Aged Care & Rehabilitation Clinical Services Plan 2007 – 2012

Aged Care & Rehabilitation Clinical Service Plan 2007 - 2012• Service equity – different generalist and specialist clinic services are available across the Area,subject to historical service development;• Interpreters – in some language groups and at particular times, there is unmet demand forinterpreter services;• Transport – many AC&RS clients identify difficulties in accessing hospital based services.Appropriate parking, including disabled parking and safe drop-off spots are required for clientsusing private transport. Organised transport to and from geriatric clinics facilitates access andimproves safety;• Physical capacity – AC&RS clients are usually accompanied by carers and/or family membersand often have mobility aids to assist them in the activities of daily living. Clinic space mustinclude sufficient room to accommodate these needs; and• Data collection and management – there is a need for standardised data collection andmanagement across outpatient services, to assist in service performance management andmonitoring. Such a system must recognise the variability in funding sources and reportingrequirements. Improving these systems will allow clinical staff to have a greater focus on thedelivery of clinical services.Projected Future ActivityIf equity of service provision across the Area is to be achieved, and services are able to meet theneeds the target group, additional medical, nursing and allied health staff, as well as administrativesupport will be required.Future Model of CareOutpatient clinics will continue to be a core service within AC&RS, with a focus on early identificationand treatment of illness or functional decline, to prevent avoidable hospitalisation and/or prematureadmission to residential aged care, as well as post-acute care, support and maintenance. Patientsmay be referred to these clinics by their General Practitioner, ASET/ED based services, ACAT, orinpatient unit.These clinics will complement other services within the service model. They will be client focussed,offering ‘whole of patient’ care, where appropriate in a multidisciplinary model.The range and scope of clinics at each facility should be based on local demand and the localservice system, including access to medical or other expertise. An aged care/geriatrics clinic shouldbe available at all sites with an aged care medical presence. Highly specialised services should beavailable across the Area, particularly memory, falls and balance and continence clinics. Some ofthese clinics will need to be linked with other services, such as the Specialist Mental Health Servicefor Older People. A rehabilitation clinic should be available at all sites with a rehabilitation medicalpresence, and highly specialised services should be available at central locations. These areconsidered in Section 8.Recommendation – Outpatient ClinicsOutpatient geriatric clinics are established at Camden and Bowral Hospitals by 2010 and alloutpatient clinics are expanded across the Area in line with population growth and ageing6.1.5 Day Hospitals and Outpatient TherapyDay hospital and/or outpatient therapy services are provided at RPAH, CRGH, Liverpool, Braesideand Camden Hospitals. Service recipients may be under the management of either a Geriatrician orRehabilitation Specialist, or both.Day Hospital services provide a mix of medical, nursing and allied health interventions to assist olderpeople to improve functional outcomes, reduce the need for hospitalization and achieve earlierdischarge from hospital. The service is usually associated with the provision of a range of therapiesover the course of up to 4 hours, which provides opportunities for socialization and a shared meal.Transport to and from the day hospital is also provided.Beyond these basic services, there is a specialised diabetes and pulmonary rehabilitation service(Canterbury Hospital), a specialised amputee rehabilitation service (Liverpool and RPAH/Balmain), aHACC funded Community Rehabilitation and Physical Disability Team (Camden Hospital), andExtended Care Services (via Bankstown-Lidcombe and Bowral Hospitals).Page 41