Karen Betony Clinical Nurse Educator Nurse Maude

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1 Karen Betony Clinical Nurse Educator Nurse Maude

2 Aim: to increase awareness of issues surrounding discharge to home-based health care services Objective: Refresh knowledge of discharge planning process Increase knowledge of referral to home based health care services in Canterbury Increase insight and understanding of the implication of poor discharge planning

3 What information do you need when a patient comes into your service? When do you receive this information?

4 In Canterbury, ALL referrals for nursing services including: hospital discharges for ACC District Nursing care; Rural DN; palliative care equipment; falls prevention and non ACC short term (<8 wks) home based support services go through Canterbury CCC Canterbury; Capital and Coast; Hutt Valley Their work includes: Clinical screening of referrals - meet criteria; legibility; all necessary information Allocate client to provider

5 Eligibility Criteria Description Service Referral Pathway Meals, Linen, Continence and Disability Supplies Fresh daily meal deliveries. Linen laundry and exchange service Health & Mobility shop for products and supplies needed to support community care. Eligibility criteria apply for subsidies. All services also available privately. To enquire about subsidies available or to arrange services privately contact Nurse Maude direct: ph Nurse Maude Community Services and Referrals Pathways NOTE: More than one service can be accessed at any one time. Nurse Maude work within a patient centred model of care and will do our utmost to coordinate care across our services working in partnership with you as their general practice team. More information about all our services is available at ACC District Nursing General Nursing Interventions and Wound Care as a result of Injury. Services Required as a result of injury. Current ACC claim. Physically requires service delivered in the home and/or complexity of care not suitable for general practice GPs refer directly to Nurse Maude Community Service Referrals Ph: Fax: Hosp refer through CCC General Homecare: General District ACC Homecare Specialist Nurses Crest Total Care Personal care and/or domestic assistance Nursing Maximise Independence for Serious Injury. Return to Independence Services Required as a result of injury. Current ACC claim. Assessed as eligible by ACC assessment service Referrals to Nurse Maude are managed by ACCESS. Put ACCESS on the ACC18 referral form and Fax to ACC Claims (Tell the patient they will be rung by a referrals manager and they will need to say they choose Nurse Maude) Urgent/Short-term Domestic Assistance must have CSC and not be living with able-bodied person. Personal Cares Urgent and shortterm care universally available on referral Long-term Requires assessment from relevant needs assessment service. Over 65: ph Disability, Chronic Condition, Mental Health: ph Lifelinks You may refer for urgent short-term services and simultaneously for an assessment for long-term entitlement. To put care in place for a short-term need or urgently pending assessment for longterm Fax to CCCC Phone: / General Nursing interventions. Wound Care. Non-blister packed medication administration. General community palliative care. IV Therapy Only available to those unable to access GP services (or where service not able to be delivered by GP). (NB cost barriers to GP access are in isolation not an accepted reason for eligibility) Specialist community nursing support for primary care management of complex patients. Includes: Specialist wound care; Continence; Stomal; Diabetes; Specialist palliative care All patients with a complex need requiring a specialist nursing / multidisciplinary approach to care CCCC Fax: Phone: / Intensive community rehabilitation targeted for Hospital Avoidance or Discharge Support for older adults Potential for recovery with home based rehabilitation within 6 weeks Able to transfer with one person The client s home is safe and appropriate Medically stable FAX referral to CREST liaison team: ph: Fax Resthome or hospital level care at home. Includes nursing and care delivered in an integrated individualised careplan. Requires OPH needs assessment for residential care eligibility. No WINZ assessment required for Total Care. NB. Referral form must state the patient would like to consider TOTAL CARE as alternative to residential. Referrals to SPOE ph: Fax Referral forms available on To ensure the care is provided by our service you must name NURSE MAUDE as the patient s chosen provider on the referral form. Alternatively ph Mary-Anne Stone to arrange to have us listed as your preferred provider for all referrals.

6 Home based support: Domestic assistance If patient has a Community Services Card and no able bodied person at home, they may be eligible Personal Assistance Generally eligible for 3 showers per week up 45 mins and will be reviewed after about 6 weeks. Aim to continue rehabilitation and reduce needs Generalist care District nursing Catheter management Continence management Diabetes care Medication management Palliative care Wound care/compression ACC Early supported discharge/ Community Rehabilitation Enabled Support Team (CREST)

7 Acute Demand Cardio thoracic Continence management and products IV Methadone Paediatric outreach and Palliative care Respiratory care Specialist Palliative care Stomal therapy Wound

8 Referral criteria Requires a home visit by a nurse in order to maintain a state of wellbeing. Is unable to access general practice or clinic for care due to mobility, finance, or transport barriers. Has no suitable person (relative or friend) to administer care in the home. Exclusions In residential care. If currently receiving CREST services any district nursing needs are referred to the CCCC by the CREST coordinator. Where possible, the CCCC ensures continuity of any previous district nursing provider. For other district nursing needs (outside of CREST) refer via CCCC. The referral guidelines for Community nursing and Specialist nursing services are available on Health Pathways at

9 When to start? What can patient /family do for themselves? Who is the best person to manage ongoing care? What fits with patients lifestyle? What does the patient want? Do they really need additional services just in case? What can be done prior to discharge?**

10 Assessed for equipment many patients could manage without home based support i.e showering if a shower stool is provided on discharge If a patient needs pressure relieving equipment up to discharge- they will need it at home Medications arranged up to 50% of patients discharged to community miss doses of medication immediately after discharge including warfarin, high dose steroids. If a dose due within an hour of discharge, please administer before they leave Providers can be contacted for case discussion send referral to CCC and request nurse contact the dept/ward, if complex case

11 What information do community providers need when a patient comes into their service? When do they need to receive this information?

12 Include this information in your referral: Date of referral and Name of referrer Date when the service needs to start. Patient condition and diagnosis Reason for referral Specific condition details, ie, Catheter insertion date and details, wound treatment chart Current Medications and the name of community pharmacy. Medication Chart if required The patient's preferred provider: - specific provider may only be available for some conditions. - providers currently working with the patient e.g., home support service providers, CREST. Information regarding barriers preventing the patient's accessing to other services e.g., general practice. Known risks that the nurse may encounter when making a visit e.g., home detention, security while in ED or hospital, unsafe home environment, history of violence, undesirable associates Discharge Summary

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15 Send referral before the patient leaves the ward. Referral can be sent several days before discharge- it is easier to cancel a visit that set up the service late in the day If you send a referral late in the day to start that evening or early the following morning, especially for a large package of care - this may be declined Ask if a patient has a current or preferred provider. Ask if they want to change current provider if returning to service. If a patient contacts ward after leaving saying they can t manage- send urgent referral Medication management: if supervision to ensure taking on time etc., no blister pack required If need assistance taking medication: blister pack needed and yellow card If prescribed medication, including cream, eye drops, etc., to be given : medication chart needed. Be specific of reason for referral - just pop in or check following discharge is not appropriate

16 The boks or the hospital of angry nurses larajan.blogspot.com

17 Delayed discharge from hospital Confusion Deterioration in condition Insufficient equipment- shower stool, pressure relieving equipment care = cannot be given Insufficient information-patient has to repeat themselves; key information remains unknown by provider. Readmission to hospital Delayed visit-missed health care: meds, wound care; catheter care; Disconnected care

18 Communication Professional courtesy Patient centred approach

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