Transition Service Team Community Screener

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• Transition Service Team - Community Screener
• Presented by Nandita Chandar TST Nancy Cho PT

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Purpose

• To identify critical issues that help reliably
  set the most appropriate referral priority
• To case find patients/clients at high risk for
  post-operative complications

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Assumptions

• Patients health status can change once they
  return home.
• First best service is physiotherapy, unless PT
  priority is lower than nursing priority
• First best service is responsible to assess if
  short term HS hours are needed

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To receive home care

• The patient must first meet one of the following
• Needs medication management
• Unable to consistently mobilize independently
  (transfers, ambulation)
• Requires wound care

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Priority One contact/visit within 24 hours

• Psychological issue (anxiety or mental health
  issue)
• Pathway variance
• Ø informal supports
• ? cognitive function
• ASA gt3 co-morbidities
• DVT risk or previous hx
• Vascular problems
• LTC client needs HS review

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Priority Two - contact/visit within 48 hours

• Informal caregiver in place PO
• ROM restricted
• Co-morbidities mild systemic disease (ASA 2 or
  higher)

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Priority Three - contact/visit within 3 7 days

• ?informal caregiver in place PO
• No major co morbidities - healthy (ASA 1)
• Transfer from transitional care (Bradden, Purdy
  3),
• Discharge from in-patient rehab (HFH, or GFS)
• Return to residential care facility
• Previous joint replacement
• ? VCH clinical pathway

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Transition Services Data

• April 1 /06 Jan 31 /07
• of clients screen - 621
• clients id needing service 127
• Hips 81 Knees 46
• of clients missed - 1

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Evaluation

• Screening Tool
• 4 sites SPH,HFH,UBC,VGH
• Reliable at identifying patients needing home
  services PT, Rn, or OT
• ASA alone did not correlate to need for home
  service

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Evaluation

• Referrals primarily for Physiotherapy
• Referral reason Impeded mobility
• Architectural barriers _at_ home stairs
• Unmanaged pain which prevents rehab
• Anxiety about ability to follow PO routine
• Aggravation of existing medical condition

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Opportunity for improvement

• ?Decrease patient anxiety
• ? confidence in self care ability before d/c
• Set realistic expectations
• Reinforce pre-op teaching
• ?Self care ability to ? need for inpatient rehab
• ?Peer support
• Hear past experiences from patients at pre-op or
  in acute

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Next steps

• Use a tool to measure patient confidence prior to
  discharge
• Reinforce self care abilities - skill development
  pre-op
• Along the continuum - reinforce knowledge and
  skills at each care transition