LMNCC Transition Care

Making a Difference Prepared by :

Michele Anderson & Kim Bailey 2013

• LMNCC TACP is community based

• Currently 28 places are allocated to Lower Mid

North Coast Cluster

• Local Referral Hospitals include Manning

Rural Referral Hospital, Wingham

Rehabilitation Hospital, two Private Hospitals ,

Introduction

• Coastal

• % Retirees

• Rural

• % Isolation

AREA

• Due to LMNCC area, distances travelled ,

staffing resources TACP currently covers:

– Forster, Tuncurry, Hallidays Point, Failford, Nabiac

– Tinonee, Old Bar, Wingham, Taree, Harrington

– Coopernook, Lansdowne

– Rural challenges include isolation, limited

transport, communication, reduced medical

services

Location

Limited or no services available

OPTIONS

• TACP

• Assist at home

• Carer Support

• Plan for future

• Registered Nurses, Enrolled Nurses,

• Physiotherapist,

• Occupational Therapist

• Hospital Assistant.

• Access to dietetic & social work services

• No brokerage to any other service provision

LMNCC TACP TEAM

• LMNCC TACP is located within the Aged Care

and Rehabilitation Service building

• Provides ready access & works closely with:

ACAT staff , Geriatrician ,Clinical Nurse

Consultants, Nurse Practitioner, Social Work,

Speech Pathology, Podiatry and Dementia

Support.

Unique & Direct Access to Services

Client Outcomes Monitored

• Multidisciplinary Care Plans are developed

with the client, family, carer’s, GP’s, service

provider’s

• Case Management Reviews - weekly & as

needed

• Multidisciplinary team meetings - weekly

Discharges 1/01/2012 – 1/01/2013

Outcomes 1/01/2012 – 1/01/2013

LOCAL AREA

Rural Obstacles

CHALLENGES

Case Study - Background

• Beth is a 77 yo woman who lives alone on a beef cattle

property. She has 3 children with two daughters living locally

• Beth was referred to TACP by Wingham Aged Care and

Rehabilitation Service post CVA complicated by pneumonia.

Beth had been in rehab for ----- weeks.

• Past medical Hx – Hyperthyroidism, Asthma, pace maker,

Unsuccessful r/o cataracts, # vertebrae- chronic lower back

pain, rheumatoid arthritis.

• Cognitive Behaviour/Psychological Aspects.

• Mobility

• Self-Care:

• IADL’s:

• Bartels

• Home Environment

Case Study- Function on Discharge

from Hospital

Case Study

• Goals for program

• To return to driving tractor

• Safe mobilisation around garden and be safe

in house yard.

• To be able to hang washing out

• Independence with personal care.

Challenges and Triumphs

• Rehabilitation hindered due to rheumatoid arthritis

and pain- slowed progression.

• Poor mobility on DC from hospital.

• SOB

• Poor vision

• Fatigue and nausea

• Very challenging goal

• Reaching the goal through sheer determination

Case study - Interventions

Physio OT Nursing Speech Dietician

Assessment

Mobilising with

4ww indoors and

outdoors.

Walking stick

indoors

Step ups

Hand exercises

Education

Grab Rails

Personal care

assessment

Cognitive

assessment

Upper limb

assessment

Daily Visits

Observations

Assist with

personal care

encourage

independence

Supervise HEP

Swallowing and

language

assessment

Dietician

assessment.

symptoms such

as poor appetite,

taste changes

and early satiety

plan of 6x small

meals per day

with high energy

options.

Progress and Outcomes

Week 1

initial assessments-

mobilising 30 m around home.

Assist with personal care

Week 3-4

50 m with 4ww around house.

Hand exercises

10m 4ww on grass- supervised

Step ups 2 each leg

Assist with personal care. Alternate sponge with shower.

Wee k 5-7

40m 4ww on grass

Tractor transfer managed well with supervision

3 step ups each leg

Became confident to attend wash independently assist with shower.

Beth’s Journey Continues

Week 7-9

Step ups x5 each leg

Independent with tractor transfers

Patient drove off on the tractor

Independent with shower.

Week 9

Final physio- independent with 4ww outside

Independent inside short distances with stick

Grip strength and finger coordination improved.

Regularly driving tractor.

GOALS

ACHIEVED

A JOB WELL

DONE !

Beth’s TACP Experience

Beth Planning for Goals

Goals achieved

Making a Difference for Older People

This is Why We Do What We Do

• Aged Care & Rehabilitation Services

»65151800

LMNCC TACP