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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

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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)

the team
The Team
  • Manager- Trish Algate
  • Primary health
  • ACAT
  • Diabetes educator
  • Aboriginal primary health workers
  • Maternal and child health
  • Mental health
the team1
The Team
  • Allied health
  • Visiting specialists
  • Transport
  • Palliative care
  • Case management
  • Sexual and Womens health
  • Domestic violence counselling
  • Early Intervention worker
rationale
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
rationale1
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
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 summary1
In Summary
  • Creating better outcomes
  • For the client and service providers
scenario
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
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 respond1
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 respond2
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 respond3
NSW Respond
  • Respite
  • Wound management
  • Podiatry
  • Ongoing case management
conclusion
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

Questions ?

Answers…..

slide17

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

rationale2
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
rationale3
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
Criteria
  • Presents to hospital post fall
  • Resident of NSW
  • Over 65 years of age
  • Aboriginal and over 45 years of age
  • Intellectual disability
scenario1
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
scenario2
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
scenario3
Scenario
  • Referral to ACAT
  • Referral to physiotherapist
  • General practitioner
  • ACAT carries out comprehensive assessment
  • Case management provided
outcomes
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
outcomes1
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
conclusion1
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
questions1

Questions?

Answers…….

slide29

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:___________________________________________________