OCCUPATIONAL THERAPY
REFERRAL PATHWAYS
ie
health
Inner East Community Health
This project received funding from the Commonwealth and Victorian Governments.
EASTERN METROPOLITAN REGION
EXECUTIVE SUMMARY
2
SCOPE OF PRACTICE
3
Acute and Emergency Department OT
3
Sub-Acute OT
3
Ambulatory Care OT
4
Community Health Services OT
4
GUIDELINES FOR SWEP APPLICATIONS
5
REFERRAL TOOLS
7
From Acute Inpatient Occupational Therapy
7
From Acute Inpatient OT Requiring Pressure Care Follow up
8
From Sub-Acute Inpatient OT for Equipment Needs
9
From Sub-Acute Inpatient OT for Home Modification Needs
10
From Ambulatory Care OT for Equipment Needs
11
From Ambulatory Care OT for Home Modifications
12
The Eastern Metropolitan Region (EMR) Occupational Therapy (OT) Referral Pathway Project was initiated by Manningham Community
Health Services Ltd (MCHSL) on behalf of all partner agencies, in mid-2012. The goal of this project is to improve client outcomes
through the establishment of standardised referral pathways for Occupational Therapy within the Eastern Metropolitan Region.
EXECUTIVE SUMMARY
CONTENTS
The following partner agencies collaborated on the project:
•
EACH•
Eastern Health•
Inner East Community Health Service•
Inspiro Community Health Service•
Knox Community Health Service•
Manningham Community Health Service•
Monashlink Community Health Service•
Whitehorse Community Health Service•
Yarra Valley Community Health Service•
Royal District Nursing Service•
District Nursing ServiceScope of Practice for OTs within each sector was defined:
•
Acute and Emergency Department OT Scope of Practice•
Sub-Acute OT Scope of Practice•
Ambulatory Care OT Scope of Practice•
Community Health Service OT Scope of PracticeThe Working Group developed six (6) referral pathways, which include:
•
EMR acute patient OT for equipment and home modification needs•
EMR acute patient OT for pressure care•
EMR sub-acute patient OT for equipment needs•
EMR sub-acute patient OT for home modification needs•
EMR ambulatory care OT for equipment needs•
EMR ambulatory care OT for home modificationsAll partners remain dedicated to this project and MCHSL will continue convening the Working Group to ensure the ongoing review of the pathways for compliance, relevance and evaluation of impact to client outcomes.
Jenny Jackson
MCHSL Chief Executive Officer August 2013
Occupational Therapists (OTs) working in the acute hospital environment, facilitate discharge within the context of the acute reason for hospital admission. Patients are commonly admitted to the acute hospital with chronic or pre-existing medical conditions, however the acute OT may not be referred to assess these patients, particularly if their conditions are not directly related to the reason for hospital admission or have not caused an acute change in functional status. Therefore it cannot be assumed that acute hospital admission will result in automatic OT intervention. The role of the acute OT is to ensure the patient is appropriate for discharge; within this scope of practice the acute OT may prescribe low cost items of equipment and assess for low cost home modifications (under $1000) if they will prevent hospital re-admission or assist in facilitating home discharge.
Patients are provided with equipment for 30 days post discharge and/or encouraged to purchase low cost items should they require them (i.e. they present with long-term needs). As a result, OTs working in Emergency Departments and acute hospital wards rarely apply for SWEP funding. On the occasion when a patient cannot afford a low cost item of equipment and the ongoing need (post 30 days) is obvious, then the acute OT will complete the SWEP application.
Acute OTs will prescribe and provide pressure care equipment (cushions and mattresses) that are assessed as suitable to manage the pressure injury at the time of discharge from the acute hospital setting. Equipment will be trialed on the acute ward and funded for 30 days post discharge. Acute OTs will collaborate with nursing staff to initiate a referral to community nursing (RDNS or Eastern at Home) for wound care. Acute OTs will liaise with the community nursing service regarding equipment prescription and recommendations for ongoing care at the time of discharge. Community nursing will monitor wound healing and refer to Community Health OTs should the pressure injury require long term equipment prescription.
Occupational Therapists in the acute setting will refer to Community Health Centre OTs for assessment of long term items of equipment when:
•
The patient’s level of occupational performance is not stable on discharge.•
The patient does not have goals that indicate referral to the Eastern Health Community Rehabilitation Program (CRP) but has high cost and/or complex equipment and/or home modification needs.•
A trial of multiple different models for an item of equipment is required.•
Multiple home assessments are required to trial items of equipment and/or assess for permanent home modifications.Patients may be admitted to Sub-Acute following an acute admission. They are often neurological or orthopedic patients. All patients are assessed by an OT. Due to reduced length of stay, inpatient rehabilitation goals usually surround the bare essential occupations that a patient needs to be able to perform on discharge. Unfortunately equipment issued on discharge is limited to available hire stock, therefore patients are often sent home with the available, adequate item rather than the “perfect” model of equipment. Patients are often referred on to community services (i.e. Personal Care Assistance, Home Help) for tasks that they do not achieve independence with on the ward. Often these patients are also referred onto CRP to progress independence in these areas if their condition is likely to improve with the potential goal of reducing services required.
Examples of common sub-acute goals include:
•
Independent self care•
Independent drink and light meal preparation•
Adequate home setup for occupational performance needs on discharge•
Independent implementation of energy conservation strategies•
Independent implementation of falls prevention strategies Occasionally SWEP applications are completed in sub-acute. Patients are mainly encouraged to purchase equipment if their occupational performance is unlikely to improve post discharge and they require low cost items on a permanent basis.In instances where major modifications are required to facilitate discharge from hospital, and are to be funded by patient/family, the inpatient therapist would make their recommendations and arrange for Archicentre plans. The OT may then arrange quotes (or family may pursue quotes) from a registered builder who may then follow through with completion of these works.
In instances where the patient’s level of functioning may change or is unclear, temporary equipment or minor modifications may be recommended by the inpatient therapist rather than more major modifications. Any future modifications would then be followed through in the community when long-term functional status is clearer.
In instances where major modifications are requested, but not required to facilitate safe discharge, and the patient/family wish to fund modifications, the OT may refer on to Community Health to follow this through.
As with acute, higher cost items that are generally required by patients with more complex needs may not have a SWEP application completed on the ward due to:
•
the patient’s level of occupational performance is not stable on discharge;•
inability to trial different models of equipment;•
need to trial different models of equipment in patient’shome/usual environment;
•
need to complete multiple home assessmentsThese patients will be referred onto ambulatory care if they have rehab needs, or Community Health to determine long term equipment needs. Sub-acute OTs may refer to both Ambulatory Care and Community Health if the patient requires major home modifications (over $1000) funded through SWEP.
Acute and Emergency Department OT
Sub-Acute OT
Ambulatory Care OTs provide treatment to clients within their own home. Length of stay is approximately 6 – 12 weeks. In order to be eligible a client must satisfy the following criteria:
•
Have rehabilitation goals (time limited, functional)•
The reason for referral to Occupational Therapy servicesto address equipment and/or modification needs must be related to the reason for admission for rehabilitation. If they fail to meet the criteria for rehabilitation they will be referred to Community Health or private Occupational Therapy services for ongoing input.
Community Rehabilitation Occupational Therapists will:
•
Provide equipment and minor home modifications wherethe need for OT input relates to the reason for admission (i.e installation of a rail at the front access to enable community access for a client who has had a recent hip replacement).
•
Submit SWEP applications for eligible clients when theequipment or home modification does not require OT sign off (i.e under $1000) when funding becomes available.
•
Consider provision of equipment/modifications over the cost of $1000 if the client is willing to purchase/pay upfront and it is evident that equipment will be provided/work will be completed within the estimated length of stay of the CRP admission and not delay discharge.•
Consider whether referral to a private OT for follow up may better suit the client with use of a GP Allied Health care plan. Community Rehabilitation OTs will not:•
Accept ‘equipment only’ referrals when no other discipline is involved, as all CRP eligible clients must have interdisciplinary rehabilitation goals. These referrals will be directed back to the referrer to refer onto the appropriate Community Health Service. If another discipline is involved, OT will accept a referral for equipment provision, provided it meets the criteria set out above for interventions relating to equipment provision.•
Start a SWEP application for major bathroom modifications/ equipment prescription over $1000 for an admitted client and refer onto Community Health. These clients should be referred directly onto Community Health either at the acute/ Sub-Acute stage or during the CRP admission depending upon satisfaction of CRP criteria above. Concurrent referrals to Community Health and Community Rehabilitation OTs will be accepted to enable rehabilitation goals to be pursued as well as major home modifications/costly equipment.•
Accept referrals for driving assessment or referral onto driving services only.Occupational Therapy services provided by Community Health Services are guided by the Home and Community Care Priority Guidelines produced by the Department of Health. Through discussions held between Community Health and Eastern Health, Community Health OTs have also agreed to the following. Community Health Occupational Therapists will:
•
Accept referrals for major bathroom modifications/ equipment costs over $1000 where SWEP application and sign off is required for funding and length of application time will exceed length of CRP admission.•
Accept concurrent referrals whilst CRP OT is involved where the above conditions apply, when the client is safe and set up to manage care at home while awaiting input for more permanent modifications/equipment. Where able, consideration will be given to joint sessions for handover to enable continuity of service appropriate to client need.•
Accept referrals from any allied health discipline either atacute, sub-acute or ambulatory level that meets Community Health OT acceptance criteria.
Community Health OTs will not:
•
Accept referrals to “sign off” on SWEP applications that have been previously submitted by Eastern Health OTs.•
Accept referrals when equipment requires maintenance and checkup post prescription.•
Accept referrals for home modifications/equipment that is required for a safe discharge.•
Accept referrals to complete a SWEP application for a low cost item of equipment.Ambulatory Care OT
Community Health Services OT
SCOPE OF PRACTICE ΈCONTINUEDΉ
Ambulatory Care
Sub-Acute
Acute & ED
Community Health
GUIDELINES FOR SWEP APPLICATIONS
Toileting
Equipment
Over Toilet Frame Bedside Commode Transporter Commode Referral accepted from acute only
Self-Propel Commode If doesn’t require
SWEP sign off
Bathing
Equipment
Shower Stool Bathboard
Transfer Bench If OT home visit completed
Bath Hoist
Seating
Equipment
Low Back Chair If OT home visit completed
High Back Chair If OT home visit completed
Electric Lift Chair
Often these referrals are for chronic needs
Wheelchairs
Transit/Carer WheelchairNo customisation Clients needs not complex
Manual Self-Propel Wheelchair
Need for multiple models to be trialled within home/community. Client condition not stable and best model cushion not certain.
Power Wheelchair
Need for multiple models to be trialed within home/community. Best model cushion not certain
Scooter
This Table should be used as a guide, with consideration given to individual patients on a case by case basis. Occupational Therapists in Eastern Health will only complete State Wide Equipment Prescription (SWEP) applications if the patient’s occupational performance issues are stable and the permanent need for the item of equipment is obvious.
Ambulatory Care
Sub-Acute
Acute & ED
Community Health
Pressure Care
Pressure Care Cushion• For Transit Wheelchair • For items under
$1,000 that don’t need sign off • If wound is long term
and stable
No customisation required Clients needs not
complex
If referral is for pressure care only with
no other discipline involvement - refer to CH For customized cushions only Pressure Care Cushion
• For Self Propel /
Power Wheelchair Complex pressure care needs.
Need for multiple models to be trialed within home/community
Pressure Mattress
Bed
Equipment
Cot Sides Referral
accepted from acute only
Self Help Poles Referral
accepted from acute only
Hospital Bed
OTs to consider if long term need is clear, client can pay gap and hire equipment trialled/loaned is suitable i.e multiple trials not required. Then Eastern Health OTs to consider SWEP application
due to high expense of hiring
Portable
Ramps
Small Ramps to Access Home
• permanent need for
ramp obvious Only if item is under $1,000 and
doesn’t need sign off
Ramps for Community Access
Home
Modification
Shower Rail If OT home visit completed
Toilet Rail If OT home visit completed
Banister Rail
essential for access in/out of home
Complex Banister Rail
(bends and pathways)
Platform Chair Raiser Referral
accepted from acute only
Hand Held Shower Hose
Major Bathroom Modification
From Acute Inpatient Occupational Therapy
Presenting Issue: Patient admitted to Eastern Health Acute Hospital with a plan for home discharge
Equipment Required
Is Home Assessment indicated to facilitate safe home discharge?
Provide equipment 30 days post discharge for hire
+/-Provide details and encourage patient to purchase low cost items
Prescribe basic hand/bannister rails Prescribe equipment that facilitates home
discharge from acute setting
NO
YES
NO
YES
•
Complete SWEP paperwork for basic handrails/equipment (see Table).•
Refer to Community Health Centre OTif complex modifications/equipment required (SWEP application not commenced)
Does the patient require ongoing OT input
•
Refer to handyman for equipment installation•
Provide equipment 30 days post discharge for hire
+/-•
Provide details and encourage patient to purchase low cost itemsNO
YES
If rehab goals identified Refer to CRP
Refer to CHS when:
•
Complex home modifications required•
High cost item existing item requires review•
Trial of high cost items is required Discharge from OTJoint referral can be completed to CRP/CHS – ensure both parties are aware of concurrent referral
REFERRAL TOOLS
RDNS/Eastern at Home/District Nursing to refer to CHS if pressure area requires
long term equipment prescribed Management of Pressure Area
Is pressure care required? (cushion/mattress)
Discharge from OT if no other issues
•
Hire equipment 30 days post discharge and provide details if ongoing hire required•
Refer to RDNS/Eastern at Home/District Nursing for ongoing monitoring if required•
Refer directly to CHS if nomonitoring required and client’s existing item of equipment needs to be replaced ( e.g worn)
NO
YES
From Acute Inpatient OT Requiring Pressure Care Follow up
Presenting Issue: Patient admitted to Eastern Health Acute Hospital with a plan for home discharge
NO
YES
YES
NO
Refer to CRP Include review of more appropriate equipment – see Tablefor items covered
Refer to CHS
Joint referral can be completed to CRP/CHS – ensure both parties are aware of
concurrent referral Complete SWEP application Refer to CHS Refer to CRP Include review of more appropriate equipment – see Table
for items covered
NO
YES
Equipment required for discharge See Table for items covered
Is the equipment required long term
Client discharged with hire equipment for 30 days with details of
how to continue/ purchase if required
If ongoing pressure care is an issue refer to RDNS/ District Nursing for
monitoring. RDNS to refer to CHS as
required
Is the hire stock equipment suitable?
NO
YES
Does the client have ongoing rehab
goals?
Is equipment within SWEP funding limit/ client able to pay
excess? OT to organise equipment for purchase
YES
NO
NO
YES
If Condition is not stable and OT is unsure of long term requirements – refer directly to CHS
From Sub-Acute Inpatient OT for Equipment Needs
Presenting Issue: Patient admitted to Eastern Health Sub-Acute setting with plan for home discharge.
Arrange hire equipment plus determine how to obtain equipment
long term Is trial of equipment necessary?
NO
Home assessment completed Modifications required
(< 2visits)
Major modifications required
•
Complex bathroom modifications•
Ramps•
Complex step modifications•
Archicentre report/sign off requiredMinor modifications required – under $1,000 (See Table)
•
Handrails•
Simple step modifications•
Simple bannister railsNO
YES
OT to organise temporary set up/ alternate discharge destination Refer to CHS Sub-Acute OT to organise Complete SWEP application Refer to CHS Is equipment within
SWEP funding limit/ client able to pay
excess? Refer to builder/ handyman service
YES
NO
NO
YES
Is modification required for safe discharge?Is funding an issue?
Can client fully self fund?
YES
From Sub-Acute Inpatient OT for Home Modification Needs
Presenting Issue: Patient admitted to Eastern Health Sub-Acute Hospital with plan for home discharge
NO
YES
Is the equipment required long term?
Client discharged with hire equipment for 30 days with details of
how to continue/ purchase if required
If ongoing pressure care is an issue refer to RDNS/ District Nursing for
monitoring. RDNS to refer to CHS as
required
Does the equipment cost less than $1000?
NO
YES
Ambulatory Care (Community Rehabilitation) Referrals accepted for patients with
ongoing rehabilitation needs See Table for items covered
NO
YES
Complete SWEP application
Refer to CHS Is client able to purchase?
Is equipment within SWEP funding limit/ client able to pay
excess? OT to organize equipment for purchase
YES
NO
Refer to CHSFrom Ambulatory Care OT for Equipment Needs
Ambulatory Care (Community Rehabilitation) Referrals accepted for patients with
ongoing rehabilitation needs
NO
YES
Complete SWEP application Refer to CHS Is equipment withinSWEP funding limit/ client able to pay
excess? Refer to builder/ handyman service
YES
NO
Is funding an issue? Refer to CHSFrom Ambulatory Care OT for Home Modifications
Presenting Issue: Patient admitted to Eastern Health Ambulatory Care with plan for discharge
REFERRAL TOOLS ΈCONTINUEDΉ
Major modifications required
•
Complex bathroom modifications•
Ramps•
Complex step modifications•
Archicentre report/sign off requiredMinor modifications required – under $1,000 (See Table)
