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Sir Charles Gairdner and Osborne Park Health Care Group:
Committed staff, clever researchers – caring for patients
How I became a juggler
Managing the needs and demands of
all stakeholders on the pathway to
Transition Care
Amanda Humphreys, NMHS Transition Care Central Coordinator
TCP in WA
Residential and restorative
pathways
Metropolitan:
Residential and community programs
Rural:
the Great Southern, the Midwest and the
South West. TCP Community services are
available.
TCP in WA
Residential and restorative pathways
Metropolitan and rural There are three rural
areas in which TCP is delivered; the Great
Southern, the Midwest and the South West.
In these areas, TCP Community services
are available.
Residential and community programs
Central Coordination
Model of TCP Management
Pre 2011
The new way
Process
Responsibility
The stakeholders
The patient
Their family and significant others
The referring hospital
The treating team
The area health service
The TCP providers
The Department of Health
Government
The TCP Central Coordinators
The TCP patient in the system
The patient
Family/carers
Treating team
Referring hospital
Area Health service
TCP Providers
WA Dept of Health
Government
Patients
Core values care based on:
Respect
Choice and empowerment
Equality and access
Emotional support
Information
Involvement of carers and families
Patient involvement in health policy
Patients
“I wanted to know someone would help me get better to get home”
“I know they don’t want me to stay in hospital any longer then I have to. They need the beds for sick people”
“I want to go home but I know I probably can’t and I need time”
Family and carers
Expectations
Concerns and needs
Impact of consumerism
Treating Team
Professional assessments and opinions
Direct patient care imperatives
Hospital demands:
Sir Charles Gairdner Hospital
NEAT:
Admitted, transferred or discharged
within four hours
Impact on patient flow
ABF
Funding based on patient activity
DRGs and impact on patient flow
The Budget
North Metropolitan Health Service
Perth metro : NMHS & SMHS
Hospital medical and surgical services to adults @ SCGH, OPH, Swan Districts, Kalamunda and Joondalup hospitals
1749 beds, 3000 m2, 1 million=40% of State
TCP Providers
Organisational demands and goals: NMHS
= 2 organisations
Reputation and credibility
Budgets
Managing resources in patient care
Health Department of WA
Contractual requirements and constraints
Herding cats
Interplay with Providers and TC
Coordinators
Government
Steering the ship: National guidelines
Policy on ageing
State versus Federal in implementation
Juggling the system: becoming
comfortable with discomfort
Central Coordinator
Patient and family
Health system
TCP Providers
Juggling skill set
Teamwork
Communication
Leadership
Conflict resolution and negotiation
Systems Theory
Managing external pressures
Aged Care Reform impact
Contractual lag and constraints
Location, accessibility and satisfaction
Strategies
Information, information, information
Listening, the lost art
Collaborative problem solving
Chocolates and strategic thinking
Education Working Party
Process mapping – identification of
education needs
Representation of perspectives
Survey
EWP Survey: True or False
The good ones
Handovers are essential when transferring a
patient to TC (TRUE)
Both residential and community based TC is
available (TRUE)
Patients/families receive a "TC Fact Sheet" from
the hospital Social Worker when discussing TCP
as an option (TRUE)
All patients admitted to TCP will be discharged to
a residential aged care facility (FALSE)
Highest incorrects
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
rehabilitation Nursing handov at anytime
IV antibiotics are NOTeligible
functioning is expectedto decline
Incorrects
Highest Not sures
29.20%
29.40%
29.60%
29.80%
30.00%
30.20%
30.40%
30.60%
30.80%
31.00%
TCP fees must be paidregardless of economic
circumstances
Nursing handovers may beprovided to the TCP facility atany time after the referral is
made
All TCP facilities have singlerooms with ensuites
Not Sure
EWP Survey: We Like
44.0%
46.0%
48.0%
50.0%
52.0%
54.0%
56.0%
58.0%
60.0%
Brochure Group Education Profession specific educationsession
We Like
EWP Survey: The Top Three
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
Health site education includingcase studies
Website Profession specific educationsessions
The Top Three
EWP Survey: No, thanks
62.0%
64.0%
66.0%
68.0%
70.0%
72.0%
74.0%
76.0%
78.0%
80.0%
82.0%
84.0%
DVD Podcast
A Definite No
From Here to eternity…
Change is constant
Electronic referral and database system
Contracts and relocations
Budgets
More of the same, less of the same