Healthy At Home
What is Healthy at Home? | Why Healthy at Home? | How does it work? | Key elements of the programWhat is Healthy at Home?
Healthy at Home (formerly Sub Acute Fast Track Elderly (SAFTE) Care) is an interagency program for service providers who provide care to frail older people in the community who are over 65 years (over 45 years for Aboriginal and Torres Strait Islander people) and have emerging acute care needs.
By providing more integrated and tailored care, before a crisis occurs, this program will help to keep elderly people well and out of hospital.
Healthy at Home seeks to build on and better co-ordinate existing services. It is currently available in four sites in New South Wales.
Why Healthy at Home?
Australia's population is ageing. The current challenge in service delivery for older people is to better integrate services, so that older people get the right care at the right time. Difficulties in accessing appropriate services in the community to support and compliment GP care often leads to (a preventable) hospital admission.
Too many frail elderly people end up in hospital emergency departments. Older patients are at risk of significant complications and adverse outcomes in acute hospital settings.
Healthy at Home has been developed using Australian and international studies and programs. Research shows that hospital admission can be avoided if events such as declining mobility, falls or respiratory infection are managed earlier in the community, before an acute crisis requires emergency care.
Frail older people often present with a range of special needs that pose a challenge to existing systems of care. A recurring issue in the cases studied in the Survey of Pre-Acute Care of Older People was the challenge of organising and providing quick access to a range of services in the primary care setting. Without early interventions problems escalated to a point of crisis and need for emergency care.
The Healthy at Home program aims to address some of the gaps in service provision that arise when an older person in a sub-acute phase of illness or an emerging crisis requires prompt and effective intervention.
How does it work?
GPs and other service providers such as aged care assessment teams, community services workers and ambulance officers, can refer patients, 7 days a week, to assist with fast tracking diagnosis, diagnostics and clinical assessment of patients.
A community case manager (Community Options Program & Compacks staff) will assist the older person to manage at home with implementing support services such as cleaning, personal care assistance and transport.
Key elements of the program
Referral Information Center (RIC) Telephone 1800 152 149
RIC provides a seven-day intake service and is staffed by nurses and other clinicians. By calling 1800 152 149, service providers are able to make a referral to expedite a Healthy at Home Service within 48 hours of referral.
Healthy at Home teams
Rapid response teams for older people have been created by enhancing existing teams to provide a fast, expert, service for older people in their homes or other primary care settings such as hostels and nursing homes.
Within 48 hours of referral the patient is assessed where they reside. This assessment will be conducted by a clinician such as a nurse and a Community Options Case Manager. As part of the Healthy at Home pilot the Ongoing Needs Identification (ONI) Tool will be used for a comprehensive assessment. Evidence suggests that valid and reliable serial functional assessments such as the ONI promote early identification and proactive care planning, and in addition can indicate an individual's rate of decline and prognosis
Community Options
Community Options is a case management service for clients whose needs cannot be met by mainstream Home and Community Care (HACC) services. The community options approach begins with a holistic and comprehensive assessment of the individual client's needs. It works with the client to develop a care plan that may involve HACC service providers, private agencies, family or neighbours.
Community Options' focus is to plan and coordinate services around the individual in a way that ensures flexible, client-focused service delivery.
ComPacks
ComPacks is a case-managed package of care for up to 6 weeks. This service has been established for people who need two or more community services to ensure that they can live at home safely with appropriate care in place.
The types of services, which can be accessed during the ComPacks and/or to which referral can be made during the ComPacks, include domestic assistance, personal care, meals, social support, transport and other services.
The model of case management used in ComPacks is a collaborative model of individual client focused service delivery that includes comprehensive assessment, planning, implementing and monitoring a mix of culturally appropriate services for support in the community. The aim is to link the individual with appropriate levels of ongoing support in order to optimize their independence in the community.
