Download CAP REPORTING PROFORMA: PATIENTS AWAITING

Department of Health
Government of Western Australia
OPERATIONAL DIRECTIVE
Kathy Stack
Tel.: (08) 9222 4318
Supersedes:
OP2067/06 (11/05/2006)
OP1882/04 (02/12/2004);
OD 0043/07
29 March 2007
06-04797
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OP1576/02 (01/08/2002)
Number:
Date:
File No:
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Enquiries to:
Technical Bulletin 73/0 (01/07/2002)
Subject:
1. Purpose
CARE AWAITING PLACEMENT PROGRAM AND OTHER TRANSITION CARE
OPTIONS FOR THE ELDERLY
Care Awaiting Placement (CAP) has been developed to provide time limited transition care options
for aged care patients who are waiting in a public hospital bed for alternative aged care services to
become available.
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The following guidelines have been developed to provide a standardised foundation for the
operation of transition options across all Health Services in the metropolitan area. Each Health
Service has site specific procedures that they follow in regard to these transition options. The aim
of the guideline is to foster consistency in approach whilst enabling site specific procedures to be
utilised.
2. Background
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A number of transition care options for the elderly are available in Western Australia. These
include:
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Residential CAP,
Home Care Packages CAP (formerly Home Care Packages and Elderly Post Acute
Services),
• Transition Care Program
The primary aim of transition care options is to relocate patients who are waiting in a public
hospital bed and who no longer require acute care by discharging them into non-hospital care or
where possible to the patient’s own home. This relocation makes available public hospital beds for
other patients who require acute medical or surgical care. This transition care is provided in an
environment and with a style of care conducive to the aims of optimising the patient’s level of
independence whilst smoothing the transition to home or to residential care.
Principles and Minimum Standards
The following principles and minimum standards apply in caring for patients who are eligible for a
CAP service or a Transition Care Program:
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The processes and policies are administered with compassion and take into account the
individual needs of the patient and their carer or family
The patient and their carer or family are provided with sufficient information in a form that
fosters understanding and awareness of expected stages of care. This includes information
on the alternate pathways of residential care planning if returning home is no longer an
option, or accessing community support services where the plan is to return to their usual
place of residence.
Patients and their carer or family have unencumbered access to appropriate staff including
social workers to assist them through the process of arranging appropriate long-term care.
The patient and their carer or family understand and are able to assert their right to
compliment or complain and to have their complaints dealt with promptly and impartially.
A clearly defined Care Pathway is available for use and reference by health service staff at
all points in the continuum of care. The Care Pathway is the foundation for information
delivery to all stakeholders in the care of the patient.
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3. Residential CAP
Residential CAP is a fully state funded program designed to temporarily accommodate and care
for elderly patients who are in a public hospital and are waiting for permanent residential
placement (low or high).
Underlying Philosophy: To provide temporary care for elderly patients waiting for admission to a
residential facility whilst allowing beds to be available in a public hospital for other patients
requiring acute hospital intervention including elective surgery.
Access priority
Access priority to CAP residential beds is dependent on bed availability and at the discretion of the
Health Service CAP Coordinators.
PE
First priority to residential CAP beds is to be given to patients from public hospitals. Patients who
are at risk of being admitted to a public hospital are the next priority. In special circumstances
other patients can be considered for entry into residential CAP.
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Public hospital patients are eligible to access CAP residential beds outside their health region.
This option, which depends on bed availability, is at the discretion of the Health Service CAP
Coordinators.
Patient profile: The elderly patient
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Has a current Aged Care Client Record (ACCR Form 3020 [0405]) recommending low or
high permanent residential care, as assessed by the Aged Care Assessment Team
(ACAT).
Is deemed medically ready for discharge by the treating team
Is occupying a public hospital bed or is at risk of admission to a public hospital
Is confirmed to have commenced residential care planning and is actively seeking preferred
places
Family or advocate is aware that he/she will be discharged to the first available vacancy for
which they are waitlisted
Family or advocate is aware that if no vacancies arise they will be requested by the social
worker to choose additional residential facilities.
Target Time frame: to a maximum of 12 weeks
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3.1 Role and Responsibilities
3.1.1 Transferring Health Service
It is the responsibility of the transferring Health Service to ensure that:
• The patient is medically stable and deemed appropriate for transfer to a CAP facility
• The placement process has been planned and the plan is actioned prior to the patients
transfer to the CAP Unit. This should be coordinated via the Health Service CAP
Coordinators.
• A detailed hand-over is supplied to the CAP facility via the Health Service CAP
Coordinators including the specialist needs of the patient as well as any family issues of
concern. This should include outstanding outpatient and medical appointments.
• Nursing assessment has been identified and communicated to the CAP unit to address
technical nursing skills, experience and competencies that may be needed to care for the
person (e.g. CAPD, SC infusions and/or medications, PICC line etc)
• Any behavioural presentations are accurately defined and communicated such that optimal
safety of other patients and staff can be considered and appropriate bed allocation is
ensured.
• The patient and their family and carer is clearly informed of the temporary or transitional
nature of the CAP residential service, of fees and charges and of their rights to compliment
and complain about the service
• CAP Reporting is accurate and maintained weekly.
PE
3.1.2. Admitting CAP Facility
It is the responsibility of the admitting CAP Service to ensure that:
• The patient receives a detailed assessment of needs and a plan of care is documented and
actioned
• The placement process is progressed in a timely and sensitive manner
• The patient and their family and carer is clearly informed of the temporary or transitional
nature of the CAP residential service, of fees and charges and of their rights to compliment
and complain about the service
• If the patient again requires acute care, they will be transferred to an acute care facility in a
timely manner,
• Maintain adequate records of patients and ensure that evaluation criteria are recorded and
reported weekly.
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4. Home Care Packages CAP
Home Care Packages (HCP) has been created through the combination of what has previously
been referred to as “Home Care Packages (HCP)” and “Elderly Post Acute Services (EPAS)”.
HCPs are part of the CAP program and as such are fully state funded.
Underlying Philosophy: To allow the frail elderly who have been discharged from a public
hospital following an episode of acute illness to return home with the assistance of support
services. The service is also targeted at the frail elderly who are at risk of readmission to hospital
allowing them to remain in their own home with the assistance of a support network.
The service aims to provide short-term care that is related to improving the health status and
independence of the patient. The packages can provide therapy or non therapy based services
and post acute care treatment services. It is not a substitute for hospital care. The service may
provide a short-term alternative for patients waiting for other services, though all other care options
should be explored before the package is activated.
Access Priority:
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Access priority to HCPs is dependent on the availability of a package and at the discretion of the
Health Service HCP Coordinators.
First priority to HCPs is to be given to elderly patients who are ready for discharge from a public
hospital. Patients who are at risk of being readmitted to a public hospital following a recent
discharge are the next priority.
Patient Profile:
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Public hospital patients are eligible to access HCPs from outside their health region. Often patients
are admitted to hospitals outside their home area. In planning an appropriate discharge it may be
more appropriate for continuity of care to consider arranging a HCP with the Health Service HCP
Coordinator close to the patient’s home. If the discharging Health Service provides an HCP to a
client outside their region this service is able to request full cost recovery for the HCP from the
appropriate Health Service. Sites are encouraged to develop arrangements between them to
facilitate this process.
The elderly patient:
• is assessed by an ACAT or multidisciplinary team as requiring short term therapy and/or
home care services post discharge
• is assessed as having potential to improve level of functional independence.
• is medically ready for discharge from acute care
Target Time frame: to a maximum of 8 weeks
5. Transition Care Program
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PE
The Transition Care Program is a joint Commonwealth and State funded initiative designed to
provide short term flexible care options for the frail elderly at the interface of the acute/subacute
and residential aged care sectors. They are goal oriented therapy/treatment-based programs that
aim to reduce inappropriate extended hospital lengths of stay and reduce premature and
inappropriate admission to residential aged care. The service is provided in a residential facility
and/or in a patient’s home.
Underlying philosophy: Following an acute care episode, many frail elderly people require more
time and less intense therapy and treatment than is provided in an acute hospital setting to return
to a higher level of independence. Providing further recovery time in a non acute setting or in the
patient’s home offers the elderly patient a greater opportunity to optimise their level of
independence whilst they and their family and carers make appropriate long term care
arrangements.
Patient profile:
The elderly patient
• Has a current Aged Care Client Record (ACCR Form 3020[0405]) recommending Transition
Care, as assessed by the Aged Care Assessment Team (ACAT).
• Is deemed medically ready for discharge from hospital by the treating team
• Can enter the Transition Care Service directly upon discharge from hospital
• Is assessed as having the potential and motivation to actively maintain or improve to either
a lower level of care or higher level of functioning or need time to make a long term care
decision
• Is suitable for GP management
• Family or advocate agrees to transfer to the service
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Target Time frame:
up to 12 weeks
(possible extension of 6 weeks with further ACAT approval)
6. Evaluation and Reporting
CAP reporting is used to determine the maintenance and potential expansion of the program.
They are also used to inform the longer term planning strategies especially towards supporting the
increase of residential aged care beds/packages with the Australian Government.
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It is expected that each site will evaluate its own CAP programs, however, as part of the program
evaluation, the Aged Care Policy Directorate of the Department of Health (DOH) requires each
health service to report their CAP activity.
The Department of Health requires two distinct CAP reporting mechanisms.
1. Weekly CAP Reporting: Patients Awaiting Residential Care (See Appendix: Reporting
instructions and proforma)
2. Quarterly CAP and HCP Reporting
The Transition Care Program is reported separately by the responsible organization.
7. Managing Complaints
Patients and their family and carers have the right to complain and to have their complaints dealt
with promptly and impartially. All Health Service sites are required to have a complaint’s
management process.
Complaints related to a patient’s stay in hospital or to their transfer to a CAP residential facility or
to a HCP need to be managed by the transferring health service.
PE
Complaints regarding the CAP residential facility need to be initially directed to the CAP facility
itself and then to the transferring Health Service if the complaint cannot be resolved by the CAP
facility.
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Complaints regarding the Transitional Care Service need to be initially directed to the Transition
Care Service itself. If the Service cannot resolve the complaint, then the complaint can be directed
to the State Department of Health as the Approved Provider or to the Office of Health Review.
Dr Neale Fong
DIRECTOR GENERAL
DEPARTMENT OF HEALTH
CAP REPORTING PROFORMA: PATIENTS AWAITING RESIDENTIAL CARE
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INSTRUCTIONS FOR SITE COORDINATORS
This proforma is to be used across all metropolitan public health services to record the
weekly number of inpatients in a public health service bed who are ready for discharge
and are awaiting a permanent vacancy in residential care.
WHO SHOULD BE INCLUDED ON THE LIST?
Only inpatients that satisfy all the criteria numbered below should be reported on this list.
These patients are defined for reporting purposes as “Ready for Discharge” as per the
proforma.
Ready for discharge inpatients are those who are:
1. ACAT assessed and approved for permanent residential aged care, low or high
and have a current and completed Aged Care Client Record (ACCR Form
3020[0405])
2. Medically ready for discharge. This does not include those patients who are
currently receiving acute medical or surgical interventions, as these patients are
deemed to be acute regardless of whether they have a current ACAT approval and
are on the waiting list for residential care.
Please also note the following:
• The data should include all people waiting for permanent residential care and not just
those waitlisted to enter a Care Awaiting Placement (CAP) facility.
• Inpatients (and their families) who do not accept a move to a CAP facility are still to
be included on the weekly list as waiting, if the above criteria have been met.
• Patients do not require to be classified as “Nursing Home Type Patients” (NHTP) to
be included on the list. Often patients who are waiting will also be NHTPs.
The “No of days awaiting residential care” is the number of days since the patient was
deemed “Ready for Discharge”, as per the above definition.
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REPORTING
• Sites are to report data as at every Wednesday to the Department of Health.
• If patients are discharged please complete the discharge date and discharge location.
Please specify if the patient has been discharged to a CAP facility.
• If the patient is deceased, the date of death is recorded in the discharge date column
and destination is recorded as “deceased”.
• Patients who were “ready for discharge” and were discharged within the week, but
outside the reporting snapshot (i.e. Thurs-Tues) should also be included in the first
Wed following their discharge.
• Please remember to change “today’s date” as this required for the formulas in the
proforma to work.
• Please forward weekly data to: [email protected]
*
Health Service beds include acute, non-acute and psychogeriatric beds
CAP Patients Awaiting Residential Care Site Coordinator Proforma Instructions 2004
Updated 29 March 2006
HOSPITAL NAME:
Name
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CARE AWAITING PLACEMENT
UMRN
Site
Patient
New or
Report Date Existing
Se
x Age
P/C
Health
Service (& Clinical
ACAT Area) Speciality
days 1
(No of
High
days
Care / Secure /
Date Ready since
Low
Non
Date of Acute for Discharge admissio Discharge
Care
Secure Admission
(By Doctor) n)
Date
Please fill in all columns from A to N. P& Q columns to be filled in where applicable.
Formulas in O, R, S & T columns (THESE WILL AUTOMATICALLY CALCULATE ONCE THE OTHER COLUMNS ARE FILLED IN)
Discharge
Location
(please
specify if
CAP)
Nursing
Home
Type
Average
Patient
Length of Days Over
Stay
35
No of Days
Awaiting
Residential
Care
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 #DIV/0!
0
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CARE AWAITING PLACEMENT