Elderly transition care a lifesaver
A new pilot program at Rockingham General Hospital is helping elderly patients connect with primary health care providers after being discharged from hospital.
The aged care transition program began in October and is being funded by the WA Primary Health Alliance.
RGH aged care transitional and liaison nurse Deb Jones said the program was designed for older patients with complex health care needs who required health care and social support following hospital discharge.
“When the patient is discharged from hospital I visit their home to see what kind of support is needed, liaise with their GP and pharmacist,” she said.
“My role is to connect patients with their community-based primary health services.”
Anchorage resident Beverley Watts has been in and out of RGH sith several health concerns — the latest a carpal tunnel injury from her 20 years as a cleaner. “After one surgery, I was sent home to wait for my next surgery for severe stenosis of the back,” she said.
“When I got home, I had no support and didn’t know how I was going to make it through.
“My partner has emphysema and I am his carer — I couldn’t help him and he couldn’t help me.”
Ms Watts was referred to the aged care transition program by one of the geriatricians at RGH.
Because of their situation, crisis care was provided for Ms Watts and her partner until her next hospital admission.
There was also liaison with Silver Chain and Ms Watts’ pharmacist and GP to facilitate the care plan she had been given at RGH.
“It was such a miracle — we had carers staying overnight, which is the most frightening time to be left alone,” she said.
Ms Jones said the program aimed to reduce stress for patients and keep them on top of their health problems and out of hospital.
“It’s a very vital program because when you’re in hospital you’re receiving a lot of different information and discharge plans can be quite complex and include follow up appointments and changes to medications,” she said.
“So through the program, we help facilitate where patients need to go next.”
The results of the pilot program will be evaluated later this year.
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