Transition Care Program Guidelines 2011

Attachment A - Appendix 2: Transition Care Quality Report

Up to Publications

prev page| TOC |next page

PDF Printable version of Transition Care Quality Report (PDF 132 KB)

Below is a text version of the report please print the PDF for reference.

---

The Transition Care Quality Report is a self-assessment report which covers:

• Name of Approved Provider (state/ territory):

• Name of Transition Care Provider Organisation/Agency:

• Name of Transition Care service:

• Address of Transition Care service:

• Size and funding of this Transition Care service:

…….. residential based places …….. community based places …….. mixed places


$ ……… estimated total annual funding

• Please provide a brief description of the Transition Care service at this location.
  Please include an outline of the service model and a staff profile, including the number and professions of allied health and other clinical and care staff dedicated to Transition Care.

• Please indicate what quality accreditation the organisation/ agency has that is relevant to the services provided under Transition Care and the period of this accreditation. If providing residential Transition Care, please also indicate which building requirements are met. If you have more than one service with different accreditation, list one per row.

  Name of service

  Service type(s) provided

  Quality Accreditation of Transition Care Service Provider or other external regulation

  If providing residential Transition Care, please indicate:

  Residential aged care accreditation

  ACHS EQuIP

  QIC

  ISO 9002

  Community Care

  HACC

  Other – please name

  Period of accreditation

  building requirements met:

  Period covered:

  Residential aged care certification

  Other – please name:

  … /… to … /…

  … /… to … /…

  … /… to … /…

  … /… to … /…

  … /… to … /…

  … /… to … /…

  … /… to … /…

  … /… to … /…

  … /… to … /…

  … /… to … /…

  … /… to … /…

  … /… to … /…

  … /… to … /…

  … /… to … /…

• Does the service broker or sub-contract the delivery of services to other agencies or individuals?

........... No ............. Yes- If yes, please list all other agencies or individuals in the following table:

Name of broker / sub-contractor

Type of service provided by broker / sub-contractor

Quality Accreditation of broker / sub-contractor or other external regulation

If providing residential Transition Care, please indicate:

Residential aged care accreditation

ACHS EQuIP

QIC

ISO 9002

Community Care

HACC

Other – please name

Period of accreditation

building requirements met:

Period covered:

Residential aged care certification

Other – please name:

… /… to … /…

… /… to … /…

… /… to … /…

… /… to … /…

… /… to … /…

… /… to … /…

… /… to … /…

… /… to … /…

… /… to … /…

… /… to … /…

… /… to … /…

… /… to … /…

… /… to … /…

… /… to … /…

Top of page

Overview of service

• Are there any particular aspects of the Transition Care service which the provider(s) would like to highlight? For example, this may include new or innovative arrangements for Transition Care such as shared care arrangements or protocols established within the provider organisation or with other services.

• Have any formal complaints been received about the Transition Care service?

.............No
.............Yes- If yes:

• were the complaints resolved to the satisfaction of all parties?..........No........Yes
• please state under which complaints process these were handled:

..............Internal service specific complaints mechanism;
..............State / territory health complaints process;
..............Australian Government aged complaints process;
..............Other – please describe: ………………………………….…………………………

• please describe any changes to the way you provide services made as a result of the complaint(s):

• Please describe any particular challenges faced by the service and how these have affected the service model and/or clients:

Table A attached to this report lists a range of information which may be useful in thinking about the results of Transition Care service delivery. All of these items may not be available but as the Transition Care Program rolls out, additional information is likely to become available. You may collect some information through sampling, say 10%, of care plans or client files.

Transition Care Program Quality Standards & Evidence

Sources of evidence may include client files, policy and procedural documentation, service and brokerage agreements, stakeholder feedback and results of interviews and observations. Evidence may be quantitative or qualitative. Examples of possible quantitative background material are provided in Table A attached to this report.

Standard 1:

Optimising Independence and Wellbeing – The Transition Care service optimises the independence and wellbeing of its clients

Outcome 1.1 Assessment Processes:	Evidence of meeting Transition Care Requirement	Comments / suggestions	If requirement not met, please describe any action required /recommended so that requirement is met in the future:
Allow clients, assisted by carers and families as appropriate to make informed choices between Transition Care service options in order to define and set their goals to optimise their independence and wellbeing.
Include an assessment of clients’ physical and cognitive independence, as well as their psycho-social needs.
Consider special needs groups, including people from Aboriginal and Torres Strait Islander communities, people from culturally and linguistically diverse backgrounds, and people who have a physical or cognitive impairment.

Outcome 1.2 Care planning is focussed on optimising independence and wellbeing and includes a goal-oriented care plan for the client that:	Evidence of meeting Transition Care Requirement	Comments / suggestions	If requirement not met, please describe any action required /recommended so that requirement is met in the future:
Responds to the identified needs of the client and targets those goals which optimise independence while taking into consideration the psycho-social needs of the client.
Provides the client with required therapies and treatments designed to teach the client to achieve their own goals.
Improves the client’s functioning by promoting independence and monitors that improvement in consultation with the client, carers and families, clinicians, and therapists.

Note: For further detail on care planning, go to outcome 2.2.

Outcome 1.3 The Transition Care service demonstrates that its service:	Evidence of meeting Transition Care Requirement	Comments / suggestions	If requirement not met, please describe any action required /recommended so that requirement is met in the future:
Provides a coherent and integrated case management process that enables clients to meet their goals and takes into consideration the psycho-social situation of the client.
Actively promotes self-management and self-sufficiency by providing interventions that support clients to make the most of their own capacity and achieve their full potential.
Encourages clients to seek support from carers and families, community groups and others to foster their independence when required.
Assists clients to achieve an optimum level of independence and wellbeing so that care needs are minimised over the longer term.
Where applicable, provides facility-based residential Transition Care services in a more home-like, less institutional environment. This may include: communal living space/living room environment which is completely separate from sleeping areas and the location of acute/subacute care provision, i.e. a space that encourages carers, families and visitors to spend time with clients; a dining area and clients encouraged not to eat in bed; clients being encouraged and supported to dress every day; facilities for clients to prepare snacks for themselves and their visitors; privacy, particularly for personal care and bathing arrangements; space for clients to mobilise, especially outdoors; physical arrangements which support the involvement of carers and family in the therapeutic activities; and a model of care and staff knowledge that supports the intent of the Transition Care Program to promote the client’s health and independence.

Note: Transition Care services may also be provided in rural and remote hospitals where appropriate. The requirements for a more home-like environment may be relaxed on a case by case basis in these locations, if relevant.

Any additional comments?
Any other improvement ideas or suggestions?
Any examples of interesting practice which the service is prepared to share with other Transition Care providers:

Top of page

Standard 2:

Multidisciplinary Approach and Therapy Focussed Care – The Transition Care service provides its clients with high quality, evidence-based therapeutic services focussed on maintaining or improving function in line with established goals

Outcome 2.1 Assessment processes include:	Evidence of meeting Transition Care Requirement	Comments / suggestions	If requirement not met, please describe any action required /recommended so that requirement is met in the future:
Assessment of the client’s Transition Care needs by the multidisciplinary team (MDT) at the beginning of the Transition Care episode.
The use of validated assessment tools deemed appropriate by clinicians/therapists.*
Measurement of a baseline level of functioning using validated assessment tools, and re-assessment of functional performance at pre-determined intervals.
Evidence of discharge planning throughout the continuum of care.

*Note: The use of the Modified Barthel Index for assessments by the Transition Care service at entry to and exit from the Transition Care Program is mandatory for Australian Government subsidy payments.

Outcome 2.2 Care planning processes demonstrate that:	Evidence of meeting Transition Care Requirement	Comments / suggestions	If requirement not met, please describe any action required /recommended so that requirement is met in the future:
A goal-oriented therapy program is developed by the provider in consultation with the client, carer and family prior to the commencement of therapy or treatment, with input from the multidisciplinary team of the transferring hospital and the ACAT.
The therapy program duration is estimated and informs planning for the client’s discharge.
Hospital discharge information is incorporated into the initial care planning process.
Care provision is responsive to the identified needs and goals of the client.
Therapy goals agreed with the client or their representative/carer are documented and prioritised.
The client receives timely and appropriate access to therapy, care and equipment across the health, aged and community care sectors. This is demonstrated by: ensuring aids, appliances, equipment and services required for a client’s therapy are provided in a timely manner; providing a broad range of services tailored to meet the client’s therapeutic goals to improve or maintain function; providing the client with low intensity therapy from appropriately qualified staff to achieve their individual documented goals; and actively encouraging client, carer and family participation in all aspects of Transition Care service provision.
The client’s progress against therapy goals is regularly evaluated throughout their Transition Care episode and on exit, with changes in function measured and recorded to demonstrate achievement of the client’s goals.
The client’s changing needs are reflected as they move between care settings.
Client goals are delivered in accordance with the care plan, using an integrated case management approach.

Outcome 2.3 The multidisciplinary team (MDT) approach to the planning and review of client care demonstrates that:	Evidence of meeting Transition Care Requirement	Comments / suggestions	If requirement not met, please describe any action required /recommended so that requirement is met in the future:
Documented procedures and protocols are available to support the multidisciplinary team in the care and review of clients. This includes processes for communicating client information to relevant health professionals.
Care planning is carried out by members of the MDT with relevant clinical experience in goal-oriented, low intensity therapy.
Care plan reviews/case conferencing include those members of the MDT involved in the client’s treatment and occur at predetermined intervals.
Care is informed by discussions with and between the relevant Geriatrician and the client’s GP, where possible, and/or other appropriate medical input.
MDTs have integrated client records.
The MDT comprises an appropriate mix and level of staff, enabling the provision of effective client services.
A coordinator/case manager is in place to oversight and promote effective MDT and inter-agency working.

Any additional comments?
Any other improvement ideas or suggestions?
Any examples of interesting practice which the service is prepared to share with other Transition Care providers:

Top of page

Standard 3:

Seamless Care – The Transition Care service uses a collaborative service delivery model that delivers seamless care

Outcome 3.1 Assessment processes:	Evidence of meeting Transition Care Requirement	Comments / suggestions	If requirement not met, please describe any action required /recommended so that requirement is met in the future:
Follow agreed protocols for the effective transfer of client information between primary, community, acute and aged care services.
Recognise and incorporate hospital assessment, care planning and discharge arrangements, including ACAT assessment and approval recommendations.
Enable staff of the receiving Transition Care service to meet and assess the client’s care needs and the Transition Care service’s ability to meet these care needs prior to the client’s admission into the service, where possible.
Provide for a verbal as well as a written handover of client information and status whenever the client moves between or within services, where practical.

Outcome 3.2 The Transition Care service works within an integrated system of care with other organisations by:	Evidence of meeting Transition Care Requirement	Comments / suggestions	If requirement not met, please describe any action required /recommended so that requirement is met in the future:
Establishing relationships and communication strategies that govern collaboration between acute/subacute aged and primary care services promoting a clear understanding of each other’s roles, responsibilities and admission criteria.
Establishing systems for the secure, timely and effective transfer of Transition Care client information between service providers.
Strengthening partnerships with GPs and other Transition Care support services.
Facilitating effective interagency case conferences.
Facilitating the client’s entry to and exit from Transition Care so that the client experiences a seamless move.
Effectively coordinating the client’s needs and goals between services.
Keeping the client and/or their representatives well informed prior to moving to a new service.
Facilitating education, training, networking and support across sectors and service boundaries in the broader health and aged care community where appropriate.
Facilitating access to ongoing care and service provision post discharge from the Program, as required.

Outcome 3.3 The Transition Care service develops systems for the safe discharge of clients that help prevent re-admission, including:	Evidence of meeting Transition Care Requirement	Comments / suggestions	If requirement not met, please describe any action required /recommended so that requirement is met in the future:
Providing Transition Care service discharge care planning to any subsequent care organisation.
Providing appropriate discharge documentation to be given to the client, specifying: length of stay in Transition Care; destination post Transition Care; goals which client agrees have been achieved or not achieved (with reasons for non-achievement); client functional levels on discharge from Transition Care, assessed using the same validated instrument used on admission; client carer and family education and support to improve functioning following discharge; all services and equipment to be provided to the client on discharge from Transition Care, with key supplier contact details; an up-to-date list of prescribed discharge medications; and other follow-up arrangements/referrals such as information for the client’s GP, which are the responsibility of the client and/or their representative.

Any additional comments?
Any other improvement ideas or suggestions?
Any examples of interesting practice which the service is prepared to share with other Transition Care providers:

Top of page

• Have any concerns been identified about areas of immediate health, safety or well-being risks to consumers, staff or other stakeholders?
............No ............ Yes – if yes, please describe the concern(s) and actions to be taken:


• What improvements are proposed to the Transition Care service?

	Priority 1	Priority 2	Priority 3
Area:
What we want to achieve:
What we intend to do:
Who is responsible?
Planned completion date:

This report was completed on ……./…../…… by the following members of staff / Transition Care Review Team:

Name: ......................................................................................
Organisation: ..........................................................................
Position: ...................................................................................


Name: ......................................................................................
Organisation: ..........................................................................
Position: ...................................................................................


Name: ......................................................................................
Organisation: ..........................................................................
Position: ...................................................................................


Name: ......................................................................................
Organisation: ..........................................................................
Position: ...................................................................................

Table A:

Possible quantitative items which may be useful contextual information.
Please note: Transition Care services are not required to complete this table.

	Number	% of Sample		Sample size
Clients whose functional skills (measured by standardised and validated measures) have been maintained or improved while in Transition Care.
Clients and other stakeholders who have indicated via feedback that they are satisfied with the outcomes of their Transition Care.
Care plans/case notes which display continuation of community and other key contacts and activities while in Transition Care.
Clients who have achieved their personal Transition Care goals.
Clients who have achieved their clinical Transition Care goals.
Clients who have been discharged to their desired destination (recorded at admission).
Clients who have returned to the community or to their former residential setting.
Clients and other stakeholders who have indicated via feedback that they were satisfied with the timeliness and duration of their Transition Care.
Care plans which have been reviewed and refined during Transition Care.
Client’s case notes which show evidence of planning for their post discharge setting from early in their Transition Care episode.
Sample of care plans which show that therapy services are delivered as predicted in care plans.
Clients and other stakeholders who have indicated via feedback that they are satisfied with the quality and responsiveness of the Transition Care and support received.
Care plans and care delivery notes which demonstrate multidisciplinary input and collaboration of medical, therapy and care staff from all involved services.
Staff who have attended in-service training on, or met with peers from other providers to review, leading practice in Transition Care over past year.
Client documentation which shows that the duration between ACAT approval and admission to Transition Care is less than 4 weeks.
Clients and other family stakeholders who have indicated via feedback that they are satisfied with the types and amount of support proposed to be received on discharge.
Transition Care and other staff who have reported, via feedback: satisfaction with the collaboration and/or joint training between Transition Care and other services; and enhanced skills and understanding arising from this collaboration and/or joint training.
Transition Care and other staff and service representatives who have indicated, via feedback, that inappropriate blockages and delays have been reduced or eliminated.
Care plans which show that any barriers to accessing needed support have been identified and that attempts have been made to remove or reduce these barriers.
Clients and other stakeholders who have indicated via feedback that discharge from Transition Care and organisation of subsequent support was timely.
	This service		Average for State/Territory
The average length of stay of Transition Care clients at this service compared with the average for this State/Territory.	weeks		Weeks
The average duration between ACAT approval and admission to Transition Care for this service compared with other services in this State/Territory.	weeks		Weeks
Comparisons with other Transition Care services*:

* Other comparative data may be available from services taking up benchmarking opportunities with other Transition Care services.
Top of page

prev page| TOC |next page