LMNCC Transition Care
Making a Difference
Prepared by :
Michele Anderson & Kim Bailey 2013
• LMNCC TACP is community based
• Currently 28 places are allocated to Lower Mid
North Coast Cluster
• Local Referral Hosp...
• Coastal
• % Retirees
• Rural
• % Isolation
AREA
• Due to LMNCC area, distances travelled ,
staffing resources TACP currently covers:
– Forster, Tuncurry, Hallidays Point,...
Limited or no services available
OPTIONS
• TACP
• Assist at home
• Carer Support
• Plan for future
• Registered Nurses, Enrolled Nurses,
• Physiotherapist,
• Occupational Therapist
• Hospital Assistant.
• Access to dietet...
• LMNCC TACP is located within the Aged Care
and Rehabilitation Service building
• Provides ready access & works closely w...
Client Outcomes Monitored
• Multidisciplinary Care Plans are developed
with the client, family, carer’s, GP’s, service
pro...
Discharges 1/01/2012 – 1/01/2013
Outcomes 1/01/2012 – 1/01/2013
LOCAL AREA
Rural Obstacles
CHALLENGES
Case Study - Background
• Beth is a 77 yo woman who lives alone on a beef cattle
property. She has 3 children with two dau...
• Cognitive Behaviour/Psychological Aspects.
• Mobility
• Self-Care:
• IADL’s:
• Bartels
• Home Environment
Case Study- Fu...
Case Study
• Goals for program
• To return to driving tractor
• Safe mobilisation around garden and be safe
in house yard....
Challenges and Triumphs
• Rehabilitation hindered due to rheumatoid arthritis
and pain- slowed progression.
• Poor mobilit...
Case study - Interventions
Physio OT Nursing Speech Dietician
Assessment
Mobilising with
4ww indoors and
outdoors.
Walking...
Progress and Outcomes
Week 1
initial assessments-
mobilising 30 m
around home.
Assist with
personal care
Week 3-4
50 m wit...
Beth’s Journey Continues
Week 7-9
Step ups x5 each leg
Independent with
tractor transfers
Patient drove off on
the tractor...
Beth’s TACP Experience
Beth Planning for Goals
Goals achieved
Making a Difference for Older People
This is Why We Do What We Do
• Aged Care & Rehabilitation Services
»65151800
LMNCC TACP
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Michele Anderson & Kim bailey, Hunter New England Local Health District - Making a difference – Unique Challenges of Providing TaCP in a Rural Area

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Michele Anderson, Acting CNC/Team leader and Kim Bailey, Registered Nurse, TACP, Aged Care Services,
Hunter New England Local Health District delivered the presentation at the Transition Care: Improving Outcomes for Older People Conference 2013.

The Transition Care: Improving Outcomes for Older People Conference explores a combination of residential and community transition care programs. It also features industry professionals' experiences in transitional aged care, including the challenges and successes of their work.

For more information about the event, please visit: http://www.communitycareconferences.com.au/transitioncareconference13

Published in: Healthcare, Health & Medicine
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Michele Anderson & Kim bailey, Hunter New England Local Health District - Making a difference – Unique Challenges of Providing TaCP in a Rural Area

  1. 1. LMNCC Transition Care Making a Difference Prepared by : Michele Anderson & Kim Bailey 2013
  2. 2. • LMNCC TACP is community based • Currently 28 places are allocated to Lower Mid North Coast Cluster • Local Referral Hospitals include Manning Rural Referral Hospital, Wingham Rehabilitation Hospital, two Private Hospitals , Introduction
  3. 3. • Coastal • % Retirees • Rural • % Isolation AREA
  4. 4. • Due to LMNCC area, distances travelled , staffing resources TACP currently covers: – Forster, Tuncurry, Hallidays Point, Failford, Nabiac – Tinonee, Old Bar, Wingham, Taree, Harrington – Coopernook, Lansdowne – Rural challenges include isolation, limited transport, communication, reduced medical services Location
  5. 5. Limited or no services available
  6. 6. OPTIONS • TACP • Assist at home • Carer Support • Plan for future
  7. 7. • Registered Nurses, Enrolled Nurses, • Physiotherapist, • Occupational Therapist • Hospital Assistant. • Access to dietetic & social work services • No brokerage to any other service provision LMNCC TACP TEAM
  8. 8. • LMNCC TACP is located within the Aged Care and Rehabilitation Service building • Provides ready access & works closely with: ACAT staff , Geriatrician ,Clinical Nurse Consultants, Nurse Practitioner, Social Work, Speech Pathology, Podiatry and Dementia Support. Unique & Direct Access to Services
  9. 9. Client Outcomes Monitored • Multidisciplinary Care Plans are developed with the client, family, carer’s, GP’s, service provider’s • Case Management Reviews - weekly & as needed • Multidisciplinary team meetings - weekly
  10. 10. Discharges 1/01/2012 – 1/01/2013
  11. 11. Outcomes 1/01/2012 – 1/01/2013
  12. 12. LOCAL AREA
  13. 13. Rural Obstacles
  14. 14. CHALLENGES
  15. 15. Case Study - Background • Beth is a 77 yo woman who lives alone on a beef cattle property. She has 3 children with two daughters living locally • Beth was referred to TACP by Wingham Aged Care and Rehabilitation Service post CVA complicated by pneumonia. Beth had been in rehab for ----- weeks. • Past medical Hx – Hyperthyroidism, Asthma, pace maker, Unsuccessful r/o cataracts, # vertebrae- chronic lower back pain, rheumatoid arthritis.
  16. 16. • Cognitive Behaviour/Psychological Aspects. • Mobility • Self-Care: • IADL’s: • Bartels • Home Environment Case Study- Function on Discharge from Hospital
  17. 17. Case Study • Goals for program • To return to driving tractor • Safe mobilisation around garden and be safe in house yard. • To be able to hang washing out • Independence with personal care.
  18. 18. Challenges and Triumphs • Rehabilitation hindered due to rheumatoid arthritis and pain- slowed progression. • Poor mobility on DC from hospital. • SOB • Poor vision • Fatigue and nausea • Very challenging goal • Reaching the goal through sheer determination
  19. 19. Case study - Interventions Physio OT Nursing Speech Dietician Assessment Mobilising with 4ww indoors and outdoors. Walking stick indoors Step ups Hand exercises Education Grab Rails Personal care assessment Cognitive assessment Upper limb assessment Daily Visits Observations Assist with personal care encourage independence Supervise HEP Swallowing and language assessment Dietician assessment. symptoms such as poor appetite, taste changes and early satiety plan of 6x small meals per day with high energy options.
  20. 20. Progress and Outcomes Week 1 initial assessments- mobilising 30 m around home. Assist with personal care Week 3-4 50 m with 4ww around house. Hand exercises 10m 4ww on grass- supervised Step ups 2 each leg Assist with personal care. Alternate sponge with shower. Wee k 5-7 40m 4ww on grass Tractor transfer managed well with supervision 3 step ups each leg Became confident to attend wash independently assist with shower.
  21. 21. Beth’s Journey Continues Week 7-9 Step ups x5 each leg Independent with tractor transfers Patient drove off on the tractor Independent with shower. Week 9 Final physio- independent with 4ww outside Independent inside short distances with stick Grip strength and finger coordination improved. Regularly driving tractor. GOALS ACHIEVED A JOB WELL DONE !
  22. 22. Beth’s TACP Experience
  23. 23. Beth Planning for Goals
  24. 24. Goals achieved
  25. 25. Making a Difference for Older People
  26. 26. This is Why We Do What We Do
  27. 27. • Aged Care & Rehabilitation Services »65151800 LMNCC TACP

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