A Practice Framework for Shared Transfer of Care in Home Care

A Practice Framework for Shared Transfer of Care in Home Care A Prompt Care initiative proudly supported by Aged & Community Services Tasmania and Primary Health Tasmania JUNE 2016

Contents Acknowledgements 2 About this Practice Framework 3 1. Background and Context 4 2. Objectives and Outcomes 6 3. Issues to be Addressed 6 4. Transfer of Care Guidelines 7 5. Tailored Tools for Shared Transfer of Care 11 Appendix 1: Terminology 13 Appendix 2: Transfer of Care Plan for Home Care (Tool) 17 Appendix 3: Consent to Share Personal Information Form (Tool) 19 Appendix 4: Care Transfer Review Form (Tool) 21 Appendix 5: Red Flag Checklist for Home Care Transfer (Tool) 23 Appendix 6: Communication Checklist for Home Care Transfer (Tool) 27 Appendix 7: References and Resources 31 Appendix 8: Tips when using an Interpreter 33 Acknowledgements Prompt Care is proud to have partnered with Aged and Community Services Tasmania (ACST) and Primary Health Tasmania as part of the Shared Transfer of Care initiative funded by the Australian Government. We also wish to acknowledge the invaluable input and advice received from the Project Working Group and participants who attended the two workshops conducted as part of this project. Prompt Care 63 Main Road, Moonah TAS 7009 Phone 1800 472 273 www.promptcare.com.au AGED & COMMUNITY SERVICES TASMANIA 2 A Practice Framework

About this Practice Framework In 2016, Primary Health Tasmania (PHT) developed Guidelines for Shared Transfer of Care 1 to guide service providers and promote person-centred practice. The PHT initiative was part of the Streamlined Care Pathways Programme, which was funded in 2012 through the Australian Government s Tasmanian Health Assistance Package. The aims of the Streamlined Care Pathways Programme included: Improved transfers of care between health and aged care sectors; Building capacity and enabling system-wide changes to reduce avoidable hospital usage. In December 2015, Prompt Care Tasmania successfully responded to a call for Expressions of Interest (EOI), issued by Aged and Community Services (ACST) in collaboration with PHT, calling for aged care input into the Shared Transfer of Care initiative. Prompt Care s proposal to conduct a 6-month project, entitled Effective Transfers of Care in Home Care was accepted. This Practice Framework was developed as part of this initiative. It has a focus on high level aged care in the home and emphasises the pivotal roles played by the person receiving care and their families in decisions about care transfers and the ongoing delivery of consumer-driven Home Care Packages (HCPs). It has primarily been developed for use by HCP providers. However, some of the aspects of the guidelines and some of the tools and resources may be suitable for use (or modification) by practitioners in other health and aged care programmes. Shared Transfer of Care in Home Care 3

1. Background and Context RATIONALE Why focus on Home Care? Older people with complex and ongoing care needs are likely to experience multiple transfers within and across the health and aged care sectors. Responsive person-centred practice is required to achieve positive care outcomes for older people experiencing care transfers. Supportive approaches are also needed to engage families and carers who are often pivotal members of the older person s care team in the community. Home Care Packages (HCPs) deliver coordinated services for older people with ongoing complex care needs who are living in their own home. They operate within four funding tiers with Levels 1 and 2 offering lower level care and Levels 3 and 4 addressing higher care needs which may include significant nursing and clinical care requirements. General Practitioners (GPs) are responsible for the medical care of HCP clients. The purpose of a HCP is to support the older person to continue to live at home. Care planning involves the setting of holistic care and wellness goals that will assist the client to remain living at home. These goals may include clinical and health care goals. Care practitioners working in the provision of HCPs are expected to liaise closely with the client s GP to enable health care goals to be met. Liaison with the client s pharmacist may also be required for the safe administration of medication. People are living longer and clearly expressing a preference to age at home. People who might previously have moved to a Residential Aged Care Facility (RACF) are now more likely to remain living at home with a high level care package (Level 3 or 4). Families often remain committed to supporting older people in this choice and many family carers are providing significant levels of care coordination, personal care and domestic support in home care delivery. As a result HCP providers are experiencing unprecedented growth in demand for high care at home. Consequently there has been an overall increase in the clinical acuity of clients being supported in the community. HCP clients are likely to require significant ongoing input from health services and may experience episodes of acute care necessitating the careful management of the care transfer process. It is clear that a robust Shared Transfer of Care Framework for Home Care is needed to take account of input from the client s General Practitioner (GP), health care teams, community pharmacists and home care providers as well as older people and their family carers. Shared care transfer plans and other shared resources are essential. Agreed processes for obtaining the person s consent to share information are also needed to minimise clinical risks and improve client outcomes. 4 A Practice Framework

POLICY CHANGES Impacts on Home Care Providers Major policy changes are taking place in aged care as a whole, with far reaching policy shifts occurring in the home care sector. These changes require community care providers to alter their documentation and update their referral protocols. Demand pressures on aged care and health services are also impacting on care transfers that involve community aged care clients, necessitating smooth and agreed communication processes. One of the most significant policy changes has been the requirement for HCP providers to adopt a new practice model with the introduction of Consumer Directed Care (CDC) 2. This approach to care planning requires careful consideration by all stakeholders involved in a care transfer for a HCP client. Within CDC a client and their family may choose to have some or all of their packaged care services delivered by an agency other than the approved provider in receipt of funding. In these situations a range of shared care challenges arise. A clear process for shared care plan documentation is needed. This is particularly important in the shared delivery of complex high care in the home, due to the clinical risks arising when care governance responsibilities are unclear. Changes to the scope and distribution of HCPs at different care levels have further highlighted the need for close attention to care transfer processes. There is a need for close attention to clinical risks and family support when older people need to shift from low care at home (Level 1 or 2 HCP) to a high care package (Level 3 or 4). This may involve a transfer from one provider to another and may also require the involvement of other agencies as subcontractors in provision of brokered care services. Transfers at the interface between the Commonwealth Home Support Programme (CHSP) and HCPs also require good communication between providers or between different teams operating within the same agency. FAMILY AND CARERS A Vital Role in High Level Packages Family and friends play a vital role in all home care services. This is particularly important in provision of high care in the home. When a person is allocated a high level care package, there is usually considerable family carer input required. High levels of support are frequently provided by a spouse who may also have a range of health needs. In such cases it may be necessary to develop a support plan for the primary carer as an essential element of the client s overall home care plan. Critical issues in care transfers may arise when families are supporting older people at home with undiagnosed dementia. Dementia is a major cause of disability in later life, and home care clients often require the support of a representative in making decisions about care and service options. This creates a challenge for providers to deliver consumer-driven care transfers that include a strong carer focus. The timely appointment of an Enduring Guardian or Person Responsible (i.e. substitute decision maker for health care and lifestyle decisions only) is needed. Family members are not always in full agreement as to what is in the best interests of their elderly relative. The appointment of a suitable client representative is often a difficult and contentious process. This issue comes to stark prominence in transfers for HCP clients moving out of hospital when the question will invariably be asked as to whether the client should return home or move to a residential care facility. The proactive engagement of HCP clients and their family carers in developing Advance Care Plans that address care location decisions (e.g. a strong preference for home care) can assist in this regard. Shared Transfer of Care in Home Care 5

2. Objectives and Outcomes The objectives of this Framework are to: Enable a culture of shared learning within care networks involved in high level care in the home; Document a practice framework based on action learning methods; and Provide resources and tools with the capacity to improve a shared approach to care transfers. This Framework aims to achieve the following outcomes: Increased connectivity and more streamlined referral channels between home care providers, acute health services, residential aged care services and primary health practitioners; Improved awareness of care transfer issues in the home care sector, and how these can be addressed and overcome; Wider knowledge of resources and tools available to facilitate shared care transfers into, out of and within HCP services; Increased engagement of clients and family/carers in care transfers; and Improved client and carer outcomes through use of a shared care transfer evaluation tool. 3. Issues to be addressed A wide array of issues in home care transfers were identified through engagement of multiple stakeholders including home care providers, residential care facilities, primary health practitioners, pharmacists, acute health care services, family carers and advocacy groups. The following major issues affecting care practices in transfers involving home care clients were highlighted: Consumer Directed Care what it means in practice when care transfers occur; A lack of suitable tools to empower clients and family carers to play an active role in care transfers; A need for improved referral tools and shared clinical risk protocols for transfers involving home care providers and health services including GPs, hospitals and pharmacists; Care governance concerns especially for high level home care clients when clients move from one home care provider to another or packaged care services are brokered/subcontracted by the approved provider to another agency; and A need for greater attention to the appropriate use of interpreters in care transfer communications for people who speak a language other than English. Practice guidelines and care management tools are documented in Section 5 with reference to these high priority concerns. Broad stakeholder involvement also identified a range of existing resources that help address these barriers. They are summarised as Appendix 7. 6 A Practice Framework

4. Transfer of Care Guidelines Elements of an Effective Shared Transfer of Care The following elements of good practice in care transfers are drawn from the Shared Transfer of Care Framework for Action (Consultation Draft) released by Primary Health Tasmania in November 2015. They have been modified and expanded (to include Shared Learning) with particular reference to transfers involving HCP clients: 1 Sharing with People A person, their family and carers are involved in transfer planning and decisions; 2 Sharing Accountability Assessment and care planning are based on person-centred practice; Clients and carers are given the information needed to make shared decisions about their transfer of care. The responsibility of the transfer of care is not relinquished by the referrer until the referred service/ organisations/carer has the information they need to care for the client; 3 Sharing Communication Timely communication occurs between providers, clients and their carers; 4 Sharing Documentation Care documentation is shared between providers with client/carer consent; 5 Sharing Coordination Clients and their carers are supported to play a full and active role in coordinating care transfers; 6 Sharing Learning This occurs through shared care reviews that involve clients and family carers. Legal Considerations Five important legal considerations impinge on care transfers in and out of, within and across HCP services: 1 User Rights within the context of the Aged Care Act 1997 and related Principles, most particularly the User Rights Amendment (Consumer Directed Care) Principles 2015 3 ; 2 Proper appointment of a client/consumer representative to support HCP clients with cognitive changes with decisions about care goals/budgets and service types/providers within the context of CDC; 3 Transparent and timely processes for gaining and recording client consent to share their personal and health information in preparation for the care transfer; 4 Clinical governance and the HCP provider s duty of care; and 5 Appropriate documentation of contractual arrangements for subcontracted (brokered) services within a high level HCP so that clinical and care governance are well managed. Consumer Directed Care (CDC) Principles The User Rights Amendment (CDC) Principles 2015, state that all HCPs must be delivered on a CDC basis. The key elements of CDC have been embedded in the principles. All consumers entering into a HCP from 1 July 2015 must receive a Home Care Agreement that reflects CDC including: Choice and flexibility (days/times of care, care staff, service provider); Care and services (choice of service types and providers); and An individualised budget and monthly statement that reflects a goal-based care plan. Shared Transfer of Care in Home Care 7

The Client Representative If the older person has a diagnosis of dementia, has other cognitive changes or is suspected of having dementia, it is essential that the HCP provider identifies a key family contact person who is able to support the client with care transfer decisions. This relative/carer may already be an appointed Enduring Guardian or nominated Person Responsible in the client s Advance Care Directive; if not, steps should be taken to enable this to occur. If there is no suitable family member to enact this role, it may be necessary to have an Enduring Guardian appointed. Where the client does not have a clear diagnosis of dementia, an appointment for the client with their GP should occur as soon as is practicable. It is advisable for a family member/carer to attend this appointment with the client. The involvement of a geriatrician may be beneficial, as determined by the GP, if the diagnosis is complex or unclear. Involvement of Alzheimer s Australia may also be helpful for provision of support and information. When a care transfer is occurring or being planned for a HCP client, attention may be needed to an Advance Care Directive but close attention is also needed to enable person-centred decision-making about living arrangements and care delivery when there is no imminent or foreseeable risk of the older person dying. When a HCP client is admitted to hospital, there is a heightened risk of unnecessary or premature admission to residential aged care. At this time, the client will be at their most vulnerable and may lack confidence and/or information about their right to return home with an appropriate level of support. It is advisable that the client s Advance Care Directive should make specific reference to the client s preferences in relation to home care and note circumstances in which they may deem it appropriate to move into residential aged care. Life affirming decision processes that empower older people to live as they wish and where they choose should be paramount in all care transfers. When the older person lacks testamentary capacity, this should be based on a health professional s assessment with input from the client s guardian/representative. It is advisable for the implications and outcomes of these choices to be clearly documented in the client s Advance Care Directive and in the client s HCP record. In such situations, the HCP client s engagement in decisions should still be sought with a view to meeting their preferences to the degree that is feasible with reference to clinical and environmental safety and the availability of family/carers to provide support. The needs and preferences of the older person receiving care may have to be balanced against the needs and choices of their family/carers and their capacity/desire to provide care at home. In these circumstances, there may be differences of opinion between family members, which may require mediation and a supportive approach within the transfer decision process. 8 A Practice Framework

Consent to Share Personal Information Concerns about client privacy and a related lack of clarity about privacy legislation act as a major barrier to the reasonable and necessary sharing of health related information in transfers of care. It is essential to overcome this barrier in order to mitigate and manage clinical risks for HCP clients with complex health and care needs. To assist with greater clarity about the obligations of Home Care Package providers in this regard, the most relevant Australian Privacy Principles (APPs) under the Commonwealth Privacy Act 1988 as outlined in the Australian Privacy Principles Guidelines (updated 2015) 4, are summarised below: APP 6: Use and Disclosure of Personal Information This principle is pertinent to sharing of personal details and health information by aged care providers in care transfers. It is a requirement of the Aged Care Act 1997 that HCP providers operate in a manner that is consistent with all the Australian Privacy Principles. Home Care Agreements (individual care provision contracts) between HCP clients and providers must include information to this effect. APP 11: Security of Personal information states that the record is protected by security and safeguards are taken against unauthorised access, use, modification/disclosure or misuse. APP 12: Access to Personal Information confirms that the individual concerned is entitled to have access to that record. APP 13: Correction of Personal Information requires that the record keeper shall, if requested by the individual, take steps to attach to the record any statement provided by way of correction, deletion or addition. The HCP client s agreement should also explain and include consent to share information with health and care providers as necessary and as relevant to the client s care plan. It should not be necessary for a HCP provider to gain further consent when a client is transferring to another service or provider. However, a form to record the client s Consent to Share Information is included as an Appendix 3. This is for use by providers when they are unclear whether it is appropriate to provide another care provider with information about the client s health and care needs. Clinical and Care Governance The critical role of the GP in relation to medical care and clinical governance is central in care transfers for HCP clients, especially high level HCP recipients. Well managed clinical and care governance processes are needed within HCPs and clarity regarding each provider s duty of care is essential in care transfers involving HCP recipients. This is particularly important when HCP clients are leaving hospital and the medical governance baton and responsibility needs to be transferred to the GP. HCP providers have a duty of care to maintain constant shared communication channels with GPs. Family/carers can play an important role in this regard if they are well informed and resourced by their HCP provider. A proactive approach is needed to ensure that the client s GP has a copy of the HCP Care Plan. Keeping the GP informed about changes to the Care Plan is important. The GP s involvement in care transfers is also important to maintain continuity of medical governance. In communicating with acute health care providers, GPs and medical specialists, the HCP provider has a duty of care to ensure they are well informed about their client s health and clinical care needs. A proactive approach is suggested when a HCP client is admitted to hospital Don t wait to be asked. It is recommended the HCP services should share all relevant information with the treating team in the hospital by whatever means they can. Similarly, when the client returns home from hospital - Don t wait to be told. Call for an update on the client s current status, medication and immediate health care risks (if any). The client s carer/representative can play an important role here so long as HCP providers ensure they have access to current information e.g. most recent care plan, service timetable. Into the future it is hoped that the client s My Health Record can include the client s HCP Care Plan and other key documents/tools relevant to care transfers and ongoing collaboration in relation to care governance. It is also hoped that processes can be put in place to enable GPs and other health practitioners who are playing a key role in the HCP client s care to have access to the client s information on the My Aged Care portal. This is particularly important when a GP refers a client for a HCP so that they can track the process of assessment, wait-listing and HCP activation. Shared Transfer of Care in Home Care 9

Subcontractor Requirements Brokerage Agreements Subcontractors should be engaged using a Standard Brokerage Agreement that specifies compliance with the Home Care Common Standards and the most recent version of the HCP Programme Guidelines (currently December 2015) 5. Case conferences should be held with brokerage staff as/when required especially for clients with complex clinical, behavioural or special care needs. Audits should cover the subcontractor s compliance with requirements for AFP checks, staff competence, risk management and CQI prior to commencement of their services and (at least) every 12 months thereafter, or more often as required. Contract management processes need to cover home safety checks, insurances and staff training in respect of CDC and special needs practices. Reference should also be made to shared communication processes with regard to care/clinical governance essential when clinical/nursing care is brokered. Consumer feedback should be sought on the quality of care received from brokerage agencies and improvement initiatives implemented in response. Use of Interpreters The Translating and Interpreting Service (TIS National) is an interpreting service provided by the Department of Immigration and Border Protection for people who do not speak English and for agencies and businesses that need to communicate with their non-english speaking clients. These services also enable non-english speakers to independently access an organisation s services and information. TIS National has access to over 2500 contracted interpreters across Australia, speaking more than 160 different languages. TIS website https://www.tisnational.gov.au/en TIS Client Liaison (general enquiries) 1300 655 082 TIS Immediate Phone Interpreting (available 24 hours, every day of the year) 131 450 TIS National provides access to the following interpreting services: Immediate and pre-booked phone interpreting Voice automated voice-prompted immediate phone interpreting On-site interpreting The interpreter s role is to accurately convey the whole spoken message from one language to another while abiding by the Australian Institute of Interpreters and Translators (AUSIT) Code of Ethics. See Appendix 8 for tips on interpreter use. 10 A Practice Framework

5. Tailored Tools for Shared Transfer of Care A number of useful tools and resources were developed as part of PHT s Shared Transfer of Care Initiative. Some have been modified and alternate or additional forms and checklists have been developed to respond to the key issues and communication requirements associated with care transfers that involve home care clients. Care Transfer and Care Coordination Checklists The PHT Transfer of Care Planning Checklist is clear and easy to follow; it empowers people to take control of the transfer process. However, it has a strong (although not exclusive) focus on transfers out of hospital. Therefore, additional specific checklists have been devised to enable streamlined care transfers in and out of a HCP (including hospital admissions) and transitions across aged care programmes as follows: Red Flag Checklist for Home Care Transfers (Appendix 5) instructions for its suggested use are included on the form. Communication Checklist for Home Care Transfers (Appendix 6) this form is designed for flexible usage according to the services involved in the individual HCP client s care. However, it has an emphasis on communications with the GP and the local pharmacist as well as suggested shared communications with the client and their family/carer/representative with the context of CDC. It may be used to guide and/or record communications or it may act as a review form to ensure that all relevant individuals and agencies have received information relevant to care transfers either at or near the time of transfer or in a proactive manner so that critical information is to hand when unplanned transfers occur, especially into an acute care setting. Care Transfer Review A Shared Evaluation Tool The Consumer Evaluation Form developed by PHT is largely focused on transfers from hospital to home and would be better used in this care arena rather than applying it to other settings. Within the context of CDC, a shared evaluation approach would be more applicable for HCP clients. The Care Transfer Review Form (see Appendix 4) has been developed for this purpose. It is not a prescriptive form. It can be modified as appropriate for different organisations. In its current form, it can be used collaboratively with family, carer and care provider input or it can be used to enable an internal review process. It articulates an Active Learning approach to continuous improvement. Transfer of Care Plan for Home Care The PHT Transfer of Care Plan is a very useful template which was designed to be adjusted for different settings; it has been modified to become the Transfer of Care Plan for Home Care (Appendix 2). This revised form maintains a structure based on the popular ISOBAR mnemonic. This was done to enhance communication between home care teams and health practitioners who are usually familiar with this approach to providing referral information in care transfers. It can be used by HCP case managers/coordinators when transferring clients to another provider. It could also be used to inform the client s GP about any care transfers that have/ are occurring for their patients and it may also be useful to provide to acute care teams when a HCP client is admitted to hospital. It is designed to be completed by the service that the client is transferring from. A copy can, where appropriate, be provided to client s/family carers and ideally the client and/or their carer/representative should be involved in its development in a manner that is consistent with CDC. Shared Transfer of Care in Home Care 11

Passport to Better Health This is a hard copy booklet (see images at right) developed by PHT. It acts as a means of engaging with and supporting the older person to manage their health care and information. It is designed to be owned, maintained and carried by the older person to show to different care providers in order to facilitate communication within and across the health and aged care networks. It has provision for noting information about Advance Care Plans and recording details of family Passport to better health carers/client representatives. Ideally every HCP client would be issued with one of these 1 booklets and receive support/assistance as needed to complete the personal details section and ensure that the care information and care provider sections remain up to date. It has been suggested that the Red Flag Checklist (Appendix Personal details Name Address Care information Use this page to direct care providers to additional information about your care. Yes, I have a Care Plan Location ABOUT ME 5) could be useful and be completed and stapled inside this passport for HCP clients, especially those with relatively Telephone Mobile Yes, I have an Advance Care Directive Location Yes, I have an Enduring Guardian high care needs to ensure that clinical and other risks can be addressed in an ongoing manner and at the time of transfer. Date of Birth Email Medicare No. Location Yes, I have a person who can make decisions on my behalf Name In its current version, it lacks specific provision for inclusion Pension No. Private Health fund Relationship of contact details of home care or home support providers. Yes, I have a DVA Card Telephone Mobile Such information is likely to be very important for older people receiving care and support to remain at home. It is Yes, I have a Hearing Services number Yes, I have an NDSS Card Other care information recommended that full details of these services are included 6 7 in the Care Provider section of booklet. A number of HCP providers have adopted the practice of providing each client with a card clearly stating their name, contact details and the type/level of care package they are Medications Name of Medication Reason Care providers List the services and/or providers who are part of your care. E.g. doctor, support worker, psychologist. Doctor/Practice Contact receiving. This could be attached to the passport booklet to facilitate proactive communication when a client presents at, or is admitted to, an acute care hospital. Pharmacy Hospital Contact Contact MY HEALTH Service Contact Service Contact Service Contact 20 21 12 A Practice Framework

APPENDIX 1 Terminology TERM DEFINITION/EXPLANATION A Transfer of Care Refers to the movement of people between care programmes, care locations or service providers as their care needs change or when they choose to receive some or all of their care from another agency. Transfers of care occur when a Home Care Package (HCP) client enters and leaves hospital, when they enter and leave a RACF for respite, when they transition from one HCP provider to another and when a HCP provider is subcontracting care to another agency. Transfers of care also occur when a person is referred to a HCP via an Aged Care Assessment Team (ACAT). This transfer may come from a Commonwealth Home Support Programme (CHSP) provider. Shared Care Refers to care practices that involve two or more services in a collaborative approach to care planning and delivery. Primary Health Tasmania s Shared Transfers of Care project articulates key elements of a shared approach to transfers of care. Shared care encompasses care models that directly involve family and other unpaid carers in care decisions and care delivery. All HCPs involve a degree of shared care, in that the client s GP (and possibly the local pharmacist) are included in the delivery of a holistic wellness-focused care package. Care packages commonly involve the subcontracting of home maintenance/gardening and allied health services, which may not be available directly though the HCP provider. Within a CDC framework it is necessary to offer the client the option of receiving care from a range of providers. Shared care arrangements may involve a number of agencies involved in the HCP client s care. Clients This term has been used, as a preference, to refer to people receiving care and services. Other terms are also sometimes used e.g. person, patient, care recipient, service user, citizen and consumer. Carers This term is used to refer to family members (or friends) who are involved in supporting the client. This support may involve direct care provision. It may also refer to assistance with decision making about care and/or coordination of home care services. Health Care The health care sector in Australia encompasses acute and primary care as well as specialist medical services. It also covers dental care, mental health services and services that aim to minimise the impacts of chronic diseases through health promotion and initiatives that aim to reduce demands on hospitals. Outpatient hospital clinics (which can be of major importance for older people living in the community with ongoing health care needs) are referred to as Ambulatory Care. Aged Care Refers to programmes and services targeted to older people (typically defined as people aged 65 years and over) and people experiencing age-related care needs at an earlier stage of life. The Australian Aged Care system includes community and home-based care options as well as care provided in Residential Aged Care Facilities (RACFs). Aged care services include a focus on nine special needs groups (see page 14). A significant component of all aged care services involves attention to the older person s health care needs. Access to all aged care services is via the My Aged Care Gateway programme with eligibility for a HCP or Residential Aged Care determined by the relevant regional Aged Care Assessment Team (ACAT). Consumer Directed Care (CDC) This is a way of providing and funding HCPs that assists the client to choose services (from specified service types) that will assist with the achievement of their care goals. It involves systems and processes that enable clients and/or their legal representative/s to monitor funding income and service costs on the basis of individualised monthly care package budget statements. Shared Transfer of Care in Home Care 13

Terminology (cont.) Active Learning Active Learning is a modification of the Action Learning methodology developed to improve communication processes in hospital care. It has the following continuous improvement cycle: DO what is needed to ensure the client receives high quality care; REVIEW what has occurred involve client, carers, families and other providers; LEARN together talk and discuss with a focus on what we can learn not what others should do; IMPROVE tools and processes and continue to strive for high quality care and sound clinical governance. Active Learning involves a learning attitude it requires a shared recognition that everyone can improve and everyone can continue to learn. It also acknowledges that clients and family carers can assist us to learn and improve our care practices. This approach has been used in reviewing transfers of care. It encourages a shared approach to improving care transfers. Wellness and Reablement This philosophy of care focuses on assisting the client to maintain and/or regain functional capacity and good health. It may involve care goals and approaches to minimise the impact of worsening health conditions. All HCPs are expected to be delivered within a wellness service model. Special Needs Groups All Aged Care providers are expected to provide care tailored to meet requirements of nine special needs groups under the Aged Care Act (1997 and subsequent amendments): People from Aboriginal and Torres Strait Islander (ATSI) communities; People from culturally and linguistically diverse (CALD) backgrounds; People who live in rural and remote areas; People who are financially or socially disadvantaged (FSD); Veterans and War Widows/Widowers; People who are homeless, or at risk of becoming homeless; People who are lesbian, gay, bisexual, transgender or intersex (LGBTI); People who are care leavers (previously in a care institution or foster care during childhood/ adolescence includes the stolen generations and children brought to Australia from overseas during and after WWII); Parents separated from their children by forced adoption or removal. Some HCPs are allocated to give priority of access to one or more of these groups. Dementia is not defined as a special needs group; it is considered a care issue. Some HCPs may be allocated to give priority of access for people with dementia. A Dementia Supplement of 10% (calculated on the client s daily care subsidy) is payable for people assessed as eligible by a medical practitioner or Registered Nurse. 14 A Practice Framework

Terminology (cont.) ISOBAR SHARED The ISOBAR SHARED method was developed to provide a person-centred approach to the clinical communication framework for handovers by medical and nursing staff in a hospital setting as follows: Identification of patient Situation and status Observations of patient and call to medical emergency team (if indicated) Background and history Action, agreed plan and accountability Responsibility and risk management Safe Heard Agreed Plan Relationships Easy information Destination Duty of Care Within the context of a transfer of care, this term refers to a provider s legal obligation under common law to adhere to reasonable standards of service provision in a way that addresses and minimises foreseeable harm to the people receiving care. The HCP Programme Operational Manual (Dec 2015) provides the following pointers to duty of care considerations in HCPs: Discover, discuss and decide with the consumer engage clients in care decisions; Balance Duty of Care and the Dignity of Risk risks cannot be fully eliminated only mitigated; Discuss and work with consumers choices provide clear information about care/service choices; Decline requests (if necessary) and document do not provide care/services assessed as carrying unacceptable levels of risk; Use disclaimers and note disagreements keep objective and timely file notes in clients records about identified care risks and related discussions and decision processes. These considerations require a particular focus in care transfers into, out of and within HCPs. Client Representative A person who is nominated by the client to speak on their behalf and/or assist with decision making. This representative may be the: primary carer; family member; Enduring Guardian or Person Responsible; or an advocate who has been requested by the client and accepted by the provider. Enduring Guardian An Enduring Guardian is a legally appointed substitute decision maker for health care and lifestyle decisions only. In Tasmania, adults who have capacity are able to appoint an Enduring Guardian by completing the appropriate form and lodging it with the Guardianship Administration Board. A client s appointed Enduring Guardian can make decisions about their care on their behalf should they lack the capacity to be able to do so. Person Responsible A Person Responsible can be named and recorded by an individual on their Advance Care Directive. They are an identified person who can speak on the client s behalf (be their substitute decision maker) for health care and lifestyle decisions only if or when the client lacks capacity to make decisions about their own care. Enduring Power of Attorney In Tasmania, a person who has capacity can legally appoint an Enduring Power of Attorney to manage their money and property on their behalf, if or when they lack capacity to make their own financial decisions. The Enduring Power of Attorney can only manage money and property. They cannot act as a substitute decision maker for health care and lifestyle decisions. Shared Transfer of Care in Home Care 15

16 A Practice Framework

APPENDIX 2 Transfer of Care Plan for Home Care AFFIX PATIENT / CLIENT LABEL HERE FOR HEALTH SERVICE USE IF REQUIRED About this plan: To be completed by the case manager or care coordinator. This Transfer of Care Plan can be used when Home Care Packages (HCP) clients are transferring from one HCP provider to another when their care needs change. It may also be used when HCP clients are being admitted to hospital in a planned manner (e.g. for elective surgery) or when they are transferring to Residential Aged Care for respite or long term care. This tool is structured to reflect the ISOBAR acronym: Identification, Situation, Observations, Background, Action and Recommendations. The Red Flag Checklist may also be completed to highlight specific risks in the transfer process. CLIENT Name DOB Pension/DVA Number REFERRING AGENCY Name Position Care Programme/Level IDENTIFICATION Medicare Number Organisation Address CONTACT DETAILS In-hours PRIMARY CONTACT After hours Client Client Representative Address Phone Mobile Carer/Relative/Important people contact details: GP/General Practice contact details: Pharmacy contact details: SITUATION Reason for Care Transfer or Referral: Transfer from: (note HCP Level if relevant): Transfer to: (note HCP Level if relevant): What risk factors have you observed? e.g. chemical risks, falls, medication, nutrition OBSERVATIONS What enablers/strengths have you observed? e.g. family support, client insight, self care skills Shared Transfer of Care in Home Care 17

Transfer of Care Plan for Home Care (cont.) BACKGROUND What is the person s background: (include social and medical history, and as relevant; advanced care directive, substitute decision maker i.e. Enduring Guardian and/or Person Responsible, other care providers involved)? Past life information: e.g. occupations, interests, hobbies ACTION Assessments completed Results: e.g. Barthel Index, MMSE, IADL, MOCCA tool or other Red Flag Checklist completed: Yes No Date completed: Recommended/Current Care Plan Goals: (tick all relevant) Directed by client Directed by carer/substitute decision maker Set by Provider Care Domain Goals Services Needed By Whom By When Health Risk Minimisation Nutrition/Hydration Mobility Continence Medication Cognition, Mood & Behaviour Family/Carer Support (Note if primary carer is unwell or at risk) RECOMMENDATIONS Special Needs (e.g. ATSI, CALD) Management Plan for Medication: Medication Management Plan attached Medications supplied Medication List given to person/carer Medication Risks e.g. anticoagulants (e.g. Warfarin), narcotics, insulin (please note details): Other services providing care to the person, to whom a copy of this plan has been sent: Webster/Blister pack in use Name and address of service Contact name Service provided Name of receiving provider or organisation: Address & Phone: Family/carer/client provided with copy of transfer plan: Yes No Unknown Consent provided to share information: Yes No Discussed/shared with: Completed by: Organisation and role: Signature: Date: 18 A Practice Framework

APPENDIX 3 Consent to Share Information FIRST NAME LAST NAME DATE OF BIRTH (DD/MM/YYYY) ADDRESS SUBURB POSTCODE SECTION 1 INFORMATION TO BE SHARED As required for the provision of the care package (e.g. GP, medical specialist, other care providers) Note details: For specific services/individuals Note details: SECTION 2 RECORD OF CONSENT Written client consent: The worker/practitioner has discussed with me how and why certain information about me (as above) may be shared with other service providers. I understand this and I give my consent for the information to be shared. Signed Date (dd/mm/yyyy) OR Verbal client consent: I have discussed with the client how and why certain information may be shared with other service providers. I am satisfied that this has been understood and that informed consent for the information to be shared as above has been given. OR Client does not have the capacity to provide consent (i.e. they do not understand what they are consenting to, or the consequences) Consent given by authorised representative (name): There is no authorising representative or they were uncontactable, therefore the information will be shared as set out in the Australian Privacy Principles, 2014*. *If it is not reasonably practical to obtain consent from an authorised representative or the client does not have an authorised representative, health information can still be shared as set out in the Health Records Act 2001. This includes where the sharing of information is done by a health service provider and is reasonably necessary for the provision of a health service or where there is a statutory requirement. Shared Transfer of Care in Home Care 19

Consent to Share Information (cont.) WORKER/PRACTITIONER Tick the following when completed. This ensures that the client s authorised representative has made an informed decision about consenting sharing this information. Discussed with the client the proposed sharing of information with other services/agencies Explained that the client s information will only be shared with these services/agencies if the client has agreed and, when referring, advised that the referral can still proceed if the client does not want information disclosed Provided the client with information about privacy, such as the brochure Your Information It s Private Provided the client with a copy of this form when completed CONSENT OBTAINED WITNESSED BY: Name Position/Agency Contact number Signature Date Australian Privacy Principles information: https://www.oaic.gov.au/privacy-law/privacy-act/australian-privacy-principles 20 A Practice Framework

APPENDIX 4 Care Transfer Review Form Purpose: The purpose of this form is to guide community care practitioners in a process of reviewing Care Transfers within home care and in and out of home care. The aim is to find out: What worked well? What outcomes were achieved for the client/family/carers? What could be improved in the future? Philosophy: The philosophy of this review process is Active Learning which was reported by Ronald Revans in the 1980s to improve communication processes in hospital care in London. Prompt Care teams use this approach to continuously improve care practices and systems. Active Learning has the following cycle: First DO what is needed Then REVIEW what has occurred involve client and families Then LEARN together talk and discuss Then IMPROVE the tools and systems The most important thing is to maintain a learning attitude everyone can improve; everyone on the care team can continue to learn. Our clients and family carers can help us to learn! STEP 1: SUMMARISE THE BACKGROUND SITUATION Client s needs and preferences? Family/Carer s needs and preferences? When and why the Care Transfer was required? STEP 2: DESCRIBE THE CARE TRANSFER PROCESS What happened in the transfer? What tools, forms, resources were used? STEP 3: WHAT HAPPENED AS A RESULT OF THE CARE TRANSFER? DOCUMENT THE TRANSFER OUTCOMES: For the client: For the family/carer: For the service provider/s: Shared Transfer of Care in Home Care 21

Care Transfer Review Form (cont.) STEP 4: NOTE WHAT ISSUES/BARRIERS OCCURRED STEP 5: REFLECT AND IMAGINE, WHAT COULD HAVE BEEN IMPROVED? STEP 6: SUGGEST YOUR RECOMMENDATIONS FOR CHANGES INTO THE FUTURE IN HOME CARE TRANSFERS PLEASE NOTE Individuals/organisations involved (E.g. Carers, Providers and/or GP?) COMPLETED BY Name/s Position/s Organisation/s Date SHARED ACTIONS TO IMPROVE THE QUALITY OF FUTURE CARE TRANSFERS What When By Whom 22 A Practice Framework

APPENDIX 5 Red Flag Checklist for Home Care Transfer AFFIX PATIENT / CLIENT LABEL HERE FOR HEALTH SERVICE USE IF REQUIRED Purpose: This checklist identifies clinical and other red flag risks that may occur when a HCP client is transferring from one care arrangement to another. For example: into or out of hospital, into or out of a Residential Aged Care Facility or from one Home Care provider to another. This checklist may also be used when a person is being referred for a HCP from another service or programme (e.g. from a Home Support service) and it could be used when a package provider is making a referral to a subcontractor for brokerage care services. Who should use this checklist: This checklist can be used by health care professionals and care package teams, as well as family members and carers. Hospital staff may find it useful when discharging a Home Care Package client back to the community. How to use this checklist: This checklist is not prescriptive. It should be used flexibly, with questions answered according to information that is available at the time. This checklist should be completed pro-actively, and routinely on care package commencement. It should be provided to the client s GP and other care providers involved in personal or nursing care. It should also be provided to health care teams when the client attends the Emergency Department and on admission to hospital. CLIENT PERSON COMPLETING THIS FORM Name Name DOB Position/role Pension/DVA Number Organisation Medicare Number Address (inc postcode) Address (inc postcode) Phone Phone Mobile Mobile Discussed with: DATE COMPLETED Sent to: Carer/Relative/Important people contact details: GP/General Practice contact details: Pharmacy contact details: Home Care Package (HCP) Provider contact details: HCP Level: (circle) 1 2 3 4 or Wait-listed Yes / No (circle) Shared Transfer of Care in Home Care 23

Red Flag Checklist (cont.) 1. Does the person have medical needs that require attention? Yes No Unknown If yes, check the following as required: Comments/Details Diabetes History of recent or recurrent Urinary Tract Infections History of Pneumonia Other: (e.g. Delirium) 2. Does the person have dementia care needs that require attention? Yes No Unknown If yes, check the following as required: Comments/Details Possible undiagnosed dementia (cognitive changes) Diagnosis of dementia Challenging behaviours Other: 3. Does the person have recent care events that indicate a need for added attention? Yes No Unknown If yes, check the following as required: Comments/Details Recent falls Pain control needs Recent hospital admission Recent illness Other: 4. Does the person have particular medication needs or issues? Yes No Unknown If yes, check the following as required: Comments/Details Anticoagulants e.g. Warfarin Narcotics Recent medication change Insulin Other: 24 A Practice Framework