Guidelines
Funding Conditions
Brokered care allocations are from health funds. Allocation and usage of these funds will remain under close scrutiny and review by the Adahps Co-ordinator to ensure expenditure is related to maintaining or improving health outcomes.
Conditions of brokered care are as set out below:
- The client needs to meet the following conditions:
- A PLWHA referred to ADAHPT for co-case management,
- Has an HIV related cognitive impairment (for example ADC, PML, toxoplasmosis), and
- Has a high level of dependency/disability and complex care needs. The complex needs typically require multiple agencies to assist the case manager to implement components of the care plan.
- Co-case management and case management needs to be in place, or be planned.
- A local case manager is identified and has accepted the role to organise or help with organising key services to assist in care planning, implementing the plan, monitoring implementation, and in maintaining a communication between all services and the client and/or carers.
- The local case manager establishes a partnership between the client, any carer/s (or guardian), the ADAHPT co-case manager, and identified services to work together to develop goals, develop strategies to implement tasks and to periodically review tasks.
- This partnership is developed during a care plan meeting facilitated by the case manager. This involves a round table meeting, which could be by a telephone conference or via a Telehealth link, chaired by the case manager and ADAHPT, with the client and the services involved in treatment, care and support, to establish a care plan and to co-ordinate services. Tasks in the care plan are to be clearly identified. Additional local resources may need to be explored. (See ADAHPT fact sheets: Case management plan common contents and ADAHPT Case management model.)
- A timeframe for review is established within the care plan.
Initially the local case manager should apply to their local HACC and/or Community Options Programs for a community client (or Compacks for an inpatient). Community Options Programs provide a case management and coordination role to link clients with a range of services such as HACC and community based services, personal care, home help, and meal services and home care assistance. HACC provides domestic assistance.
The case manager can seek up to 4 weeks of funding from ADAHPT while actively seeking HACC and/or Community Options Programs involvement. At the end of one month ADAHPT will consider a further funding period on a case-by-case basis. The Department of Ageing, Disability & Home Care, which administers the HACC program in NSW, can be contacted on (02) 8270 2000 or at www.dadhc.nsw.gov.au.
- The local case manager meets with the brokered care worker regularly, initially to define tasks and objectives, for example to go with client to shop and model shopping, and later to monitor and oversee the activities of brokered care.
- The primary need for brokered care needs to be related to HIV and not to other health conditions.
- The ADAHPT co-case manager is responsible for ensuring the local case manager is acquainted with these procedures.
- The Adahps Coordinator is the final decision maker, and he/she will prioritise applications based on need and the availability of funds.
- Prior to any public holiday, alternatives to ADAHPT funded brokered care support arrangements are to be considered for the public holiday period.
- Any changes to the brokered care tasks or specified hours need to be in consultation with ADAHPT.
Examples
Brian, 49 years
Brian has a diagnosis of AIDS Dementia Complex. He lives alone in a one-bedroom cottage that he rents in a small rural town, 30 kms from the sexual health clinic. He has limited social supports and his elderly mother lives in a retirement village in Sydney. Brian is used to independent living and drives to appointments at the sexual health clinic. Recently his behaviour has deteriorated and he can no longer drive a car, he has increased his use of recreational drugs, has adherence issues, is forgetful, his personal care has deteriorated, he is having difficult mood swings and regularly 'sacks' his nurse then re engages the local community health nurse. Brian now has access to limited HACC services for cleaning and personal care, however, there is no local transport service to take him to his appointments or to a support group. The local case manager approached ADAHPT to provide a neuropsychology assessment to determine his cognitive ability and capacity to live independently, and for ongoing assistance with strategies to manage his behaviour. A case management meeting was convened and chaired by the case manager and ADAHPT. Brian, the sexual health clinic nurse, the social worker, support group coordinator, ADAHPT and community nurse case manager, the section 100 prescriber and his local GP attended. As HACC was unable to supply further assistance, brokered care funds were allocated to meet care plan activities relating to the transport of Brian to his neuropsychological assessment, specialist doctor's appointments and attendance at the support group. ADAHPT funds 4 hours of brokered care a fortnight to support Brian. As Brian's care and support needs change, this level of care will be reviewed on a regular basis, and may change to include social activities and behaviour modelling. The case manager continues to seek additional HACC funds. The AIDS Co-ordinator is liaising with mental health administration to seek a psychiatric assessment. The HIV Neurologist, St Vincent's Hospital has agreed to provide consultant advice on Brian's treatment. ADAHPT are organising a respite bed in the Bridge so that he can attend this assessment. Brian's elderly mother is linked in with the Tree of Hope for regular telephone support. Brian says he is relieved that he now has more assistance and that he can remain at home.
Sarah, 51 years
Sarah, a PLWHA for 16 years, was released from prison on parole. ADAHPT visited her before release and worked with her and Justice Health to prepare follow-up care and support. Sarah appears frail, is cognitively impaired, and has limited skills to live independently in the community. In prison she was treated for a mental illness. Sarah has limited social supports, limited mobility and has difficulty attending to Activities of Daily Living (ADLS). She lives in an outlying suburb of the city where access to services is limited and is without access to support services. Sarah needs assistance to maintain her tenancy, as she will be unable to cope with the stressors of illness, disability and independent living. Having her own home is very important to her. She values the support of Pozhet.
Sarah's local case manager invited ADAHPT to a case conference to discuss the available options for Sarah. Also in attendance were Sarah's S100 prescriber, parole officer, community social worker and occupational therapist, housing support worker and Sarah's sister. ADAHPT agreed to provide 6 hours of brokered care a week to support Sarah until HACC services are implemented. The brokered care supports the payment of a private agency support worker to assist Sarah with prompting and assistance with household chores such as cooking, cleaning & laundry and with limited social activities. Once the HACC services become available to Sarah, brokered care will continue for 3 hours per week for social activities. The Ankali Project have agreed to allocate a volunteer and CSN are willing to assist when a volunteer is available with a vehicle to visit Sarah. ADAHPT will regularly assess her neuro-psychological state and will allocate a co case manager to share in-home visiting and assist with the development of strategies to assist her to live independently. A referral has been made to the mental health team for a re-assessment.
Jack 55 years
Jack has progressive multifocal leukoencephalopathy (PML). He is physically disabled, walks with a walking frame and has no awareness that he can't walk down stairs. He was referred to a suburban hospice for rehabilitation. In spite of his deterioration it has not been possible to organise a nursing home placement. After one year in the hospice, Jack is very demoralised and is not coping with the constant deaths. There are no beds at the Bridge, BGF House or the Villa, and even if there were beds his dependency needs are greater than these services are designed for. Jack wants to go home to his inner city flat. HACC, Community Options, BGF, CSN, Community Health nursing, social work, physiotherapy and occupational therapy, the Office of the Public Guardian, the Protective Office and ADAHPT have been mobilised by the clinical nurse consultant and the social worker. These services have worked with Jack to establish a care plan. The roles and responsibilities of each service are incorporated in the plan. ADAHPT is to fund an additional 16 hours per week for care and support at home. This is a trial, and will be reviewed in a month. This is an expensive option and requires close monitoring, although hospitalisation is more costly.
This web page is managed and authorised by AIDS Dementia & HIV Psychiatry Service. Last updated: 16 March, 2009