University of Canberra Public Hospital (UCPH)
Model of Care
Version Control
No. / Date / Remarks1.0 / 28- Jul-14 / Extracts of report issued for Round 1 User Group consultation (sections 2, 3 & 4)
1.1 / 8- Aug-14 / Updated following Round 1 User Group meetings
1.2 / 12-Aug-14 / Extract of report for Round 2 User Group meetings
1.3 / 30- Sept- 14 / Updated extract for Round 2 User Group meetings incorporating feedback from Linda Kohlhagen – for reference at meetings only (not for circulation)
1.4 / 8-Oct- 14 / Updated draft following Round 2 User Group meetings
1.5 / 28- Nov- 14 / Updated draft incorporating feedback following Round 2 User Group meetings and targeted work re ambulatory services.
1.6 / 5-Dec-14 / Updated draft incorporating feedback and outcomes of targeted work re inpatient services.
1.7 / 19-Dec-14 / Updated draft following Round 3 User Group meetings
1.8 / 9-Jan-15 / Updated draft for Round 4 User Group meetings
1.9 / 23-Jan-15 / Updated draft for Reference Group meeting 28/1/15. Incorporates feedback received from Round 4/5 User Group meetings including document restructure.
2.0 / 13-Feb-15 / Final incorporating outcomes of Reference Group meeting and other feedback provided.
3.0 / 9-Mar-15 / Final incorporating feedback provided
4.0 / 1-Oct-15 / Final incorporating definitional clarification around models of care and models of service delivery and structural changes
Table of Contents
1Introduction
1.1Consultation Process undertaken to inform this document
1.2Acronyms and Glossary
1.2.1Acronyms
1.2.2Glossary
2Profile of Current RACC Activities
2.1Inpatient Services
2.1.1Inpatient Care Settings
2.1.2Inpatient Service Pathways
2.2Ambulatory Services
2.2.1Ambulatory Care Settings
2.2.2Ambulatory Service Pathways
2.3RACC Benefits/Strengths of Current Services and Areas for Improvement
2.3.1Strengths/Benefits of Current Services
2.3.2Areas for Improvement
2.4Known Innovations to be incorporated for future RACC Services
3Overarching Future Model of Care for RACC Services across the ACT
3.1Description of Service
3.1.1Overarching Principles
3.1.2Care Settings
4RACC Services to be provided at UCPH
4.1Inpatient Services
4.1.1Service Elements
4.1.2Inpatient Care Continuum/Patient Pathway
4.1.3Inpatient Care - Service Delivery Team
4.2Ambulatory Services – Day Programs and Sessional Therapy/Services
4.2.1Service Elements
4.2.2Ambulatory Services Care Continuum/Patient Pathway
4.2.3Ambulatory Services - Service Delivery Team
4.3Therapeutic and Recreational Spaces at UCPH
4.4RACC Clinical Services Based Off-Site from UCPH
4.5Hydrotherapy
5RACC Community Based Services
6Appendices
6.1Reference Documents
6.2Outline of UCPH Service Streams and RACC Services
Table of Tables
Table 1: Outline of Current Community Based Services (based at Community Health Centres)
Table 2: Outline of Future RACC Community Based Services
Table of Figures
Figure 1: Outline of Existing RACC Services
Figure 2: RACC Inpatient Services Pathway – Rehabilitation
Figure 3: RACC Inpatient Services Pathway – Geriatric Services
Figure 4: RACC Referrals
Figure 5: RACC Continuum of Care
Figure 6: Outline of RACC Services to be provided at UCPH
Figure 7: RACC Referral/Intake Process for a New Patient
Figure 8: RACC Referral/Intake Process for an Existing RACC Patient
Figure 9: Generalised RACC Patient Pathway
1Introduction
The ACT Health Infrastructure Program (HIP) plans for the future health infrastructure requirements of the ACT and regional catchment areas. It focuses on service planning and delivery of major capital works. HIP has delivered a number of capital projects in recent years including developments at the Canberra Hospital and community health centres. The University of Canberra Public Hospital (UCPH) is one of the key major infrastructure projects currently being planned.
UCPH will be located on the University of Canberra campus on the corner of Aikman Drive and Ginninderra Drive. UCPH will form part of a planned network of ACT Health hospitals and facilities designed to meet the needs of our ageing and growing population.
Extensive planning has been undertaken to define the services to be provided at UCPH. This planning information is publicly available in the Service Delivery Plan and Functional Brief, both of which are available on the ACT Government Time to Talk website.
UCPH will deliver sub-acute care consisting of adult Mental Health inpatient rehabilitation and day services, and adult and geriatric inpatient rehabilitation,day and ambulatory services.
UCPH will not have an Emergency Department and will not deliver acute services. Specialist palliative care and psychogeriatric care will not operate from the site.
The Division of Rehabilitation, Aged and Community Care (RACC)will be a substantialprovider of services at UCPH. The development of the new UCPH facilities will enable significant enhancement and increased capacity of RACC services in the ACT. Centralised care provision for rehabilitation and geriatric services at UCPH will be facilitated by:
- inpatient and ambulatory services provided from a single facility;
- collocation and integration of rehabilitation services and specialised staff;
- centralised specialised services with a greater critical mass enabling the maintenance of specialised skills;
- optimised sharing of knowledge and staff training; and
- capacity to flex up/down rehabilitation specialised wards to meet changing patient demand.
The new facilities will also enable the provision of rehabilitation and geriatric day programs.
A Model of Care describes how clinical services are /will be delivered. While this document describes the overarching Model of Care for RACC services throughout the ACT, itfocuses on the direct clinical services that will be provided at UCPH. However, some support services which are integral to care provision (e.g. information and communications technology (ICT) and administration/booking/scheduling) are also described in thisdocument, where relevant.
Throughout the consultation process that was undertaken to complete this document, the emphasis has been on developing an innovative model for future care provision and service provision. The Model of Care proposed in this documenthas been developed to enhance existing service strengths and address any weaknesses or gaps in existing service provision.
A similar process has already been undertaken for the adult Mental Health services to be provided at UCPH.Consultation on theseModels of Care took place in 2014, and these Models of Care have now been endorsed.
1.1Consultation Process undertaken to inform this document
This document has been developed in consultation with key ACT Health representatives through the following consultation process:
- Two Reference Group (RG) meetings (30 July 2014and 28 January 2015).
- Four rounds of User Group (UG) meetings
-30-31 July 2014 to profile the current RACC activities;
-1 October 2014 to develop the overarching future Model of Care for RACC at UCPH;
-10-11 December 2014 to develop the overarching future Model of Care for RACC at UCPH; and
-14-15 January 2015 to develop the Model of Service Deliveryand Transition Roadmap for UCPH.
- Targeted consultation undertaken by ACT Health to develop the future Model of Care for UCPH inpatients and ambulatory services (27 October 2014 – 21 November 2014).
- Out of session feedback/clarification.
Membership of the RG and UGs included:
- Executive Director, RACC, CHHS;
- Executive Director, Clinical Support Services, CHHS;
- Director of Nursing, Clinical Support Services, CHHS;
- Senior Manager Security Operations, Business and Infrastructure, Strategy and Corporate;
- Director Logistic Support, Business and Infrastructure, Strategy and Corporate;
- Executive Director, Mental Health, Justice Health and Alcohol and Drug Services, CHHS;
- Director Geriatric Medicine, RACC, CHHS;
- Director Rehabilitation Medicine, RACC, CHHS;
- Director of Nursing and Assistant Director of Nursing RACC, CHHS;
- Director Acute Support, Clinical Support Services, CHHS;
- Director Allied Health, RACC, CHHS;
- Director Client Support Services, RACC, CHHS;
- Director Community Care Program, RACC, CHHS;
- Assistant Director Client Services, Security and Emergency, Business and Infrastructure, Strategy and Corporate;
- Clinical Nurse Consultant, 12B, RACC, CHHS;
- Clinical Nurse Consultant Rehabilitation Independent Living Unit, RACC, CHHS;
- Clinical Nurse Consultant Acute Care of the Elderly, RACC, CHHS;
- Rehabilitation Nurse Practitioner, RACC, CHHS;
- Physiotherapy Clinical Educator, RACC, CHHS;
- Manager Speech Pathology, RACC, CHHS;
- Manager Occupational Therapy, RACC, CHHS;
- Manager Physiotherapy, RACC, CHHS;
- Manager Community Care Physiotherapy, RACC, CHHS;
- Manager Psychology and Counselling, RACC, CHHS;
- Manager Social Work, RACC, CHHS;
- Manager Exercise Physiology, RACC, CHHS;
- Manager Aboriginal Liaison Officer Service, Clinical Support Services, CHHS;
- Manager Pathology Collections; Pathology, CHHS;
- Rehabilitation Care Coordinator, RACC, CHHS;
- Manager Transitional Therapy and Care Program, RACC, CHHS;
- Manager and other nominees, Clinical Support Services, CHHS;
- Volunteer Manager Client Services, Security and Emergency, Business and Infrastructure, Strategy and Corporate;
- Manager E-Health and Clinical Records, E-Health and Clinical Records, Strategy and Corporate;
- Operational Director ACT-Wide Mental Health Service, Mental Health, Justice Health and Alcohol and Drug Services, CHHS;
- Clinical Nurse Consultant, Brian Hennessy Rehabilitation Centre, Mental Health, Justice Health and Alcohol and Drug Services, CHHS;
- Consumer representatives, ACT Mental Health Consumer Network;
- Clinical Director ACT-Wide Mental Health Service, Mental Health, Justice Health and Alcohol and Drug Services, CHHS;
- Team Leader Adult Mental Health Day Service, Mental Health, Justice Health and Alcohol and Drug Services, CHHS;
- Representatives, Carers ACT;
- Project Officer, Mental Health, Justice Health and Alcohol and Drug Services, CHHS;
- Project Officers, Healthcare Consumers Association;
- Consumer representatives, Healthcare Consumers Association; and
- Project Officers and Manager, Health Services Planning Unit, HIP.
Reference documents utilised in developing this document are outlined in the Appendix.
1.2Acronyms and Glossary
1.2.1Acronyms
Acronym / MeaningACAT / Aged Care Assessment Team
ACE / Acute Care of the Elderly (Canberra Hospital)
ACRU / Aged Care Rehabilitation Unit (Calvary Hospital)
ACTES / ACT Equipment Service
ACTPAS / ACT Patient Administration System
ADL / Activities of Daily Living
CALD / Culturally and Linguistically Diverse
CHC / Community Health Centre
CHHS / Canberra Hospital and Health Services
CHI / Central Health Intake
CRT / Community Rehabilitation Team
CSP / Clinical Services Plan
CTW / Clinical Technology Workshop
DARS / Driver Assessment and Rehabilitation Service
DORSS / Domiciliary Oxygen and Respiratory Support Scheme
EP / Exercise Physiology
ELS / Equipment Loan Service
FTE / Full Time Equivalent
GEM / Geriatric Evaluation and Management
GP / General Practitioner
HIP / Health Infrastructure Program
HITH / Hospital in the Home
LOMT / Limitations of Medical Treatment
MEWS / Modified Early Warning Scores
NDIS / National Disability Insurance Scheme
OT / Occupational Therapy
PAS / Patient Administration System (e.g. ACTPAS)
PSP / Preliminary Sketch Plan
P&O / Prosthetics and Orthotics
RACC / Rehabilitation, Aged and Community Care
RACLN / Residential Aged Care Liaison Nurse
RADAR / Rapid Assessment of the Deteriorating At-risk
RILU / Rehabilitation Independent Living Unit (Canberra Hospital)
RG / Reference Group
SAGU / Sub-acute Geriatric Unit (Canberra Hospital)
SWAPS / Specialised Wheelchair and Posture Seating
TTCP / Transitional Therapy and Care Program
UCPH / University of Canberra Public Hospital
UG / User Group
VARS / Vocational Assessment and Rehabilitation Service
1.2.2Glossary
Key terms used throughout this document are defined below.
Acute Care
An episode of acute care for an admitted patient is one in which the principal clinical intent is to do one or more of the following:
- Cure illness or provide definitive treatment of injury;
- Perform surgery;
- Relieve symptoms of illness or injury (excluding palliative care);
- Reduce severity of illness or injury;
- Protect against exacerbation and/or complication of an illness and/or injury which could threaten life or normal functions;
- Perform diagnostic or therapeutic procedures; and
- Manage labour (obstetric).
Admitted Services
Admitted services are those which are provided to patients who require formal admission to hospital and care within a hospital bed. Care provision may be overnight or day only.
Ambulatory Services
Ambulatory services are health services provided on an outpatient basis to patients who attend a hospital or health care facility and depart after treatment on the same day.
Care Plan
A care plan is a patient-centred plan agreed to with the patient and their family/support people with the clinicians. It will identify care/treatment goals and timeframes, intensity of therapy required and the multi-disciplinary team members or inreach services required.
Community Based Services
A range of RACC community based health services for people of any age including a range of technical nursing services, allied health services, health promotion and self management of chronic conditions. Service provision may be health centre based or provided within a range of community settings e.g. patient homes, workplaces and public spaces.
Consultation Liaison Services
Consultation liaison services are services that are not managed by RACC but which provide consultation services to RACC patients when necessary.
Geriatric Services
The provision of care for patients who have conditions associated with ageing. Care provision is typically provided for patients over the age of 65 years or over the age of 50 years for Aboriginal and Torres Strait Islanderpeoples; however, younger patients may be seen if they have a condition which is associated with the ageing process. Patients aged above 65 years or 50 years for Aboriginal and Torres Strait Islander peoples may access a range of clinical services of which geriatric services are one.
Inpatient Services
Inpatient overnight services are provided to patients whose condition requires formal admission to hospital. Patients receiving inpatient care require care within the hospital overnight in order to treat their condition and/or safely undertake activities of daily living.
Note: there are some inpatient services where the patient does not reside in the hospital e.g. Hospital in the Home (HITH).
Model of Care
The Model of Care describes how clinical services are/will be delivered to a patient or client.
The focus of the Model of Care description is on direct clinical service provision, however, aspects of support services which are integral to care provision (e.g. information and communications technology and administration/booking/scheduling) are also described as part of the Model of Care.
This document describes the overarching future Model of Care for RACC services across the ACT, butfocuses primarilyupon the RACC services to be provided at UCPH.
Rehabilitation
Rehabilitation is the provision of care that aims to:
- Restore functional ability for a person following a period of illness or injury;
- Enable restoration of function consistent with pre-injury/illness status and the constraints of the medical prognosis; and
- Develop compensatory functional skills to address deficits that cannot be reversed.
Sub-acute Care
Sub-acute care for RACC patients is the provision of specialised multi-disciplinary care in which the primary need for care is optimisation of patient functioning and quality of life. A person’s functioning may relate to their whole body or a body part, the whole person, or the whole person in a social context, and to impairment of a body function or structure, activity limitation and/or participation restriction.
UCPH will be a sub-acute facility providing adult rehabilitation and Geriatric Evaluation and Management (GEM) services. Palliative care and psychogeriatric care will not be provided. Emergency Department and other acute services will not operate from the site.
Other
Other terms/references used in this document are outlined in the table below.
Term / MeaningWard 11A / Canberra Hospital Acute Care of the Elderly (ACE) Ward – 26 beds
Ward 11B / Canberra Hospital Sub-acute Geriatric Unit (SAGU) – 18 beds
Ward 12B / Canberra Hospital Acute Rehabilitation Ward – 20 beds
2Profile of Current RACC Activities
Existing RACC services cover a comprehensive range of multi-disciplinary care services for patients with rehabilitation, aged and community care needs,across the entire care continuum, from inpatienttoambulatory settings. RACC services are currently provided throughout the ACT in a number of locations including hospitals, community health centres and in the community in order to best meet each patient’s care needs. Equipment Services provided by RACC are accessible to all eligible patients (RACC and non-RACC).
Rehabilitation services are provided for adults (18 years and above) while geriatric services focus on the provision of services to patients who are experiencing chronic or complex symptoms of ageing. Geriatric services are typically provided for individuals over the age of 65 years, or over 50 years for Aboriginal and Torres Strait Islander peoples, however, younger patients may require geriatric services if they have a condition which is associated with the ageing process (e.g. functional decline and interdependent problems such as undernutrition, falls, skin tears, pressure injuries, delirium etc.). Patients aged over 65,or aged over 50 years for Aboriginal and Torres Strait Islander peoples may access a range of clinical services of which geriatric servicesare one.
Equipment Services are provided for patients of all ages. RACC community based services are predominantly provided to adults noting, however, that community based physiotherapy and podiatry services are currently provided to children and young people under the age of 18, and that the Walk-in Centres provide care for people over 2 years of age.
An outline of existing RACC services is illustrated below.
Figure 1: Outline of Existing RACC Services
Existing RACC services are described below.
2.1Inpatient Services
2.1.1Inpatient Care Settings
Care settings for current RACC inpatient services include:
- Canberra Hospital
-Acute Rehabilitation Ward (Ward 12B) – 20 beds. The majority of these patients have neurology/neurosurgery, vascular, multi-trauma and oncology conditions.
-Acute Care of the Elderly (ACE) Ward (Ward 11A) – 26 beds.
-Rehabilitation Independent Living Unit (RILU) – 16 beds, includes inpatient and day program.