Hepburn Health Service TCP Team May 2012

Transcription

1 Hepburn Health Service TCP Team May 2012

2 Hepburn Health Service is a major provider of public health and wellbeing services across the Hepburn Shire. Complex range of services are needed for the rural population of 15,000 people. HHS 2012 annual expenditure budget of $23m Communities are richly diverse with wide differences in health and wellbeing status.

3 Four (4) campuses: Daylesford (Central), Trentham (East), Clunes (North West and Creswick (West). Total of 360 staff working from these four (4) facilities. Located within a major tourist region which brings added complexity and large population fluctuations. Above the Victorian state average for chronic disease, socio-economic disadvantage and in population ageing.

4 BHS contacted HHS to request our involvement in the TCP for the Region. Officially commenced at Hepburn Health Service (HHS) in July 2009 BHS provided great support in the implementation (and ongoing) and HHS enjoys the ongoing partnership with Ballarat Health Services (BHS) TCP needed Creswick Hospital and Creswick Hospital needed TCP. It was the perfect choice as the ward is small with only 10 beds; can take high and low care clients; is homely and had enthusiastic staff looking for a change. Support received from Creswick VMO s.

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6 Commenced in July residential beds in Creswick Hospital and then in October 2 community places Priority was given to clients living in the local government area; however Creswick s close proximity to Ballarat also allowed clients from Ballarat and surrounding area to enter our bed based program usually due to high care needs. In July 2010 building on the success of established Creswick a further 2 residential beds and 2 community beds were allocated- total 6 & 4.

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8 The Nursing Division of HHS which included the HHS District Nursing Service decided to expand services into the community building on the success of the community based TCP program. Submitted to the ACAR 2010 and in March 2011 commenced four (4) EACH-D and nine (9) CACP s. August Further 2 residential places & 2 community TCP received Currently 8 & 6 Decision made to place 2 residential beds at Trentham Aged Care Facility Unused old nurses home at Creswick was refurbished with capital received form Commonwealth and State (TCP) to accommodate the IAC Program staff.

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12 IAC Program Manager: Gabrielle Bence (Creswick DON & District Nursing Coordinator) IAC Program Coordinator Allison Monk TCP Case Creswick & Trentham Occupational Therapist: (0.4 EFT) 0.3 EFT Allied Health Assistants Administration assist based at Creswick Excellent Medical support for TCP from Creswick and springs Medical Centres Nursing and Personal Care provided by staff at Creswick Acute, Trentham Aged Care and District Nursing. Maintenance & Gardening provided through HHS. Contracted services for some home based care.

13 Quality Framework embedded into the existing HHS QI program. Quality Activities and Audits are done on a regular basis to ensure TCP meeting expectations of Commonwealth and State Governments, Board of Governance and most importantly clients and their families. Feedback is a vital component of the QI process. Sadies story Arthurs Story Satisfaction surveys are provided to all clients and families and are very positive. One comment was made my case manager arrived a stranger and left a friend!

14 Discharge planning: Often TCP was not considered due to lack of awareness of the program Judgments & negativity: Some ward nurses & doctors were making their own decisions about a persons eligibility for TCP thankfully diminishing with education Documentation: Clients were being sent from Acute settings with very poor documentation Leaving medical / nursing staff with little information. Strict checklist now adhered to summaries / medications must be sent day prior to admission (or no admission) Pressure on residential care beds: Making placement of bed based clients very difficult and subsequently blocking TCP beds - especially over the past 12 months

15 Very supportive medical staff attend the hospital daily & case conference weekly. Available to TCP staff as needed Excellent nursing staff that really get it TCP at HHS is becoming embedded in our Health Service culture with all staff involved in its success. Committed and cohesive TCP team: Our OT, Physio and AHA s are indispensable assets Partnership and support from BHS (regular meetings, telephone support, referring clients) BHS liaison & assessment officer (Kelly)- referrals more appropriate for the level of care we can provide. Great improvement in documentation

16 BHS TCP team have gone the extra mile to support us (and other regional teams) development Program is highly client and family centered and of great value to our communities District Nurses, doctors, families & community grapevine are constantly identifying potential clients (often well before they enter hospital) Meetings with local discharge planners increased awareness and encouragement to consider TCP as an option is improving outcomes for regional clients Talking to senior citizens the first thing they think of when they go to hospital is going home on TCP.

17 TCP has made inroads into the gap between the acute care and residential aged care areas transition at Creswick is seamless. Planned acute admissions - flagged for TCP by GP s, District Nurses, etc Maintaining good relationship with ACAS: Grampians ACAS team have worked hard to ensure prompt assessments Lastly, but by no means least: Gabrielle s and Allison's hard work and vision in the initiation of the program

18 Don t try to reinvent the wheel there are plenty of resources out there none of us are experts - someone has done it before Relationships: Support each other don t be afraid to consult your regional TCP teams they are probably experiencing many of the same issues. The close relationship Hepburn HS Ballarat HS TCP s is a good example ACAS: Foster your relationship with ACAS they are a great resource -they have been great support to us and our program Nurture your team its an invaluable asset. Our team is great! Never underestimate the value of a good OT you can learn heaps. Thanks from Hepburn Health Service TCP Team