The Transition to Transition: How TCP has bridged the

communication gap from acute

discharge to TCP admission

Presented by Vanessa Eldridge

Manager

Transition Care Program

and Restorative Care

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Geelong

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How it all started

Originally started at Barwon Health in 2006 with:

– 19 residential beds + 4 home based packages

= Total 23 packages

– In an SRS

– Completely brokered model except for Care Coordination

2.0 FTE

– Purchased all allied health, medical (GP), nursing and

personal care

– Local relationships with care providers, private therapists

and agencies

How we expanded

The program size increased in 2011:

– we moved to 2 private aged care facilities

– 34 Residential beds

– 18 Home Based packages

– 5 Restorative Care residential beds = Total 57 packages

New positions:

– Full time Admissions Administrative Assistant

– Full time Manager

– Employed Geriatrician at 0.4 FTE + 1.1 FTE Registrar

– Part time OT Grade 2

– Physio Grade 2 and part time Physio Grade 3

– Allied Health Assistant

– TCP Liaison (intake)

In 2014 we moved half the program to a Barwon Health owned

residential aged care facility.

Half of the residential beds remain in the private facility.

We still purchase:

• Podiatry

• Speech Pathology

• Dietetics

• Other occasional services purchased: Wound Consultant,

Diabetic Nurse Educator, Orthotist/Prosthetist

• We purchase all services for TCP Home Based except for

Registrar and Care Coordination

• How did patients get to TCP? 2006 +

• How do they get to TCP now? 2012 +

• What steps did we take to bridge the

communication gap? 2015 +

Referral to acceptance

2006

Patient identified as potential TCP client by ward

Ward rings TCP Care Coordinator

TCP Care Coordinator visits patient, reads notes, contacts family then accepts or rejects

referral. Referral accepted

ACAS appointment booked and held. TCP approval given

Patient moves to next available TCP bed

• In 2012, a new team was created at the acute

hospital:

– Planning and Referral Team (PaRT) – essentially a

team of expert discharge planners

– They took over the role of identifying and triaging

potential clients for all bed based services at our

health service including inpatient rehabilitation, aged

care, HITH, TCP and RC

– This coincided with the implementation of the TCP

Admissions Administrative Assistant

– This removed the role of triage by the TCP team

Referral to acceptance

2012

Patient identified as potential TCP client by ward

Ward tells Planning and Referral Team (PaRT)

Planning and Referral Team books ACAS appointment

ACAS appointment held. TCP approval given

Patient goes onto electronic TCP waiting list

TCP Admin Assistant Screens ACAS assessment and notifies

TCP Manager

TCP Manager accepts or rejects referral then tells Admin

Assistant. Referral accepted.

Patient goes onto electronic TCP waiting list

Patient moves to next available TCP bed

Referral to acceptance

2015

Patient identified as potential TCP client by ward

Ward tells Planning and Referral Team (PaRT). On the same day,

PaRT tells TCP Liaison. TCP Liaison screens patient for

suitability for TCP. Referral accepted

Planning and Referral Team books ACAS appointment

ACAS appointment held. TCP approval given

Patient goes onto electronic TCP waiting list

Patient moves to next available TCP bed

Where are the improvements?

• Reduced time between identification, referral and

acceptance

• No (or minimal) surprises for referrer, ward, TCP or client

• Patient and carer knows next steps earlier

• Patient is given one true source of information

• If patient is not appropriate for TCP, another pathway can

be determined much sooner

= less wasted bed days

= better client experience

Previously…

DAY 1

– 83 yo female presents to the University Hospital Geelong

– # NOF post mechanical fall DHS. Mobile 3m with GF.

– PMHx: recurrent UTIs, T2DM, HPT, GORD, stress

incontinence

– Previously living alone with HACC services only

– Daughter lives nearby and visits 2 x per week

– Mild cognitive impairment with STML, but functional in her

own environment

DAY 5 and DAY 8

• This lady is seen by rehab, then reviewed again 3 days later for

potential improvement. She is refused for rehab due to slow

recovery

DAY 9

• This lady is determined suitable for TCP by PaRT (Planning and

Referral Team)

DAY 10

• PaRT submit the referral to ACAS without consultation with TCP

• Until this point, TCP doesn’t know anything about her

DAY 12

• She is assessed by ACAS and consents to TCP

DAY 13

• Her delegation is completed. Paperwork is signed, including the

client agreement and a pharmacy consent form

• Her name appears on the digital waiting list – this is when we know

she is “awaiting” TCP

• The waiting list is visible to the entire organisation

• PaRT completes a written handover

DAY 13++

• A TCP bed becomes available. The TCP Admissions Administrative

Assistant checks all paperwork is finalised, checks her equipment

needs, then offers the bed and transport is arranged

The digital TCP Approvals List

2006 2012 2015

Patient identified as potential TCP client by ward

Patient identified as potential TCP client by ward

Ward rings TCP Care Coordinator

Ward tells Planning and Referral Team (PaRT)

TCP Care Coordinator visits patient, reads notes, contacts family then accepts or rejects

referral. Referral accepted

Planning and Referral Team books ACAS appointment

ACAS appointment booked and held. TCP approval given

ACAS appointment held. TCP approval given

Patient moves to next available TCP bed

Patient goes onto electronic TCP waiting list

Patient identified as potential TCP client by ward

Ward tells Planning and Referral Team (PaRT). On the same day,

PaRT tells TCP Liaison. TCP Liaison screens patient for

suitability for TCP. Referral accepted

Planning and Referral Team books ACAS appointment

ACAS appointment held. TCP approval given

TCP Admin Assistant Screens ACAS assessment and notifies

TCP Manager

TCP Manager accepts or rejects referral then tells Admin

Assistant. Referral accepted.

Patient goes onto electronic TCP waiting list

Patient moves to next available TCP bed

Patient goes onto electronic TCP waiting list

Patient moves to next available TCP bed

Patient goes onto electronic TCP waiting list

What happens now?

DAY 1

• 83 yo female presents to the University Hospital Geelong

DAY 5

• Flagged as potential for TCP and Rehab concurrently. Screened by

PaRT who then refers TCP Liaison. TCP Liaison accepts client in

principle. ACAS appointment booked – all on the same day.

– If not TCP then alternative pathways are suggested at this point.

DAY 7

• She is assessed by ACAS and consents to TCP. Paperwork signed.

DAY 8

• TCP approval delegated and her name appears on TCP waiting list

DAY 8++

• Admitted to the next available TCP bed

How have we improved the

transition to transition?

• New positions – TCP Admissions Assistant and TCP Liaison

• Written guidelines in PROMPT – Protocol Management and

Production Tool

• Transparent use of the digital TCP waiting list – renamed “TCP

Approvals List”

• Acceptance criteria defined

• Built relationships with ACAS, PaRT and Social Work teams

• Improved our screening tools

• Refined our handover tools (version 8)

• Provided education to our referrers – checklists provided

• Made ourselves more visible in the acute setting

• Drawn on expertise of other services

• Benchmarked our processes with like services

• Improved client and carer information brochures

The future: How could we improve

transfer of care?

• A complete internal model at a Barwon Health public sector

residential aged care facility

Likely to impact:

– Joint vision

– Governance

– Clinical handover

– Streamlining protocols and processes

– Access to BH medical records and IT systems

– Service wide responsibility for achieving the right care in the

right place at the right time

The future: How could we improve

transfer of care?

• Internally employed allied health team

– Increased control over quality and service design

– Increased quantity – equivalent or more EFT for the same cost

– Participate in rotations which has “word of mouth” benefits and

increased visibility across the health service

– Choice in recruitment

– Improved allied health clinical handover and consistency of

practice

The future: How could we improve

transfer of care?

• Continue to update written information for:

– Referrers

– Potential clients and their families

– Improves quality of care and setting expectations prior to

admission

• Ongoing education of referrers

– Keep the messages simple, consistent and clear

– Keep our documentation up to date

– Continue to build on relationships with referrers

– Continue to be present at the referral source

– Broaden our scope to sub-acute setting and private hospitals

What have we learnt?

• Persist

• Reflect – don’t assume you have all the answers

• Build relationships

• Benchmark

• Use data to support your goals

• Utilise networks

• Keep an open mind to change

• Value input from other departments – this may be your

best advice

Thank you from Geelong!

vanessae@barwonhealth.org.au