Quality Improvement: Hospital to Community Continuity of Care

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Quality Improvement Hospital to Community
Continuity of Care

• Eastern Post Acute Care

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Post Acute Care

• 1 of 17 PAC programs statewide
• EPAC Catchment area - 5 municipalities
  Whitehorse Manningham Maroondah
  Knox Yarra Ranges

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PACs Objectives

• Support recuperation after a hospital episode,
  via provision of an appropriate package of
  community based supports
• Facilitate safe and timely discharge
• Reduce likelihood of readmission

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PAC services are intended to

• Meet short term needs related to the hospital
  admission
• Gap-fill until long-term community supports can
  commence

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What is PAC not

• An alternative to early discharge planning or
  liaison with community agencies
• A guarantee of service availability
• Ongoing service (4 week maximum)

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PAC programs all

• Provide care co-ordination (phone based)
• Provide service co-ordination of purchased
  services
• Provide rapid response in service commencement
• Fill short-term gaps in the service system
• Actively liase between the hospital and community
  sector

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Eastern PAC staffing

• Co-ordinators based at each Eastern Health
  hospital to manage within catchment referrals
  and mediate InterPAC referrals OUT
• InterPAC office to receive manage InterPAC
  referrals IN

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Who is PAC intended for ?

• Type 2 (HACC PAC)
• Already receiving community services
• Acute illness/injury/surgery
• Needs more services for short-period of time
• May need an increase in long term supports

• Type 1 (non-HACC)
• No previous services in place
• Acute illness / injury / surgery
• Will get better in 4 weeks
• Need short-term supports to recuperate

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For PAC to work

• Care must be co-ordinated and informed
• Referrals must be initiated at the earliest
  possible point in the admission process
• Clients carers must be involved in care
  planning
• PAC cannot commence an unsustainable level of
  community supports where the needs are long term

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PAC funded services include

• Nursing (home centre based)
• Physiotherapy
• Home Care
• Personal Care
• SRS respite (price capped per episode per
  annum)
• Other Allied Health

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EPAC e-referrals

• Only used for Eastern Health Discharges
• Utilise a copy of e-referral made by OT or SW -
  provide details of planned PAC services
• Request feedback via e-referral from Council
  (progress outcome)

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Advantages of e-referral

• Establishment of referral history
• Certainty of receipt of referral
• Convenient communication

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Potential Disadvantages of e-referral

• Loss of working relationship with HACC
  providers
• Pauce detail in reply does not assist our service
  planning
• Delays in response to enquiries via e-referral
• Does not indicate if client is a pre-existing
  HACC service recipient (unless previous
  e-referral)

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Communication to PAC via s2s

• Acknowledgment
• Allocated
• Closed

• Confirm if PAC service times align with likely
  HACC commencement
• Name of worker and likely assessment date or
  timeframe
• Update if client cancels / defers assessment
  or
• Outcome of assessment, incl. planned HACC
  services and actual commencement date