Caulfield General Medical Centre

Tool kit for care of frail aged

The team:Dr Max AlexanderA/Prof David FondaA/Prof Lexie ClaytonChristine Millsteed

Intro. to Bayside Health

SDMH 90 bed community hospED, Obstets, ElectiveSurg, Medicine

The Alfred 315 Acute beds / 80 Psych beds. Tertiary hospital with prominent services in Emergency Department, ICU, trauma, cancer, ID, specialist medicine (eg cardiol and respiratory)

CGMC 120 Aged Care bedsincluding 33 acute gen medand 66 specialized AC beds78 Rehab beds ambul’y /home options120 RCS incl 65 Interim45 beds APS

Bayside ChallengesGeneral

ED Performance (by-pass, waiting times)

Elective Surgery blocked by emergencies;

Surgical admissions

Medical Admissions

Specific for Aged Care

Demography: frail aged in catchment

Maximizing turnover of aged care beds

RCS beds in community

Pressure on community care based options

The Strategic Imperative

Improving care of the frail aged is a prominent part of the Bayside strategic plan.

Present state:Some leading edge innovationsFragmented connections (randomness)Excess demand which is increasing

Opportunity to build on things that work and integrate the pieces

Tool kit

Covers services oriented to care of frail elderly across the spectrum

We offered collaborators the opportunity to take up co-work in an area(s) that matches their development

We fully expect to learn as much back.

‘Tool kit’ Highlights

Pre-hospital

•RAS & MATS

•HITH

•HARP (new)

Inpatient

•Bridging

•Disease Management

•Falls Prevention

•Continence Care

•RAU

Discharge to Community

• TITH

•Care Packages (RAS)

'Speed up'30 day + PtsDischarge

From CG M C

Transfer The AlfredBed AuditTo CG M C

Bed Audit

'30 daysto

5 days'

Prom ote earlydischargeCognitive

Im paired Pts

Early Discharge

Timely accesstheir

patientsresults etc

IntroduceEPR

O n-lineeg Hosp - G Ps

ElectronicPatientRecord

Enhancem ents