ACAT Presentation 2007 1

Osborne Park HospitalRehabilitation and Aged Care

Aged Care Assessment Team

October 2007

ACAT Presentation 2007 2

OBJECTIVES OF ACAT PROGRAM

Assess the care needs of the frail older person (observing equitable access issues )

ensure assessments are comprehensive, incorporating the restorative, physical, medical, psychological, cultural and social dimensions of care

assist the older person to gain access to the types of services most appropriate to meet their care needs

ACAT Presentation 2007 3

Aged Care Act 1997

ACAT is underpinned by the Aged Care Act 1997 and associated principles.

The Act and the Principles include the aged care planning process, approved service providers responsibilities and types of services they can provide, subsidy criteria, and processes for ACAT teams

ACAT Presentation 2007 4

OPH ACAT Team

Boundary - Wembley Downs to Two Rocks and across to Ballajura

Referrals to ACAT only - 1200 - 1600 + a month ACAT Team composition - Head of Dept - Dr Barry

Vieira, Consultant Physicians, Aged Care Home Visiting Nurses, Social Workers - Snr ACAT Social Worker/ ACAT Coordinator, Occupational Therapists and other allied health staff as required

Location - OPH F Block, 2 teams have mtg at JHC on a weekly basis

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Informal Care

HACC services

CACPs

EACH/EACHD

Low Care

Residential Care

Respite

Incr

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Figure 3: Services Against Increasing Complexity of Care Needs

ACAT Presentation 2007 6

Aged Care Services (requiring ACAT approval)

CACP’s - Community Aged Care Packages. Individually planned and coordinated packages of care tailored to help older people remain living in their own homes.

ACAT Presentation 2007 7

Aged Care Services (requiring ACAT approval)

EACH - Extended Aged Care at Home. Individually planned and coordinated packages of care tailored to meet the needs of a person who requires high level care at home.

EACHD - as above however specialise in care of dementia particularly for those with behaviours of concern.

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Aged Care Services (requiring ACAT approval)

TCS - Transitional Care Service (Residential/Community). Provides the opportunity and resources for older people discharged from a hospital episode to improve their physical functioning, mobility and to regain their daily living skills. (limited to 12 weeks)

ACAT Presentation 2007 9

Residential Aged Care Services

Residential Care is for people who, without the care and support offered in a facility, would be unable to maintain a satisfactory standard of personal care, health, nutrition and/or social well-being.

ACAT approval is required.

Low level care (hostel) - provides support and supervision not 24 hr nursing care.

ACAT Presentation 2007 10

Residential Aged Care Services continued High level care (nursing home)- is for

residents that require intense 24 hr nursing services

Dementia Specific - can be low or high care provided in a secure environment. These cater particularly for those with dementia that display challenging type behaviours eg wandering, aggression

ACAT Presentation 2007 11

Residential and Respite Services

Extra Services - an additional service available at selected facilities where extra services are provided at an additional cost to the client eg foxtel, chef choice meals, wine etc

Respite care - may be used for carer relief on a planned, regular or emergency basis to assist carers.

ACAT Presentation 2007 12

Respite Services continued

Types of Respite :• Residential respite • In- home respite• Day centre• Emergency respite

• Commonwealth Care Respite Centre– Ph 1800 059 059

ACAT Presentation 2007 13

Other Aged Care Services

Short term post - acute services - PEP (personal enablement program), HCP (Home Care Packages)

Care Awaiting Placement Independent Living Units/Retirement

Villages etc Commonwealth Carelink Centres -

• Ph 1800 052 222

ACAT Presentation 2007 14

Other Aged Care ServicesHACC - Home and Community Care.

HACC services provide a range of basic maintenance and support services for frail older people, people with disabilities and their carers. Services include:

• domestic assistance

• home modifications and maintenance

• personal care (usually limited to 3 visits per week)

• community nursing (includes medication prompts - requires a medical authority)

• food services (eg meals on wheels or frozen delivered meals)

• transport (eg subsidised taxi fares program or community bus)

• referral can be made directly eg self referral

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Other Aged Care Services

VHC - Veterans Home Care. Funded by Dept of Veterans Affairs specifically for Veterans (Gold/White Card holders)

ACAT Presentation 2007 16

How to Refer

GP referral is preferred method of referral

Consult request form Recent audit of referrals Provide as much information as

possible

ACAT Presentation 2007 17

What happens next?

ACAT clerk process referrals and creates a file(or adds to pre-existing file)

Consultant Physician (on a roster basis) review files and allocate to required program or discipline base on information provided in referral

ACAT Presentation 2007 18

How is an ACAT assessment completed?

Home Visit - completion of Standardised Assessment form and ACCR (Aged Care Client Record)

Client must give signed permission for the ACAT assessment

Multi-disciplinary focus Weekly team meetings Involvement of family/carers Feedback to GP (letter/verbal) MDS ie data collection Case example

ACAT Presentation 2007 19

Rehabilitation and Aged Care Service at OPH

Inpatient (including Stroke unit) Day Hospital Parkinson’s clinic ACAT MEU (Memory Evaluation Unit) Falls clinic HCP (Home Care Packages) CAP (Care Awaiting Placement) RAILS

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Rehabilitation and Aged Care Intervention Liaison Service (RAILS)

RAILS provides a rapid response, flexible service with ready access to a multidisciplinary team - who conduct comprehensive care planning and home visits.

Same day service Team consists of SW, RN, OT and

Physio

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Contact details

ACAT Team - • Fax: 9346 8232• Ph: 9346 8111 (ACAT clerk)• Ph: 9346 8449 (general query)

RAILS Team• Fax: 9346 8232• Ph: 9346 8315