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Model and Governance
Model and Governance
Rose's Story |
Luigi's Story
Healthy at Home was developed as a response to the rapid growth in the ageing populations. It aims to provide an effective model of care that provides a better alternative to inpatient care and supports older people in their home environment.
By providing more integrated and tailored care before a crisis occurs, this program can help to keep elderly people well and out of hospital. It seeks to build on and better co-ordinate existing services.
Rose and Luigi's patient journeys below show how Healthy at Home can help to provide better care for older people.
Rose's Story
This is a real story...only names have been changed.
| Rose's journey prior to Healthy at Home |
Rose's journey using Healthy at Home |
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It is late one Friday afternoon when the Dr Collins receives a phone call from Bernard Smith. Bernard reports that his wife Rose, who has diabetes and dementia, has been increasingly agitated in the past few days. Rose and Bernard are not coping.
Dr Collins realises that Rose is at risk of admission to hospital if some rapid action is not taken.
He calls the local Health Service (he tried a number of different options) but is unsuccessful in arranging an urgent nursing assessment or help until after the weekend.
He visits Rose later that evening. Although Rose isn't keen, Dr Collins has no option but to speak to the Emergency Department and call an ambulance to get her to the hospital.
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It is late one Friday afternoon when the Dr Collins receives a phone call from Bernard Smith. Bernard reports that his wife Rose, who has diabetes and dementia, has been increasingly agitated in the past few days. Rose and Bernard are not coping.
Dr Collins realises that Rose is at risk of admission to hospital if some rapid action is not taken. He makes a referral to the Healthy at Home team.
Within 24-48 hours of making the referral a nurse and community case manager are able to visit the Smiths at home. This assessment finds that Rose is becoming particularly agitated in the late afternoon, when her behaviour is erratic and difficult to manage.
The nurse works with Dr Collins to organize some tests to rule out any recent change in condition and also arranges review of Roses' medication by a Geriatrician. The case manager organises for a local service to take Rose for a walk every afternoon to reduce her agitation and give Bernard an opportunity to prepare dinner.
The case manager also helps to organise regular respite for Bernard and community transport so that Rose can attend day care on a regular basis.
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Luigi's Story
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Without Healthy at Home |
With Healthy at Home |
| Week 1 |
- Luigi visits GP with respiratory infection.
- Oral antibiotics prescribed.
- Luigi advised to return in 1 week or if symptoms worsen
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- Luigi visits GP with respiratory infection. "Early warning Flag"
- Phone call to SAFTE Care Line
- Oral antibiotics prescribed
- Call Centre Staff (clinician) conduct brief triage with GP
- Electronic referral sent to SAFTE Team.
- Luigi receives phone call form SAFTE team member.
- SAFTE Care team (including a Community Options Case Manager) member visits Luigi within 48 hours of referral
- Assessment identifies Luigi requires functional support and further medical review
- Chest physiotherapy treatment is recommended & arranged
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| Week 2 |
- Luigi has poor response to oral antibiotics and is too unwell to visit the GP.
- GP makes a house call one day later and diagnoses acute pneumonia.
- GP calls Geriatrician who advises Luigi go to Emergency Dept (ED) for a review.
- Luigi presents to ED via ambulance. He is assessed by Aged Services Emergency Team.
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- Luigi receives physiotherapy at home and continues on his course of antibiotics,
- Luigi is taken for X-ray by ComPacks Case Manager.
- Luigi is monitored and his condition improves.
- Support services commence.
- Luigi receives assistance with house cleaning, shopping and transport to medical appointments.
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| Week 3 |
- Luigi is admitted and is in hospital for 10 days.
- Develops secondary infection.
- Has one fall whilst in hospital
- Multidisciplinary assessment.
- Discharged with ComPacks
- Luigi returns home with discharge summary and advice to go and see GP.
- A phone referral is made to CAPAC for chest physio.
- Luigi is supported in the Community for 6 weeks by ComPacks.
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- Luigi's chest infection improves.
- The ComPacks Case manager facilitates the set up of long-term support for Luigi
- Hospital averted and Luigi is happy to have been treated at home.
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This web page is managed and authorised by Health System Performance Improvement of the NSW Department of Health. Last updated: 31 March, 2009
