“Weed if you Must”Keith’s Journey

Northern Sydney Transitional Aged Care Program (TACP)

(TRANSPAC NS) Community

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• Born in Eastwood in June 1928.• Graduated in Civil Engineering from Sydney

University in 1949.• Following graduation first worked with a firm of

consulting engineers.• Appointed in 1952 to a Lectureship in Civil

Engineering at the NSW University of Technology (now The University of New South Wales) where he taught and researched in the field of water resources until his retirement.

• Active member of St. Matthew’s Anglican Church, West Pennant Hills

• Keith and his late wife Bonny of 13 years were married in 1951 and moved in 1953 into their home in Beecroft where Keith is still living.

Kingsford WatsonDr Keith Kingsford Watson

Keith’s Story- What happened? • Hospital admission following a fall from a ladder whilst tree trimming,

13/12/2018.

• Fractures: Rib fractures x 16 with haemopneumothorax with flail segment/ Pneumonia/ Right collar bone fractured in 3 places with nerves affected in shoulder/ T1-T11 transverse process fractures/ lung contusion/ Haematoma on throat/ fractured metacarpal bone in left hand.

• PMHx: COPD/ CVA (2016) right sided weakness / Gait instability/ IHD/ PPM (2017) CABG x3 (2008)/ HT/ GORD/ OA/ LBP/ right femoral endarterctomy stent (2016)/ lymphedema right leg (2018) Prostate cancer.

• SHx: lives alone / supportive family/ reports previously independent.

• Lengthy admission: Sydney Adventist Hospital (SAN) 5 days in ICU/Acute ward: 4 weeks immobile to mobilising with a 4 wheeled walker then transitioned to the SAN rehabilitation ward for 3 weeks.

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is Transitional Care?

• A program jointly funded by NSW Health and the Commonwealth

• Aims to optimise the functioning and independence of an older person after a hospital stay

• Time limited: 12 week program • Goal orientated • Therapy focused • Brokered Model of Care• Community: 90 packages/ Residential: 18 packages• Transition Care Program Guidelines (Sept 2019)

TRANSITIONAL

AGED CARE

PROGRAM

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is the program for?

• Clients who reside in: Ryde, Hornsby, Ku-ring-gai, Mosman, Hunters Hill, Lane Cove, North Sydney, Willoughby and Northern Beaches (out of area referrals considered)

• Clients Over 70yrs

• Aboriginal & Torres Strait Islanders (ATSI) clients over 50yrs

• Clients who are currently an inpatient of a private or public hospital

• ACAT (Aged Care Assessment Team) assessment required

TRANSITIONAL

AGED CARE

PROGRAM

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Goals for TRANSPAC NS program:• Primary goal: Keith wanted to return home to live independently• To increase independence with personal care activities• To transition from a 4 wheeled walking frame onto a walking stick• To be able to attend to shopping and domestic tasks independently• To return to driving• To be able to return to light gardening tasks• To maintain a healthy body weight and monitor nutritional intake• To work with a speech pathologist on voice production and exercises• To return to social groups

ACAT Assessment: 31/1/19Commenced on TRANSPAC Program: 11/2/19 to 2/5/19 (12 weeks)

QUESTION SCORING Pre TRANSPAC Program

Post TRANSPAC Program

F FATIGUEHow much of the time during the past 4 weeks did you feel tired?A=All or most of timeB=Some, a little or none of the time

A=1B=0 A=1 B=0

R RESISTANCEIn the last 4 weeks by yourself and not using aids, do you have any difficulty walking up 10 steps without resting?

Yes=1No=0 Y=1 N=0

A AMBULATIONIn the last 4 weeks by yourself and not using aids, d you have any difficulties walking 300 metres Or one block?

Yes=1No=0 Y=1 N=0

I ILLNESSDid your Doctor ever tell you that you have?□ Hypertension□ Diabetes□ Cancer(not a minor skin cancer)□ Chronic lung disease□ Heart Attack□ Congestive heart failure□ Angina□ Asthma□ Arthritis□ Kidney disease

0-4 answers √ =0

5-11 answers √ =1

0-4=0 0-4= 0

L LOSS OF WEIGHTHave you lost more than 5kg or 5% of your body weight in the past year?

Yes=1No=0

N=0 N=0

TOTAL SCORE 3= FRAIL 0=Robust

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Frail Scale Risk AssessmentSydney North Health Network

Scoring:Robust=0Pre-Frail =1-2Frail=>3

TACP in conjunction with Keith scored the Frail Scale Risk Assessment retrospectively.

This was to gauge his frailty at the beginning and end of the TRANSPAC program.

Case Management (HammondCare)• Keith involved in decision making and planning through regular case reviews at 3, 6, 8 weeks

of program with the Case Manager, oversight of package, rostering carers and 24hr support

Practical assistance (HammondCare)• Personal Care – Keith was managing his own personal care at time of package (shower chair)• Shopping - accompanied with a carer • Transport – medical appointments• Domestic assistance – Vacuuming, mopping floors, bathroom, kitchen cleaning, and bed

linen change • Respite/socialisation- transport to church events/ groups• Nursing and podiatry- as required

Therapy (Community Rehabilitation Service: Royal Rehab) • Keith had intervention from the Physiotherapist, Occupational Therapist, Dietician, Speech

Pathologist and Clinical Horticulturist• TRANSPAC also has access to Social Work and Allied Health assistance

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Keith’s Perspective: How has the program assisted Keith?

• “Transition to ordinary life”-return to normal routine by doing everyday activities of living. “The program has fulfilled its name transitioning me from hospital to home”

• Increased in strength- “after time in hospital being able to do things with appropriate help”

• Therapy increased mobility –indoors, outdoor and community access, transitioning from the 4 wheeled walker to walking stick.

• Increased confidence- “several visits per week meant I had continued contact and support”

• Decreased frailty -“ I was rather weak but am now much stronger “

• Inner strength and spirituality

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Assessment tools used on Program

MBI (Modified Barthel index)(scored out of 100) This is a tool used by the Commonwealth for pre and post program change assessing categories of Feeding, Transfers, Personal hygiene, Toilet transfer, Bathing, Walking, Stairs, Dressing, Bowel and Bladder continenceStart TRANSPAC program 85/100End TRANSPAC Program 100/100

NEADL (Nottingham Extended Activities of Daily Living score) (max score 66)This is scored by Royal Rehab an extra tool used on our program which appears more sensitive to client change assessing - Mobility 6 aspects, Kitchen 5 aspects, Domestic tasks 5 aspects and Leisure activities 6 aspectsPre admission score 64/66Admission to program score 37/66Discharge from program score 57/66

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Keith Now• Discharged from TRANSPAC Program to existing weekly domestic assistance with

Wesley Mission Commonwealth Home Support Program MAC (My Aged Care)• Mobility- independently mobile occasionally uses a stick when out and about• Weight stabilised• Returned to driving and has passed the 2 year driving test prior to 91st birthday (no

restrictions on licence)• Returned to social groups – Tuesday Coffee group/ Wednesday Church, St Matthew’s

Anglican Church West Pennant Hills / Every 3rd Thursday Men's discussion group• Thursday (pm) attends Anglicare Health Centre- balance exercises, weights and

physiotherapy• Walks 1 km per day uses a walking pole• Assessed for Home Care package level 2 – ( next 3 months)• Returned to light gardening activities - No ladder climbing!

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Weed if You Must

Weed if you must but wouldn’t it be better, to send an email or write a letter,

to clean the gutters or paint the house, or set a trap to catch that mouse.

Weed if you must but there’s not much time,

with shrubs to trim and ladders to climb, windows to clean and leaves to rake, the list never stops, make no mistake.

Weed if you must but keep in mind,

arthritic knees are not very kind, so straighten your back and mow the lawn,

water the garden and greet the dawn.

Weed if you must but there’s much more fun in taking a book to read in the sun,

while sipping your coffee or eating some cake, relax from your chores and enjoy a good break.

Keith Watson

(Written after reading a poem titled “Dust if you must” by Rose Milligan and noting the weeds in my garden requiring removal!)

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Dr Keith Watson Client/Consumer Sarah Hobson TACP Manager