Early Notification of Complex Clients and Mandatory Aged Falls Reporting

Early Notification of Complex Clients and Mandatory Aged Falls Reporting Project Officers Sue Cooper (ACAT/ Primary Health Nurse) Rebecca Johnson (Diabetes Educator)

Introduction to the Primary Health Team NSW

The Team • Manager- Trish Algate • Primary health • ACAT • Diabetes educator • Aboriginal primary health workers • Maternal and child health • Mental health

The Team • Allied health • Visiting specialists • Transport • Palliative care • Case management • Sexual and Womens health • Domestic violence counselling • Early Intervention worker

Early Notification of Complex Clients (ENOCC)

Rationale • Notification tool to promote a multidisciplinary approach • Shared responsibility of complex clients • To facilitate appropriate referrals • Prevent inappropriate readmissions • Assist smooth transition and discharge

Rationale • Promote clear understanding of community and hospital responsibility to the client • Ensure follow up of acute and chronic conditions • Reduce cyclic admission to hospital of complex clients by early detection of community needs

In Summary • Ensuring a collaborative approach to provide seamless provision of service • Enhance discharge planning • Ensure appropriate management • Reduce the risk of inappropriate hospital admissions • Endeavor to promote self management of care of complex clients

In Summary • Creating better outcomes • For the client and service providers

Scenario • 60 year old aboriginal man admitted to hospital • Ischaemic toe • Amputation • Identified by ward staff in 24 hrs that client fits ENOCC criteria • ENOCC faxed to NSW

NSW Respond • Initial visit by aboriginal primary health worker and diabetes educator • Liaison between hospital and community staff • Hospital staff make available appropriate pathology and records • NSW provide hospital with clear community profile of client

NSW Respond • Referral to ACAT • Case management commences • Referral to primary health nurse • Case manager liaises with aboriginal services • Assessment of home safety and social welfare

NSW Respond • Referral to occupational therapy to liaise with hospital OT • Referral to dietitian • Ongoing diabetes care and education, endocrinologist • Meals on wheels • HACC services • Physiotherapy

NSW Respond • Respite • Wound management • Podiatry • Ongoing case management

Conclusion • Client receives education and care in the community • Awareness of available services • Diabetes management and overall case management reduces the potential cyclic representation of complex client

Questions ? Answers…..

Weber label Dareton Health Centre Private and confidential ENOCC Early Notification of Complex Clients Facsimile transmission To: Dareton Community Health Centre Fax: 50 274109 Primary Health/ ACAT From: Mildura Base Hospital Total 1 page Client name____________________ Phone number:____________ Consent for referral to DHC: Signature_________________ Referring person_____________ Date of admission:__/__/__ qPalliative Comments______________ qDiabetes _______________________ qChronic disease _______________________ qComplex medical issues _______________________ qMultiple admissions _______________________ qDoes not have a carer _______________________ qLives alone qCarer strain qDementia qFall qAboriginal qChild with a disability qSexual health MaternityandChild Health

Mandatory Aged Falls Reporting MAF Reporting

Rationale • The follow up of falls in the aged population NSW • Prevent the cyclic nature of aged clients presenting to A&E and wards post falls • Falls are one of the most significant reasons for presentation in acute settings • Provide better outcomes for client

Rationale • Falls are a significant cause of beds being taken up in acute wards • Preventative measures taken would significantly decrease representation of elderly clients • Notification to community health will aim to implement preventative measures

Criteria • Presents to hospital post fall • Resident of NSW • Over 65 years of age • Aboriginal and over 45 years of age • Intellectual disability

Scenario • 70 year old man presents to A&E post fall • Meets MAF criteria • MAF faxed to Dareton Primary Health Centre • Client discharged home from A&E • Primary health staff respond to MAF via phone call or home visit within 24 hours

Scenario • Initial primary health nurse visit • Client lives alone • No services in place • No significant carer • No home modifications • Lack of understanding re medications • No knowledge of services available

Scenario • Referral to ACAT • Referral to physiotherapist • General practitioner • ACAT carries out comprehensive assessment • Case management provided

Outcomes • Referral to OT home modifications ensue • Referral to home care and HACC services i.e. personal care, respite social support, domestic assistance, medication administration • Referral to visiting geriatrician

Outcomes • Contact and education with family and client • Promotion of self management • Placed on waiting list for respite and low level care • Meals on wheels • Podiatrist • Dietitian • Regular primary health visits

Conclusion • Health issues now regularly monitored by GP and primary health • Living in safe environment, utilises frame • Significantly reduces likelihood of representation to A&E

Questions? Answers…….

Dareton Health Centre Private and confidential MAF Reporting Mandatory Aged Falls Reporting Facsimile transmission To: Dareton Community Health Centre Fax: 50 274109 Primary Health/ ACAT From: Mildura Base Hospital Total 1 page Accident and Emergency Department Name:_________________________________________________ Address:_______________________________________________ Phone number:__________________________________________ Consent for referral to DHC: Reason for fall: _______________________________________________________ Injury incurred:___________________________________________ Referring person:_________________________________________ Date:___________________________________________________

Early Notification of Complex Clients and Mandatory Aged Falls Reporting