CHHS17/251

Canberra Hospital and Health ServicesOperational Procedure Transitional Therapy and Care Program: Eligibility, Referral and AdmissionContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Section 1 – Background.............................................................................................................2

Section 2 – Eligibility.................................................................................................................3

Section 3 – Referral...................................................................................................................4

Section 4 – Discharge from CHHS to TTCP................................................................................4

Implementation........................................................................................................................ 5

Related Policies, Procedures, Guidelines and Legislation.........................................................5

Search Terms............................................................................................................................ 5

Attachments..............................................................................................................................6

Attachment 1: TCCP Referral Flowchart................................................................................7

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Purpose

This procedure outlines the referral and admission processes for patients that are referred to the Transitional Therapy and Care Program (TTCP).

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Sc

ope

This operational procedure applies to all Canberra Hospital and Health Services (CHHS) staff referring patients to the TTCP.

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Section 1 – Background

TTCP is a short-term service for older people which is jointly run between ACT Health and BaptistCare. The aim of TTCP is to improve the function and independence of the person post discharge from hospital. TTCP offers a goal oriented and therapy focused program that is up to 12 weeks in length for older people who require more time and support to complete their restorative process.

TTCP has a capacity of 58 places. This gives TTCP the ability to assist 43 people in their own homes (community based care) and has 15 places in a residential care facility known as the Mullangarrie Unit. On discharge from hospital clients can go either directly home or to the Mullangarrie Unit depending upon the client’s clinical need. This will be assessed and determined by the TTCP team. Clients can also move from the Mullangarrie Unit to home or vice a versa within the one episode of care.

The Mullangarrie Unit is a residential care facility located in Red Hill. Whilst at the Mullangarrie Unit it is expected that the client will participate in low intensity therapy to work towards reaching their goals. The Mullangarrie Unit is not a respite facility. If the client is unable to participate in therapy then they should be referred to alternative services.

Medical services at the Mullangarrie Unit are provided through the Department of Geriatric Medicine at CHHS. The Mullangarrie Unit is not a medical facility and does not have either nursing or medical services outside the hours of Monday to Friday 8.30am to 4.00pm. If a client becomes unwell out of hours then they will be transferred back to The Canberra Hospital.

Clients are able to access the following services with TTCP, both in the client’s home and within the Mullangarrie Unit:

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This Standard Operating Procedure (SOP) describes for staff the process to

CHHS17/251

Occupational Therapy Physiotherapy Social work Dietitian Speech Pathologist Allied health Assistants Nursing Personal care e.g. assistance with showering, shopping, transport Case management

When the client is in their own home medical oversight is provided by their GP.

There is a fee associated with clients entering TTCP. The client may be asked to pay a maximum of 85% of the basic daily rate of the single pension if they are going to the Mullangarrie Unit and 17.5% of the basic daily rate of the single pension for care in the community. This fee can be negotiated between the patient and BaptistCare staff and no person will be denied access to TTCP because of their inability to pay.

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Section 2 – Eligibility

To access TTCP the client must: Be at a level of care that, if assessed, would be approved for residential care. Have an Aged Care Assessment Team (ACAT) approval for TTCP. Consent to participating in TTCP. Have a discharge destination, and for community based services, that must be in the

ACT. Be medically stable, i.e. has no further treatment that requires an acute inpatient stay,

with no acute symptoms for 48hrs. Be able to be managed by their GP (community based care) or sub-acute medical review

(Mullangarrie Unit). Have goals to improve physical, cognitive or psychosocial function. Be able and willing to participate and benefit from low intensity therapy. Require low intensity therapy and either nursing and/or personal care. Be able to mobilise with the maximum of 1 assist (Mullangarrie Unit).

Note: The Mullangarrie Unit is not a medical facility If a person requires 24hr Nursing or Medical Officer care they are not suitable for TTCP. Treatments such as Intravenous antibiotics, cannulas, syringe drivers, nephrostomy

tubes, or those requiring active palliative care are not appropriate for referral to TTCP.

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Section 3 – Referral

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CHHS17/251

The ward multidisciplinary team (MDT) will notify the TTCP Access Officer (AO) of any potential referrals, or the AO will attend ward team meeting to find any potential referrals.

The AO will determine if the patient is an appropriate referral for TTCP. If referral is appropriate, AO or ward social worker will make an electronic referral to the

ACAT via the My Age Care (MAC) portal. After receiving the referral, ACAT will notify the AO and ward social worker of the

assessment day and time. The AO or social worker will notify the patient and their family of the appointment time

and day. ACAT will conduct an assessment of the client as soon as possible. Once ACAT has approved the patient for TTCP, ACAT will make an electronic referral to

TTCP via MAC. After approval has been received from ACAT, AO will complete TTCP initial assessment

with client. The AO will determine if the client’s needs are best met by going to the Mullangarrie

Unit or home. The client will be placed on a waitlist and admitted to TTCP as soon as there is an

available place. The AO will keep the ward informed of the potential waiting time. Once an admission date has been determined then the client and ward will be notified so

discharge planning can take place. The client will be asked to sign an agreement that includes a TTCP start date and an

understanding that they will exit the program at or before twelve weeks from that date.

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Section 4 – Discharge from CHHS to TTCP

Medications for discharge to Mullangarrie Unit:o Ward doctor is to write external scripts and give them to the CHHS pharmacy before

1pm on the day prior to admission to TTCP.o CHHS pharmacy will send the prescriptions to Colbee Court Chemist who will prepare

a Webster Pack for the patient and deliver them to the Mullangarrie Unit.o Note: If the prescriptions are not delivered to CHHS pharmacy before 1pm the day

before discharge, then CHHS pharmacy will send 1 day worth of medications with the patient transferring to the Mullangarrie Unit as well as ensuring the scripts are sent to Colbee Court Chemist.

Medications for discharge home:o The patient is to be discharged with 3 days’ worth of medications. o If a patient requires a Webster Pack, then the CHHS pharmacist will arrange this with

the patient’s local chemist.

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CHHS17/251

Medical discharge summaries, nursing transfer summaries and allied health handovers are required to be completed and sent to the TTCP email inbox (TTCP@act.gov.au) prior to, or on the day the patient being discharged to TTCP.

Medical order forms are to be completed for wound care, catheter management or any other RN administered care for patients discharging home with TTCP.

Transport for the patient, to either the Mullangarrie Unit or home, is to be arranged by the ward or the patient’s family. If transport has not been organised for the patient, then discharge may be delayed.

Any equipment that the patient will require, either at the Mullangarrie Unit or at home, is the responsibility of the CHHS treating therapist to organise prior to the patient being discharged.

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Implementation

This Procedure will be included on the ACT Health intranet Policy Register.

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Related Policies, Procedures, Guidelines and Legislation

Guidelines Transition Care Programme Guidelines – June 2015

Legislation Aged Care Act 1997

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Search Terms

Transitional, aged care, referral, Mullangarrie, community

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Attachments

Attachment 1: TCCP Referral Flowchart

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair

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CHHS17/251

Attachment 1: TCCP Referral Flowchart

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register