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Introduction

Maximising the ACAT role within the Transitional Care Program across the ACT. Presented by Athalene Rosborough Manager ACT ACAT Annelies Konon ACAT Assessor 29 th May 2008.

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Introduction

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  1. Maximising the ACAT role within the Transitional Care Program across the ACT.Presented by Athalene Rosborough Manager ACT ACATAnnelies Konon ACAT Assessor29th May 2008

  2. The Transitional Therapy Care Program (TTCP) has enhanced capacity of frail elderly to access rehabilitation care in either the home and/or residential environment. It aims to assist the restorative process and optimise functional capacity. The ACT Aged Care Assessment Team has found the introduction of the TTCP program presents new challenges in relation to meeting an already heavy demand for ACAT assessment. Introduction

  3. Population 322,600 (ABS 2003 Census) Population of demographic region that the ACT covers is 518,000 (ABS 2003 Census) ACT is forecasted to have the highest aged growth rate nationally at 12% over the next 15 years. Australian Capital Territory demographics

  4. Summary of population for each district of the ACT

  5. Population Projections by Age Group which uses the 2001 census as a base ACT 2007 -2021

  6. ACT Health Services related to TTCP • Public hospitals – The Canberra Hospital 500 beds and Calvary Public Hospital 174 beds • Private hospitals – Calvary John James 100 beds, Calvary Private Hospital 97 beds and National Capital Private Hospital 82 beds. • Rehabilitation Units – 5 units across the public and private domains with ACAT visiting some of these units in relation to the TTCP.

  7. ACT ACAT sits within the Aged Care and Rehabilitation Service (ARCS)and aims to support a process that provides • A single point of entry for all Aged Care & Rehabilitation Program Services. • Initial triage and assessment to determine appropriate referral to services. • Reduce duplication and inappropriate referrals.

  8. ACT ACAT • One ACAT team that covers the ACT region. • Managed by ACT Health with a FTE of 14.8 including Manager and located within the Aged Care and Rehabilitation Service. • Multidisciplinary team with strong links to Geriatricians, Gerontology Nurse Practitioners, Falls Prevention, RACLN, Rehabilitation and Community Health Services. • Based at a community location.

  9. ACT ACAT activity Nov 07 – April 08

  10. ACT TTCP Program • The ACT TTCP program is a collaboration between ACT Health and Baptist Community Services. • The program has a home based community service for 20 clients and a residential unit for 15 clients. • Referral for the TTCP program is made to both Baptist Community Service and ACAT.

  11. Issues faced by the ACAT team with the introduction of the TTCP program • Increased demand for ACAT assessments on limited resources. • Difficulty meeting demand for TTCP in a timely manner that did not impinge on ACAT meeting community and hospital commitments. • Fractured referral process to ACAT and TTCP program with a lack of appropriate structure to facilitate access. • Misconceptions about focus and limitations of TTCP

  12. Transitional Therapy Care Program Transitional Therapy Care Program criteria defines that individuals should be: • Aged 70+, 50+ for ATSI • Completed an episode of acute and/or subacute care who require more time and support in a non-hospital environment to complete their restorative process. • Medically stable and ready for hospital discharge • Identified rehab goals and capacity to benefit from a package of services that include at least low intensity therapy and support services • Independently mobile with walking aid/wheelchair • Safe and determined discharge destination • Cognitively able to participate in an active rehabilitation program

  13. The ACT ACAT’s solutions • Allocated appointments for all hospital ACAT assessments. • Revisited the goals of the TTCP program and ACATs role. • Identified a need for better communication and collaboration with all stakeholders. • Agreed on processes between TTCP and ACAT to decrease confusion with health care providers.

  14. ACAT Solutions cont’d With further consideration ACT ACAT decided to: • Provide a designated TTCP ACAT assessor to consult, triage, book and assess all TTCP requests across the ACT. • Formalised processes for TTCP that consider the specific needs or goals of both ACAT and TTCP. • Maintain a collaborative process between Intake of referrals, ACAT and our TTCP provider. • Support the uptake of the TTCP program with education to all stakeholders through ACAT education and links with the TTCP education.

  15. Ongoing considerations that we face with the TTCP • Complexity of the client group that the Aged Care Assessment Program supports and willingness to use programs such as TTCP. • Required staff skill mix within the TTCP program and how to link to other health services as part of the rehabilitation process. • How to improve or support the clients journey through the health and/or aged care system care into the future.

  16. Thank You

  17. Questions

  18. ACT Government Intranet - health@act.gov.au Trends and future Estimates in the Provision of Aged Care services in the ACT Smart and Kay Pty Ltd April 2008. Australian Bureau of Statistics Cat 322.0 Population Projections Australia 2004-2101Series A, released 2005 Transitional Care Training Handbook, Commonwealth of Australia 2006 References

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