Osborne Park Hospital Rehabilitation and Aged Care

Report
Osborne Park Hospital
Rehabilitation and Aged Care
Aged Care Assessment Team
October 2007
ACAT Presentation 2007
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OBJECTIVES OF ACAT PROGRAM
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Assess the care needs of the frail older
person (observing equitable access issues )
ensure assessments are comprehensive,
incorporating the restorative, physical,
medical, psychological, cultural and social
dimensions of care
assist the older person to gain access to the
types of services most appropriate to meet
their care needs
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Aged Care Act 1997
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ACAT is underpinned by the Aged Care
Act 1997 and associated principles.
The Act and the Principles include the
aged care planning process, approved
service providers responsibilities and
types of services they can provide,
subsidy criteria, and processes for
ACAT teams
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OPH ACAT Team
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Boundary - Wembley Downs to Two Rocks and
across to Ballajura
Referrals to ACAT only - 1200 - 1600 + a month
ACAT Team composition - Head of Dept - Dr Barry
Vieira, Consultant Physicians, Aged Care Home
Visiting Nurses, Social Workers - Snr ACAT Social
Worker/ ACAT Coordinator, Occupational Therapists
and other allied health staff as required
Location - OPH F Block, 2 teams have mtg at JHC on
a weekly basis
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H AC C ser vices
R espite
C AC Ps
Low C ar e
EAC H /EAC H D
R esidential C ar e
Incr easi ng C om plexi ty of C are N eeds
Infor m al C ar e
F ig u re 3: S ervic e s Ag a in s t In c re a sin g C o m p le x ity o f C a re N e e d s
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Aged Care Services (requiring ACAT
approval)
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CACP’s - Community Aged Care
Packages. Individually planned and
coordinated packages of care tailored to
help older people remain living in their
own homes.
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Aged Care Services (requiring ACAT
approval)
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EACH - Extended Aged Care at Home.
Individually planned and coordinated
packages of care tailored to meet the
needs of a person who requires high
level care at home.
EACHD - as above however specialise
in care of dementia particularly for those
with behaviours of concern.
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Aged Care Services (requiring ACAT
approval)
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TCS - Transitional Care Service
(Residential/Community). Provides the
opportunity and resources for older
people discharged from a hospital
episode to improve their physical
functioning, mobility and to regain their
daily living skills. (limited to 12 weeks)
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Residential Aged Care Services
Residential Care is for people who,
without the care and support offered in
a facility, would be unable to maintain a
satisfactory standard of personal care,
health, nutrition and/or social well-being.
ACAT approval is required.
Low level care (hostel) - provides support
and supervision not 24 hr nursing care.
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Residential Aged Care Services
continued
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High level care (nursing home)- is for
residents that require intense 24 hr
nursing services
Dementia Specific - can be low or high
care provided in a secure environment.
These cater particularly for those with
dementia that display challenging type
behaviours eg wandering, aggression
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Residential and Respite Services
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Extra Services - an additional service
available at selected facilities where
extra services are provided at an
additional cost to the client eg foxtel,
chef choice meals, wine etc
Respite care - may be used for carer
relief on a planned, regular or
emergency basis to assist carers.
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Respite Services continued
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Types of Respite :
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Residential respite
In- home respite
Day centre
Emergency respite
• Commonwealth Care Respite Centre
– Ph 1800 059 059
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Other Aged Care Services
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Short term post - acute services - PEP
(personal enablement program), HCP
(Home Care Packages)
Care Awaiting Placement
Independent Living Units/Retirement
Villages etc
Commonwealth Carelink Centres • Ph 1800 052 222
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Other Aged Care Services
HACC - Home and Community Care.
HACC services provide a range of basic maintenance
and support services for frail older people, people
with disabilities and their carers. Services include:
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domestic assistance
home modifications and maintenance
personal care (usually limited to 3 visits per week)
community nursing (includes medication prompts - requires a
medical authority)
• food services (eg meals on wheels or frozen delivered meals)
• transport (eg subsidised taxi fares program or community bus)
• referral can be made directly eg self referral
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Other Aged Care Services
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VHC - Veterans Home Care. Funded by
Dept of Veterans Affairs specifically for
Veterans (Gold/White Card holders)
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How to Refer
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GP referral is preferred method of
referral
Consult request form
Recent audit of referrals
Provide as much information as
possible
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What happens next?
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ACAT clerk process referrals and
creates a file(or adds to pre-existing file)
Consultant Physician (on a roster basis)
review files and allocate to required
program or discipline base on
information provided in referral
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How is an ACAT assessment completed?
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Home Visit - completion of Standardised Assessment
form and ACCR (Aged Care Client Record)
Client must give signed permission for the ACAT
assessment
Multi-disciplinary focus
Weekly team meetings
Involvement of family/carers
Feedback to GP (letter/verbal)
MDS ie data collection
Case example
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Rehabilitation and Aged Care Service at OPH
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Inpatient (including Stroke unit)
Day Hospital
Parkinson’s clinic
ACAT
MEU (Memory Evaluation Unit)
Falls clinic
HCP (Home Care Packages)
CAP (Care Awaiting Placement)
RAILS
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Rehabilitation and Aged Care
Intervention Liaison Service (RAILS)
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RAILS provides a rapid response,
flexible service with ready access to a
multidisciplinary team - who conduct
comprehensive care planning and home
visits.
Same day service
Team consists of SW, RN, OT and
Physio
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Contact details
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ACAT Team • Fax: 9346 8232
• Ph: 9346 8111 (ACAT clerk)
• Ph: 9346 8449 (general query)
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RAILS Team
• Fax: 9346 8232
• Ph: 9346 8315
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