specialty Medicine and Surgery responsiveness of SSWAHS to the needs of oldereg. orthopaedics;people, people with a disability and their carers− Allied Health;25. Further develop and implement collaborative− Community Health;systems for responding to the allied health needs ofAC&RS clients and expand the availability of− Palliative Care;specialised allied health services across the Area− Biomedical Engineering;27. Improve the accessibility of AC&RS by delivering− Program of Appliances for Disabled People; targeted services in Community Health Centres where− Ventilator Dependent Quadriplegic Program; possible− General Practitioners; 28. Develop improved systems for end of life care ininpatient and community/residential settings, including
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Aged Care & Rehabilitation Clinical Services Plan 2007 Ã¢Â€Â“ 2012

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