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

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Aged Care & Rehabilitation Clinical Service Plan 2007 - 20125. SERVICE DELIVERY MODELSSWAHS residents have access to a range of acute and sub-acute AC&RS inpatient services,supported by various outpatient and community services provided by SSWAHS and other externalorganisations. A summary of all AC&R services is included in Appendix 4.Across SSWAHS, services differ in relation to the model of care utilised, staffing structures andprofiles, and availability and equity of access to services. These differences stem from historicalfactors such as SSWAHS formerly operating as two separate area health services, variation inclinical stream structure, availability of external funding to develop particular service types, ability toattract and retain staff, and structure of the local service system external to SSWAHS.To guide the development and delivery of AC&RS into the future and to ensure equity of serviceaccess across the Area, it is necessary to define and implement a consistent service model acrossSSWAHS. The service model recognises that current and future AC&RS clients are distributedacross SSWAHS in large numbers. This means that there is a need for a distribution of servicesacross the Area to ensure equity of access for all residents of SSWAHS.Figure 5.1SSWAHS Aged Care and Rehabilitation Service Delivery ModelPARTNERSHIP / ASSOCIATED SERVICESCommunity Care ProvidersSUPRA REGIONAL SERVICESOutpatient and Support ServicesResidentialAge d CareFacilitiesCommunity / Non Inpatient* preventive* early intervention* post acutecare* maintenance* supportCORE SERVICESC LIEN T /CARERGeneralPractitionersInpatient Services* acute* subacute,* transitional living unitsInpatient ServicesOther Sydney South West Area Health Serviceeg. Community Health,Mental Health,Allied HealthJanuary 2008The AC&R Service Delivery Model incorporates three key aspects:• Core services – services which are provided by AC&RS to targeted clients and whichneed to be available consistently and equitably across the whole Area;Page 30
Aged Care & Rehabilitation Clinical Service Plan 2007 - 2012• Supra-regional services – specialised services catering for a small number of people withspecific health needs. Such specialised services are to be concentrated on one site tofacilitate access to specialist expertise and equipment;• Partnership/Associated services – services providing extensive assistance to AC&RSclients and/or are operated cooperatively between AC&RS and other clinical services.This includes services provided by the non-government sector, such as community andresidential care.A service delivery system comprising core, supra-regional and partnership/associated servicesworking collaboratively, will ensure that a high quality, safe and comprehensive system of care isprovided to all AC&RS clients, at different stages within the lifecycle and disease progression.These services operate along a care continuum from community/residential care, the interfacebetween community and acute services, post-acute services and community/residential care (referFigure 5.2). Services are categorised as:• Community/Non-Inpatient Services – with a focus on prevention of illness, deteriorationand hospital admission; early intervention; post acute care; maintenance or support; and• Inpatient Services – provided in the inpatient setting – be it acute or sub-acute.As clients access AC&RS through multiple entry points along the continuum of care, this is anillustrative delineation only. AC&RS are delivered seamlessly to clients, and at a local level, servicemanagement is well integrated. Thus, a client may move between aged care and rehabilitationservices and other partnership/associated services, throughout their course of treatment.Implementation of the Service Delivery Model will be dependent on a range of factors. However,priority should be given to ensuring that the core services are available as outlined in this Plan.Supra-regional and partnership/associated services are also integral to the whole model of care. Ifthis model is implemented, clients will have timely access to appropriate services and there will bean associated reduction in unnecessary reliance on the acute setting, through implementation ofpreventative care models, early intervention systems and post discharge support.5.1 Core ServicesCore services are essential, evidence based services which should be provided across the Area toservice local catchments. It is proposed that these services be consolidated in facilities which haveadequate and appropriate back-up support, and in which the critical mass necessary to provide aquality service can be obtained. The Core Service Delivery Model is discussed in detail in Section 6.Extensive literature outlines the benefits of core evidence based services, including reducedmortality, improved function and cognition, reduction in adverse events, improved quality of life, andgains in efficiency such as a reduction in hospitalisation, length of stay and health care costs.A range of professionals (including medical, nursing and allied health staff) provide these services incommunity, residential and acute settings. They are designed to be complementary with stronglinkages between the various service settings, to ensure continuity of care, regardless of the serviceprovider. Table 5.1 lists core services according to service category.Table 5.1 Core SSWAHS AC&RS by Service CategoryService Category Service TypeCommunity / • Centralised intakeNon-Inpatient • Aged Care Assessment Teams (ACAT)(preventative, earlyintervention, post• Agedcare Services in Emergency Teams(ASET)acute care,• Outpatient Clinics – Geriatric andmaintenance and Rehabilitationsupport)• Day Hospitals and Outpatient TherapyPage 31• ComPacks• Transitional Aged Care Program• Community Dementia Teams• Centre Based Day Care• Dementia Advisory Services• Respite and Support Services• Home Based TherapyInpatient Services • Acute, Sub-Acute Aged Care & Rehabilitation Units (including dementia/delirium units)• Inpatient Geriatric/Dementia Consultation• Inpatient Rehabilitation Consultation• Dementia and Gerontology Clinical Nurse ConsultantsCore services operate within a continuum of care represented in the figure following.
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Aged Care & Rehabilitation Clinical Services Plan 2007 Ã¢Â€Â“ 2012

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