Preventing avoidable hospital presentations for residents in aged care

Transcription

1 presentations for Background information Resources for clinicians in aged care Contacting the GP - information for aged care staff Can the resident's condition be treated at home BEFORE TRANSFER to ED consider goals of care REFER EARLY to in-reach services. AFTER HOURS, WEEKENDS & PUBLIC HOLIDAYS Residents with High Level Care Needs URGENT MEDICAL ASSISTANCE? Clinical Response Service- CRS ROSS Resi-In-Reach - RIR Residents with Low Level Care Needs Hospital In The Home- HITH Hospital In The Home- HITH ROSS Resi-In-Reach - RIR Ring ED Consultant for clinical discussion. REFERRAL- Aged Care Imaging Sub- Acute Assessment Service- SAAS - elective rehabilitation admission Page 1 of 7

2 presentations for Background information This pathway has been developed for GPs and Care Managers/Nurses in charge of residential aged care services. The advice within this pathway aims to prevent avoidable presentations to acute health services by optimising the use of acute public and private* community treatment services Services included; Peninsula Health-Clinical Response Service (CRS) Peninsula Health- Residential In Reach (ROSS RIR) Peninsula Health- Hospital in The Home (HITH) Aged Care Imaging* Peninsula Health- Subacute Assessment Service (SAAS) A description of each of these services can be found in the REFERRAL sections. Before you send a resident to ED consider the following services. 2 Resources for clinicians in aged care If a resident is unwell- ROSS-RIR RACGP- Aged Care Facility- Nurse Triage Information. BPSD Guide- University of NSW and free app (available to download for FREE via Google Play and itunes) Dementia Behaviour Management Advisory Service (DBMAS) Phone Website- 3 Contacting the GP - information for aged care staff Contact the residents GP or GP deputising service for urgent review. Contact by phone is preferable to fax If the GP or GP deputising service is not available then consider the following options. 4 BEFORE TRANSFER to ED consider goals of care Involve resident and family EARLY What are the goals of care? Consider the residents pre-existing condition and health. Can this resident be treated in their residential facility (usually Yes)? Is there an Advance Care Directive? Is there a Medical Power of Attorney appointed? Is there a Statement of Choices, Medical Treatment Order or details about preferred location of care? Further information Advance Care Planning Management of palliative symptoms Page 2 of 7

3 presentations for REFER EARLY to in-reach services. Available services are; Peninsula Health- Clinical Response Service (CRS) Phone Peninsula Health- Residential In Reach (RIR) Phone (R-I-R nurses) Peninsula Health- Hospital in The Home (HITH) Phone ask for HITH consultant on call. Aged Care Imaging (private service) Phone or fax Peninsula Health- Subacute Assessment Service (SAAS)Phone or Fax Can the resident's condition be treated at home Most residents living in residential aged care will be eligible to receive in-reach services promptly and safely. Check "residents with high level care needs" & "residents with low level care needs" below to find out any conditions that may be excluded. 7 AFTER HOURS, WEEKENDS & PUBLIC HOLIDAYS Options for medical assessment and management after hours. Residential care facilities who require medical assessment of a resident should contact the residents GP/GP clinic or deputising service first. Clinical Response Service- CRS While the CRS is not a after hours service all calls and referrals left on will be triaged and responded to ASAP the next working day. It is recommended that clinicians consider if urgent consultation is required or if review can wait until the next working day. 8 Residents with High Level Care Needs Residents with high level care needs may be treated by in-reach services for ALL conditions- no exclusions apply 9 URGENT MEDICAL ASSISTANCE? Peninsula Health- Clinical Response Service (CRS) Referral phone How urgently does the resident need to be seen?- Clinical Response service(crs) can usually attend within 4 hours. AFTER HOURS- can it wait? All referrals made to CRS after hours will be responded to ASAP the next working day. Page 3 of 7

4 presentations for Peninsula Health Emergency Departments Frankston Rosebud BEFORE transfer to ED call ED consultant for clinical discussion. Peninsula Health Mental Health Triage Phone Clinical Response Service- CRS Peninsula Health Clinical Response Service- CRS Operating hours Monday-Friday Referral phone Doctors, RN s, Pharmacy, Dietetics, Physiotherapy, Care Coordination. Aim to see patients within 4 hours or referral. This service provides acute medical management in residents own environment as an alternative to ED presentation. Will also facilitate Hospital in the Home admission if possible and appropriate. EXCLUSIONS for residents with low level care needs ( not for those with high level needs) Chest pain Abdominal pain Pelvic pain Severe breathlessness Neurological symptoms Head injury on warfarin Video-consultations available 11 ROSS Resi-In-Reach -RIR Peninsula Health ROSS Resi-In-Reach -RIR Operating hours Monday- friday Weekends & Public Holidays Referral made by phone (R-I-R nurses) This multidisciplinary service provides an alternative to ED presentation for residents requiring relatively simple clinical procedures or end of life issues. ROSS R-I-R is a multidisciplinary team of nurses, physiotherapists, and occupational therapists. ROSS RIR- communicating clinical information poster. If a resident is unwell- ROSS-RIR 12 Residents with Low Level Care Needs Page 4 of 7

5 presentations for Most conditions can be treated by in-reach services in the facility; Fever, Flu, Chest infection, Pneumonia, UTI, Pyelonephritis, Cellulitis, Skin infections Swollen legs, DVT, stable PE Gastroenteritis, dehydration IV antibiotic administration Rehydration Constipation Back pain Wound care Dementia, behavioural disturbance-dementia - management Medication side effects, polypharmacy Post fall or head strike assessment Balance and mobility problems Catheter/Peg issues Palliative care, end of life issues EXCLUSIONS Chest pain Abdominal pain Pelvic pain Severe breathlessness Neurological symptoms Head injury on warfarin 13 Hospital In The Home- HITH Peninsula Health Hospital In The Home- HITH Operating hours- 24/7 everyday of the year Referral made by phone ask for HITH consultant on call. Care in a virtual hospital setting for residents with a clear diagnosis and treatment plan. Includes medical and nursing assessment and management. 14 Hospital In The Home- HITH Peninsula Health Hospital In The Home- HITH Operating hours- 24/7 everyday of the year Referral made by phone ask for HITH consultant on call. Care in a virtual hospital setting for residents with a clear diagnosis and treatment plan. Includes medical and nursing assessment and management. 15 ROSS Resi-In-Reach -RIR Peninsula Health ROSS Resi-In-Reach -RIR Page 5 of 7

6 presentations Operating for hours Monday- friday Weekends & Public Holidays * Referral made by phone (R-I-R nurses) This multidisciplinary service provides an alternative to ED presentation for residents requiring relatively simple clinical procedures or end of life issues. ROSS R-I-R is a multidisciplinary team of nurses, physiotherapists, and occupational therapists. ROSS RIR- communicating clinical information poster. If a resident is unwell- ROSS-RIR * Until 30/06/ Ring ED Consultant for clinical discussion. BEFORE transfer to ED call ED consultant for clinical discussion. Peninsula Health Emergency Departments Frankston Rosebud Peninsula Health Mental Health Triage Phone REFERRAL- Aged Care Imaging Operating hours Monday-Friday Referral made by phone or fax Service Description- Aged Care Imaging is a predominantly non-urgent mobile X-ray and Ultrasound service. Includes imaging of chest, abdomen, spine, pelvic girdle, extremities and facial bones. U/S includes- abdo, renal, pelvic, vasular including limb arterial and venous studies (DVT), thyroid, testicles. (NO Breast or Musculoskeletal U/S) Standard reporting is within 12 hours of the examination. Urgent reporting can be facilitated same day. Facilities are encouraged to contact the service by phone to discuss individual requirements. Further information about Aged Care Imaging can be found here; Cost- DVA GOLD card- Free Xray and U/S Pensioners- Xray- $65, U/S- $70 Non- Pensioners- $85, U/S- $95 18 Sub-Acute Assessment Service- SAAS - elective rehabilitation admission Peninsula Health Sub-Acute Assessment Service (SAAS) Operating hours Page 6 of 7

7 presentations Monday- Friday for residents in aged care Referral by phone or fax Phone Fax This multidisciplinary service, involving Social workers, Nurses, Geriatricians and Rehabilitation Consultants, operates from Frankston Hospital Monday-Friday and can triage patients and arrange for goal-directed inpatient rehabilitation admission if required. Referrals to this service must include; Current medical issues and context of the clinical situation Clear statement of the goals that rehabilitation would achieve Relevant pathology and/or radiology results Page 7 of 7

8 Preventing avoidable hospital presentations for Medicine/Elderly care/residential aged care Provenance certificate Contents Overview Editorial methodology Contributors Disclaimers Overview This document describes the provenance of the Peninsula Pathways, ACTION- Acute Community Treatment Options pathway. This pathway was last updated in March The Peninsula Pathways Program aims to improve the continuity of patient care between primary, community and hospital care settings in the Frankston-Mornington Peninsula region. Work groups comprising of experienced health professionals (GPs, specialists, nurses, allied health professionals) were established to review and localise pathways. This pathway has been developed to provide guidance to GPs and staff working in aged care facilities in relation to accessing acute medical intervention and care for. This pathway will assist with identifying residents that can be safely treated within the facility, eliminating the need for disruptive transfer to acute health services. Published: April 2015 Valid until: June 2017 To cite this pathway, use the following format: Map of Medicine (MoM). Acute Community Treatment Options - Frankston-Mornington Peninsula Medicare Local View. Melbourne: Map of Medicine; Editorial methodology This care map has been based on a Map of Medicine care map developed according to the Map of Medicine editorial methodology. The content of this Map of Medicine care map is based on high quality guidelines and practice-based knowledge provided by contributors with front-line clinical experience (see contributors section of this document). This localised version of the evidence-based, practice informed care map has been consulted by relevant stakeholder representatives. Editor Dr Joanne Newton GP Editor Conflicts of interest: none declared Editorial support Jennifer Sidwell- Aged Care Connections Care Pathways Project Officer, Frankston Mornington Peninsula Medicare Local Conflicts of interest: none declared Contributors Dr Fergus McGee- Clinical Response Service- Peninsula Health

9 Preventing avoidable hospital presentations for Medicine/Elderly care/residential aged care Dr Albert Ruddock- Clinical Response Service- Peninsula Health Rebecca Pang- Hospital Admission Risk Program Support Program Team Leader- Peninsula Health Alvin Tan- Physiotherapist- Residential In Reach Service- Peninsula Health Alice Urban- Senior Clinician Hospital Admission Risk Program support team- Peninsula Health Simon Shay- Director/Business Development Manager- Aged Care Imaging Conflicts of interest: none declared The pathway was reviewed by the following: Dr Fergus McGee- Clinical Response Service- Peninsula Health Rebecca Pang- Hospital Admission Risk Program Support Program Team Leader- Peninsula Health Tracy McNeair- Aged Care Connections Program Manager- Frankston Mornington Peninsula Medicare Local Dr Peter Megyessy- GP Sorrento Medical Centre Jill Li- Manager Sorrento Lodge Conflicts of interest: none declared GP reviewers Dr Martin Coffey, Dr Damian Flanagan, Dr Sue Boucher, Dr Glenn Mathieson Disclaimers It is not the function of the Pathways Program, Frankston-Mornington Peninsula Medicare Local to substitute for the role of the clinician, but to support the clinician in enabling access to know-how and knowledge. Users of the Map of Medicine are therefore urged to use their own professional judgement to ensure that the patient receives the best possible care. Whilst reasonable efforts have been made to ensure the accuracy of the information on this online clinical knowledge resource, we cannot guarantee its correctness and completeness. The information on the Map of Medicine is subject to change and we cannot guarantee that it is up-to-date