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

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Aged Care & Rehabilitation Clinical Service Plan 2007 - 2012SSWAHS AGED CARE AND REHABILITATION SERVICE PRINCIPLES The majority of AC&RS clients can live independently within the community with varying degreesof support. AC&RS will support people in a variety of settings including hospitals, workplaces,community settings, or at home, in order to facilitate their independence. AC&RS clients and their families/carers have the right to choose what care and support theyreceive and who should be involved in the delivery of these services. Health treatment and care is respectful and recognizes the privacy of clients as well as theirindividual differences and specific needs, such as cultural, religious and sexual differences. AC&RS recognize that clients have complex needs. AC&RS will offer holistic treatment andsupport, recognizing that the needs of clients may not be solely related to their physical health,but also their social, emotional and economic circumstances. AC&RS clients and their families/carers are often long term clients of the service, who undergomany changes during their interaction with AC&RS. These changes occur in a variety ofsettings. Service consistency and reliability supports the patient journey through the lifespanand through individual episodes. AC&RS are based on strong evidence and have a focus on maintaining, improving andpreventing deterioration in the health and quality of life of clients. Quality and safety isparamount to the delivery of all services. To enable smooth transition of clients between services provided by different organizations or indifferent settings, AC&RS health and support services will be well integrated and coordinated,with strong communication systems implemented to support clients and their families/carers. A range of hospital and community based AC&RS will be available locally to support localpopulations. These services will be delivered using a multidisciplinary model of comprehensiveassessment and management and be easily accessible to the community and other careproviders, with streamlined intake processes to reduce duplication of referral and assessment. Preventing hospital admission is a basic philosophy of AC&RS. However, inpatient services willcontinue to be available for clients who require specialist care in a hospital setting. Earlydischarge planning will occur to ensure that AC&RS patients are not hospitalized forunnecessary periods. AC&RS will work in partnership with clients and families/carers, other relevant clinical andsupport services in SSWAHS, and external stakeholders to improve services for clients. Information on AC&RS will be readily available through a variety of mediums to facilitate accessto services and ongoing support. Carers are an integral component of the overall AC&RS system. Respect for all carers, alongwith specific services and supports for carers, is essential to the ongoing maintenance ofAC&RS.Source:Adapted from AHMAC 2004 and the Framework for the Integrated Support and Management of Older People in the NSWHealth System. Original detail is contained in Appendix 1.1.4 The Planning ProcessThe process involved in the development of this Plan has been extensive, over a two year period2005 – 2007. It commenced in early 2005, as part of the process of developing the draft SSWAHSHealthcare Services Plan. Planning involved workshops with clinicians, management andcommunity representatives, to identify issues and develop the desired future model of care.Considerable work has also been undertaken in the planning of AC&RS in the Liverpool HospitalStage 2 redevelopment.Since the initial development work was undertaken, consultation and development has continued tooccur. This includes the preparation of SSWAHS Self-Assessment reports under the Framework forPage 12
Aged Care & Rehabilitation Clinical Service Plan 2007 - 2012the Integrated Support and Management of Older People in the NSW Health System 2004 – 2006;and the Older Persons and Aged Care Services Clinical Redesign Project.Further development of demand management strategies consistent with NSW Health policy hasoccurred, including initiatives such as the Acute Care Triage and the Medical Acute Care Unit(MACU).Overall development of this Plan has been overseen by a Steering Committee of Dr John Cullen,Clinical Director General, Geriatric and Rehabilitation Medicine (EZ), Dr David Conforti, DirectorAged Care (WZ), Dr Friedbert Kohler, Director Rehabilitation (WZ), Ms Julie-Ann O’Keeffe, SeniorService Manager GGRM (EZ), Ms Debra Donnelly, Nurse Coordinator GGRM (EZ), and Ms AdeleLubiana, A/Service Development Manager Aged Care (WZ). Appendix 2 lists other contributors.Page 13
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