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Acute/Post Acute care ( APAC) Northern Sydney Area Health Service Acute /Post Acute Care A multidisciplinary team of clinicians including Acute /Post Acute Care A multidisciplinary team of clinicians including Accredited Registered Nurses and Respiratory Nurse Specialist Acute /Post Acute Care A multidisciplinary team of clinicians including Accredited Registered Nurses and Respiratory Nurse Specialist Physiotherapists Acute /Post Acute Care A multidisciplinary team of clinicians including Accredited Registered Nurses and Respiratory Nurse Specialist Physiotherapists Occupational Therapists Acute /Post Acute Care A multidisciplinary team of clinicians including Accredited Registered Nurses and Respiratory Nurse Specialist Physiotherapists Occupational Therapists Pharmacists Acute /Post Acute Care A multidisciplinary team of clinicians including Accredited Registered Nurses and Respiratory Nurse Specialist Physiotherapists Occupational Therapists Pharmacists Social Workers Acute /Post Acute Care A multidisciplinary team of clinicians including Accredited Registered Nurses and Respiratory Nurse Specialist Physiotherapists Occupational Therapists Pharmacists Social Workers Community Care Aids APAC Model of Care • Community Care in patient’s usual residence including hostels, nursing homes, group homes and respite facilities APAC Model of Care • Community Care in patient’s usual residence including hostels, nursing homes, group homes and respite facilities Provide treatment APAC Model of Care • Community Care in patient’s usual residence including hostels, nursing homes, group homes and respite facilities Provide treatment Provide education APAC Model of Care • Community Care in patient’s usual residence including hostels, nursing homes, group homes and respite facilities Provide treatment Provide education Prevent recurrent disease in an attempt to reduce hospital admissions APAC Model of Care • Community Care in patient’s usual residence including hostels, nursing homes, group homes and respite facilities Provide treatment Provide education Prevent recurrent disease in an attempt to reduce hospital admissions Promote quality of life Expected outcomes Clinical improvement Expected outcomes Clinical improvement Improved health status and function Expected outcomes Clinical improvement Improved health status and function Identification and management of risk factors Expected outcomes Clinical improvement Improved health status and function Identification and management of risk factors Referral to community support services if required Community Acquired Pneumonia (CAP) Defined as a pneumonia occurring in individuals currently not hospitalized or those who have been in hospital for < 48hrs CAP- Causative Agents Bacteria Fungi Viruses Parasites Most Common Organisms Defined by Culture Streptococcus Pneumoniae Haemophilus Influenzae Staphylococcus Aureus Mycoplasma Moraxella Catarralis Legionella Species APAC admission criteria Lives (or treatment will be provided) within the Northern Sydney Local Area Health Service APAC admission criteria Lives (or treatment will be provided) within the Northern Sydney Local Area Health Service Patient and/or carer/guardian consents to APAC service APAC admission criteria Lives (or treatment will be provided) within the Northern Sydney Local Area Health Service Patient and/or carer/guardian consents to APAC service Safe environment for treatment APAC admission criteria Lives (or treatment will be provided) within the Northern Sydney Local Area Health Service Patient and/or carer/guardian consents to APAC service Safe environment for treatment Designated medical provider for clinical management and review process APAC admission criteria Lives (or treatment will be provided) within the Northern Sydney Local Area Health Service Patient and/or carer/guardian consents to APAC service Safe environment for treatment Designated medical provider for clinical management and review process Clinically stable Referral Process General practitioner Hospital Respiratory or General physician Community services Patient generated admission CAP may occur as; Acute Illness CAP may occur as; Acute Illness Acute on Chronic Illness Acute Illness Clinical management plan established and co-morbidities assessed Consideration given to the pneumonia severity index Allergies noted Venous access Acute on Chronic Illness Clinical management plan established to reflect chronic illness which may include: Chronic Obstructive Pulmonary disease ( COPD), bronchiectasis, cardiac failure, liver disease, renal impairment, prior hospitalization, confusion, malignancy Clinical management Plan Medical management defined and length of treatment prescribed Clinical management Plan Medical management defined and length of treatment prescribed Oral vs Intravenous antibiotics Clinical management Plan Medical management defined and length of treatment prescribed Oral vs Intravenous antibiotics Recent pathology, investigations, spirometry Clinical management Plan Medical management defined and length of treatment prescribed Oral vs Intravenous antibiotics Recent pathology, investigations, spirometry Functional assessment Clinical management Plan Medical management defined and length of treatment prescribed Oral vs Intravenous antibiotics Recent pathology, investigations, spirometry Functional assessment Psychosocial assessment Prior to admission Medical Management established Prior to admission Medical Management established Review plan arranged Prior to admission Medical Management established Review plan arranged APAC visiting times/policies explained Prior to admission Medical Management established Review plan arranged APAC visiting times/policies explained Consent obtained Prior to admission IV accessed established via IVC, PICC, CVAD Prior to admission IV accessed established via IVC, PICC, CVAD Chronic illness assessed and interdisciplinary plan established Prior to admission IV accessed established via IVC, PICC, CVAD Chronic illness assessed and interdisciplinary plan established Medications dispensed Prior to admission IV accessed established via IVC, PICC, CVAD Chronic illness assessed and interdisciplinary plan established Medications dispensed Previous allied health assessments noted First home visit Conducted by accredited registered nurse First home visit Conducted by accredited registered nurse Establish a baseline assessment as per respiratory care plan First home visit Conducted by accredited registered nurse Establish a baseline assessment as per respiratory care plan Determine pre illness functional level First home visit Conducted by accredited registered nurse Establish a baseline assessment as per respiratory care plan Determine pre illness functional level Provide education re treatment and condition First home visit Conducted by accredited registered nurse Establish a baseline assessment as per respiratory care plan Determine pre illness functional level Provide education re treatment and condition Assess pharmaceutical knowledge First home visit Conducted by accredited registered nurse Establish a baseline assessment as per respiratory care plan Determine pre illness functional level Provide education re treatment and condition Assess pharmaceutical knowledge Administer medications as required First home visit Organize services/equipment First home visit Organize services/equipment Medical liaison as required First home visit Organize services/equipment Medical liaison as required Advice on management of breathlessness First home visit Organize services/equipment Medical liaison as required Advice on management of breathlessness Refer to APAC clinicians as required- physiotherapist, occupational therapist, pharmacist, social worker. First Home Visit Vital signs First Home Visit Vital signs Oximetry at rest and post exertion First Home Visit Vital signs Oximetry at rest and post exertion Blood sugar level First Home Visit Vital signs Oximetry at rest and post exertion Blood sugar level Assess bowel and bladder function First Home Visit Vital signs Oximetry at rest and post exertion Blood sugar level Assess bowel and bladder function Assess Pain – pain scale First Home Visit Vital signs Oximetry at rest and post exertion Blood sugar level Assess bowel and bladder function Assess Pain – pain scale Weight First Home Visit Vital signs Oximetry at rest and post exertion Blood sugar level Assess bowel and bladder function Assess Pain – pain scale Weight BORG Assessment First Home Visit Assess breath and heart sounds Note any cyanosis ( peripheral or central) Note peripheral oedema Assess cough Assess secretion clearance Demonstrate and practice active cycle breathing technique (ACBT) First Home Visit Assess exercise tolerance Assess fluid and dietary intake Attend any dressings as required Supervise medication as required Provide education and rest/activity Subsequent visits Continue ongoing treatment as per plan Referral to respiratory nurse specialist as required Ongoing assessment from allied health professionals as required Consolidation of patient/carer education Medical Liaison Expected Outcome Patient is reviewed by the medical professional responsible for care ( or an advocate) and the condition has resolved to the point of no longer requiring APAC support Patient care is tranferred to the allocated medical professional and or community services Discharge Discuss review outcome with medical professional responsible for the patient’s care Refer to community services as required Referral to pulmonary rehab as needed Keys to Process Single Point access referral Keys to Process Single Point access referral Documentation clear and precise Keys to Process Single Point access referral Documentation clear and precise Communication pathways between APAC and patients/clinicians Keys to Process Single Point access referral Documentation clear and precise Communication pathways between APAC and patients/clinicians Accurate and timely co-ordination of home visits Keys to Process Single Point access referral Documentation clear and precise Communication pathways between APAC and patients/clinicians Accurate and timely co-ordination of home visits Skilled community clinicians Keys to Process Single Point access referral Documentation clear and precise Communication pathways between APAC and patients/clinicians Accurate and timely co-ordination of home visits Skilled community clinicians Service promotion to encourage hospital avoidance in those patients deemed suitable for APAC care Questions??
