Published on April 3, 2014
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 Hospitals include Manning Rural Referral Hospital, Wingham Rehabilitation Hospital, two Private Hospitals , Introduction
• Coastal • % Retirees • Rural • % Isolation AREA
• 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
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 dietetic & social work services • No brokerage to any other service provision LMNCC TACP TEAM
• 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
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
Discharges 1/01/2012 – 1/01/2013
Outcomes 1/01/2012 – 1/01/2013
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.
• Cognitive Behaviour/Psychological Aspects. • Mobility • Self-Care: • IADL’s: • Bartels • Home Environment Case Study- Function on Discharge from Hospital
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.
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
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.
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.
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 !
Beth’s TACP Experience
Beth Planning for Goals
Making a Difference for Older People
This is Why We Do What We Do
• Aged Care & Rehabilitation Services »65151800 LMNCC TACP
Mitos y realidades de las sustancias psicoactivas
Mitos y realidades de las sustancias psicoactivas.
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