Carol Bartlett, Brightwater Care Group - The Benefits of Seamless Transition Care
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Transcript of Carol Bartlett, Brightwater Care Group - The Benefits of Seamless Transition Care
The Benefits of Seamless Transition Care
A Case Study or Two
Outline
• Seamless Care – What does this mean?
• Brightwater Care Group - our services
• Demonstrate how the Brightwater “Model” supports
seamless care for transition clients through “A case
study or two”
Seamless Care – What is it?
• Seamless care represents the smooth and safe transition of a person through a health system. To be achieved the person’s care must be delivered consistently and without interruption
Brightwater Care Group
• Brightwater was established 110 years ago in Perth
Western Australia, as a not for profit, non-denominational organisation
• Brightwater provides care to over 2000 people and has a staff of over 2100
Brightwater Care Group continued
• Brightwater currently has 23 modern facilities located across the Perth metropolitan area • 13 of these facilities provide accommodation for older
people including 59 Transition Care beds • Two facilities are dedicated to people living with
Huntington’s Disease • The remaining 8 facilities provide a range of
rehabilitation and residential accommodation for younger people with disabilities
Brightwater Care Group continued
Other key services include: • Brightwater At Home Services provides assistance to over
800 clients • Seatec, is a specialist seating and equipment service • An over 55s community (Kingsway Court), commercial
linen and catering businesses that services our own facilities and other organisations such as hotels, mine sites and hospitals in WA
Brightwater Transition Care
Brightwater commenced Transition Care services in 2010
• 44 beds at Brightwater Kingsley
• 15 beds at Brightwater Birralee
• 20 TCC packages
Kingsley
• 66 bed residential aged care facility with 1 dementia specific secure house
• 7 houses single rooms with ensuites, 2 shared rooms
• 5 and 1/2 houses designated to TC
Birralee
• 60 bed residential aged care facility non-dementia specific
• 4 houses with 15 residents. Single rooms with ensuites
• 1 house designated to TC
Brightwater Transition Care Community has 20 Packages
Providing Seamless Care – What We Found Works and a Few Challenges
Transition Care Model
TCP Residential
• TCP Admission’s Coordinator
• TCP Coordinator
TC Community
• TCC Coordinator
Organisational Wide
• Dedicated Admission’s Team
• Monthly Internal Transfer meetings
Transition Care Team (Residential)
AH Team
Nursing
Medical
Care Workers TCP Admissions
CoordinatorCM Kingsley CM Birralee
Medical
Care WorkersNursing
AH Team
TCP
Coordinator
Service Manager
Transition Care Team (Community)
AH TeamNursing
Clients GP
Support
Workers
Transition Care
Community
Coordinator
Service Manager
Systems & Processes
TCP Admission’s Coordinator
• Registered Nurse
• Liaises daily with hospital TCP Coordinator for referrals and discharges
• Triages referrals in discussion with facility teams
• Decisions to admit based on clinical and social needs of client and facility acuity. Will visit in hospital if ? Referral.
• Prior to admission arranges equipment, pharmacy and speaks with hospital nurse for handover
• On day of admission contacts family, meets and greets, provides client with the TCP information pack and emails client summary to TCP staff
TCP Coordinator
• Social Worker
• Arranges family meeting and captures client goal/s
• Social Worker Summary
• Chairs the weekly multidisciplinary team meetings with Geriatrician
• Case manages guardianship applications, liaises with providers (both community packages and residential)
• Attends internal transfer meetings
Clinical Team
• Nursing and Allied Health complete assessments and care plan embedding resident goal/s
• Nurse assesses client competency for self administration of medications
• OT conduct home visits
• Therapy Assistant staff undertake regular therapy interventions under the direction of the therapists and care workers provide care under the guidance of a nurse
Other Things That Work
• House Team Leaders (coordinate care, arrange for follow up external appointments)
• Communication: Group email distribution list
• Regular contact with the BW TCC team
• Attendance at the Internal Transfer meeting
• TCP Team meeting minutes template (team member report on progress against client goal/s)
Birralee TCP team meeting minutes 23/05/2013
1 Name: MJ Pathway:
RESTORATIVE
Admitted: 14/05/13 12 wks 06/08/13 ACAT
Low
PMHx Hypercholesterolemia. # R Ankle, HTN Hearing loss
SERVICES Silver Chain Fortnightly
CLIENT
GOAL
To return home once functioning returns
MINUTES PT: Plaster now dry, non weight bearing, R leg using gutter frame. Ongoing PT
OT: Is socializing, will conduct home visit next Tuesday
SW: Family meeting today, confirms home preference have agreed to referral to BW TCC
Nursing: Skin intact is on daily clexane injection.
2 Name: DM Pathway:
RESTORATIVE
Admitted: 11/04/13 12 wks 04/07/13 ACAT
Low
PMHx #C7, 6TIR Shoulder Replacement 2013, Chronic back pain, Frequent Falls #NOF High Cholesterol OP GORD Anxiety
SERVICES Mercy care, referral made to TCC
CLIENT
GOAL
Return home with services when can ambulate up to 100m and manage meals and drinks
MINUTES PT: independent with walking and can walk up to 30m. Cont with strength and endurance exercise
OT: working with TA’s in meal preparation. Pain is impacting at this point. Home visit when well enough.
SW: Maintaining contact with BW TCC
Nursing: Halo has come off, is now in a semi soft collar, has been assessed for pain and commenced regular meds, has started
steroids for mouth ulcers.
Community Processes
• Process managed throughout by the TCC • Within a day of referral visits client in hospital or
residential TCP to assess and meet with family. • Clinical Nurse and Allied Health arranged to conduct
clinical assessments as required • Distributes a summary of needs to TCC team • TCC team meet 1/14 to discuss progress • Plans discharge with equipment, home meals, ongoing
package as required
Key Challenges
• Communication Communication Communication
• Backfilling key internal staff
• Maintaining strong relationships with multiple hospitals
Case Study - Rose
• Admitted from hospital to TCP following fall resulting in subarachnoid hemorrhage
• STM loss, word finding difficulties, requires supervision ADLs and transferring, ambulates frame up to 50m
• Previous living at home with no services • Family support available. Rose wishes to
discharge home however family concerned about her returning home
• Discharge plan – home with TCC and follow up package
0
20
40
60
80
100
Dec-11
Jan-12
MBIAdmission
MBIDischarge
Case Study - Steve
• Admitted from hospital to TCP following hernia repair
• Hx Parkinson’s Disease with severe dyskinesia
• 67Kg, ambulates frame, Hx over self medicating
• Doubly incontinent, assistance ADLs
• Previous living at home with Brightwater EACH
• Support 1 elderly friend, sister interstate
• Discharge plan – home
0
20
40
60
80
100
Jun-12
Jul-12
Aug-12
MBIAdmission
MBIDischarge
Summary
Key criteria to successful seamless care are:
• The “right” model of care
• Strong systems and processes
• A focus on communication and ;
• Ongoing evaluation and review to identify areas for improvement