COMMUNITY REHABILITATION, ENABLEMENT & SUPPORT

TEAM

An example of working smarter Community lead

Different services working together to improve patient outcomes to reduce length of stay avoid hospital admissions

Working across sites and across traditional boundaries

Working with older people in the Christchurch region

Targets Reduced length of stay in hospital Increased time spent at home

over a year Reduction in residential care

placement Reduction in the need for long

term home care Improvement in function

Key points Responsive to patients needs

Provides support in patient own home to facilitate functional gains (rehabilitation)

Multidisciplinary approach to goal setting that includes the patient. Goals are set after an assessment in the patients own home.

Culturally appropriate

Provides supported discharge

Ability to see and assess patient outside the 4 walls of the hospital

Ideal patient needs 2 to 6 weeks of rehabilitation

Patient Flow

Joint visit Joint assessment by coordinator and case

manager look at Confirmation of safety (environment,

medication etc) Full assessment using varies tools Identification of any additional equipment that

may be required Leads to development of goal ladder and

organisation of key workers to support rehabilitation activities

CASE STUDY

Agnes has three sons and a daughter. Her sons live in Canterbury where one of them works on the family farm. Agnes and Bill moved up to live near their daughter Liz six years ago when they retired from the farm due to Bills ill health. Liz is married with three grown up children and four grandchildren. She works fulltime at a local pharmacy. Liz visits Agnes every day and brings her dinner each night. Since Bill’s death Agnes has become a lot less active. She never had a drivers licence as Bill would drive them both around. Liz tries to take Agnes out in the car when she can but they both find this difficult now. Three months ago Liz took Agnes for dinner at a local restaurant to celebrate Liz’s 60th birthday. Agnes needed the help of one of Liz’s sons to get her in and out of the car.

After Bill’s death Agnes feels she gave up for a while. She got weaker and weaker and lost her appetite. She lost a considerable amount of weight. One night she got up to go to the toilet and fell in the bathroom. She was taken by ambulance to the local hospital where she spent three weeks recovering from a broken hip.On her discharge from the hospital Liz wanted Agnes to come and live with her; however Agnes refused to go anywhere but back to her own home. Liz has noticed that since that time Agnes has become more and more frail. She has had four falls in the last six months. The last fall was while she was walking to the toilet, she fell and was not able to get up until Liz arrived that evening. Liz had to call her grandson to help get Agnes back into her chair. When she fell Agnes cut her shin badly.

The district nurses had to come to dress the wound. Now she still has the dressing changed weekly. Liz also has noticed that her mum is constipated and this causes her pain and discomfort. She cooks her mum a meal each day and brings it round. However Agnes’ appetite is so poor nowadays that she never finishes the meals.Liz thinks that the time is coming where her mum will need to come to live with her. Agnes has always been extremely house proud but now Liz finds that she is having to do all the housework which is becoming more and more difficult. Liz does not know how she will cope as she has a bad back. She is scared she will hurt herself and then her mother would be in a worse situation.

One morning, Agnes’ 6 month old great grandchild visits and sneezes all over Agnes,

Within 2 days, she is in bed with a cold which quickly deteriorates into a pneumonia. Liz contacts the GP who starts on ABs but a day later, Liz visits and finds Agnes delirious and the GP advises visit to ED, upon which she is admitted to AMAU and 1 day later assessed by Jay (Liaison worker)

Given her past deterioration, CREST is considered and Jay informs Agnes’ GP, the CREST case manager and Agnes chooses Nurse Maude as the provider.

Agnes’ daughter collects her that afternoon and the team commences immediately.

Grocery shopping (& coffee) with Liz by x

Walking to car and getting in with help by x

Walking to dairy (450 metres) by x

Walking to letter box independently by xxx

Washing independently within 3 days

Walking to ward doors within 2 days

Dressing independently within 5 days

Walking to toilet independently day or night by 3 days

Washing independently at home by xxx

Dressing independently at home by xxx

To be able to defrost and heat MoW by xxx

For pain to be 3/10 - getting in/out bed by x

Getting in / out of bed independently by x

Drawing curtains independently by x

Preparing breakfast and snacks by x

Attending church with friend by x

Hosp. discharge

CREST discharge

Withdraw night visits

Withdraw AM visits

Withdraw weekend visits

CREST x3 a day x7

One 2 hour visit x3 week

Commenced HBSS x 2hrs

week

Term DescriptionCREST Community Rehabilitation, Enablement Support Team. Three

components, Liaison team, Assessors (either allied health or nursing) and Coordinators (nurses)

Community Support Services

Three providers (Access, Health Care New Zealand and Nurse Maude) will deliver the supported discharge team service across Canterbury. Each geographical area will include two providers allowing clients a choice as to provider

CREST Liaison Worker

Registered health professional working within the in-patient setting identifying clients suitable for CREST

CREST Case Manager

Allied health or registered nurse responsible for assessing clients at home and establishing the rehabilitation package. The CREST Case Managers (CCM) will be based in Older Persons Health Specialist Services (OPHSS) and will include two sub teams aligned to the current community team configuration and a Psychiatric Services for the Elderly (PSE) resource.

CREST Coordinator

Registered Nurse working for the Community Service Provider (CSP) responsible for coordinating individualised packages.

Clinical Assessor

OPHSS Care manager linked to GP practices responsible for total long term care package

Key Support Worker (KSW)

Unregulated worker trained to level III on the NZQA framework responsible for delivering rehabilitation programmes under the direction of the CREST coordinator.

Point of discharge from CREST GP updated

NASC have become involved if long term supports required

Referral sent to falls prevention programs