Transfer of Care - Akolade

Transfer of Care For Complex Consumers

Driving better outcomes for older people 1st - 3rd December 2015 | The Grace Hotel, Sydney

E X P E RT S P E A K E R S: Illana Halliday, Chief Executive Officer, Aged & Community Services NSW & ACT

Brett Holmes, General Secretary, NSW Nurses and Midwives’ Association

Lynelle Hales, Chief Executive Officer, Sydney North Health Network

Danielle Ballantine, Chief Executive Officer, Northside Community Forum Inc.

Key benefits of attending: • Enhance communication within multidisciplinary teams to ensure appropriate continuity of care • Involve patients and family members to create a client-centred system

Natalie Sullivan, Executive Director, Brighton and Continuing Care, Cabrini Health

Margret Meagher, Founding Executive Director, Arts and Health Australia and Member, NSW Government Ministerial Advisory Committee on Ageing

Victor Harcourt, Principal, Russell Kennedy Lawyers

Lesley English, Director Transition Care Program, Gold Coast Hospital and Health Service

James Trude, Owner and Director, Home Instead Senior Care – Lower North Shore

Ron Carroll, Founder and Director, Aged Care Connect

Walter de Ruyter, Service Manager, UnitingCare Ageing NSW-ACT and Former Director of Nursing, Shoalhaven District Hospital

Daniel Calleja, Senior Clinician Occupational Therapist and Behaviour Consultant, St Vincent’s Health Hospital Melbourne Dementia Behaviour Management Advisory Service

James Everingham, ACC&R Service Manager, Aged, Chronic Care & Rehabilitation, Sydney Local Health District

Dr Ian Scott, Director of Internal Medicine & Clinical Epidemiology, Princess Alexandra Hospital

Rosslyn Twarloh, Senior Social Worker, St George Older Adult Community Mental Health

• Reduce avoidable readmissions through thorough referrals and assessments • Ensure compliance to clinical handover standard (6) • Gain better knowledge of the legal implications of caring for complex consumers

Proudly Endorsed By:

Dean Byrnes, Discharge Co-ordinator - Transition Care Program Pharmacist, Queensland Health

Media Partners:

Senior Social Worker, Aged Care Social Work Team, St Vincent’s Hospital Sydney

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Transfer of Care for Complex Consumers CONFERENCE DAY ONE: TUESDAY, 1ST DECEMBER 2015 8:00 Registration opens 9:00 Opening remarks from the Chair Lesley English, Director Transition Care Program, Gold Coast Hospital and Health Service

NAVIGATING TRANSFER OF CARE LEGALITIES FOR COMPLEX CASES 9:10 Guardians, Administrators and Public Trustees: Using law to protect older people • Cognitive assessments and legal implications for complex consumers • Understanding legal outcomes arising from deeming a patient without capacity • Helping providers understand their responsibilities and obligations under the Aged Care Act 1997 Victor Harcourt, Principal, Russell Kennedy Lawyers

9:50 PANEL DISCUSSION What do consumers expect from transfer of care services? • Meeting consumers’ expectations • Accommodating an ageing population • What are the fundamentals of care for complex consumers? Panellists: Ron Carroll, Founder and Director, Aged Care Connect Victor Harcourt, Principal, Russell Kennedy Lawyers Dean Byrnes, Discharge Co-ordinator - Transition Care Program Pharmacist, Queensland Health Rosslyn Twarloh, Senior Social Worker, St George Older Adult Community Mental Health

10:30 Morning tea OPTIMISING ACCESS TO FUNDING 11:00 Reorienting current social capital and funding systems • Developing knowledge communities to adapt to an ageing population • Using types of bonds that improve existing practices in care • Future funding models of care Walter de Ruyter, Service Manager, UnitingCare Ageing NSW-ACT and Former Director of Nursing, Shoalhaven District Hospital

MANAGING WORKFORCE DEMANDS 11:40 CASE STUDY Complexity Scales: Are they a useful tool for operational managers in transition care?

• Optimising care processes for older patients with multi-morbidity • How health care systems can best deal with the ‘stranded patient’ • Bringing the necessary care to a suitable setting for patients and carers Dr Ian Scott, Director of Internal Medicine & Clinical Epidemiology, Princess Alexandra Hospital

2:40 Afternoon tea 3:10 CASE STUDY Training specialised staff to assist complex consumers • In house training to deliver highly specialised services • Identifying staff that exhibit ease in dealing with cognitively impaired patients • Offering ongoing training and development James Trude, Owner and Director, Home Instead Senior Care – Lower North Shore

ENHANCING COMMUNICATION AND CLINICAL HANDOVER 3:50 Polypharmacy and transitional teams: Involving pharmacists in transitional teams • Ensuring appropriate medical follow up during early transitional stages • Pharmacists as an integral and indispensable component of aged care teams • Demonstrating economic sustainability of clinical pharmacy outreach Dean Byrnes, Discharge Co-ordinator - Transition Care Program Pharmacist, Queensland Health

4:30 iMASH: Interteam Multidisciplinary Structured Handover • Enhancing client care via increased communication and multiteam care planning across ACC&R Teams • Improving employee job satisfaction via increased collaboration and working relationships • Monitoring client outcomes via achievement of client-centred goals James Everingham, ACC&R Service Manager, Aged, Chronic Care & Rehabilitation, Sydney Local Health District

5:10 Closing remarks from the Chair and end of day one Lesley English, Director Transition Care Program, Gold Coast Hospital and Health Service

CONFERENCE DAY TWO: WEDNESDAY, 2ND DECEMBER 2015 8:00 Registration opens

• Predicting service delivery needs including length of stay • Identifying changes in client groups over time • Informing workforce composition and managing clinical risk

9:00 Opening remarks from the Chair

Lesley English, Director Transition Care Program, Gold Coast Hospital and Health Service

DELIVERING CUSTOMER-CENTRED SERVICES

12:20 Lunch 1:20 PANEL DISCUSSION Comparing hospital-based and brokerage transfer of care models • Weighing advantages and disadvantages of different transfer of care models across the country • Navigating the wide range of home care service delivery programs • Streamlining services across hospital-based and age care provider allied health teams Panellists: Walter de Ruyter, Service Manager, UnitingCare Ageing NSW-ACT and Former Director of Nursing, Shoalhaven District Hospital Dr Ian Scott, Director of Internal Medicine & Clinical Epidemiology, Princess Alexandra Hospital Senior Social Worker, Aged Care Social Work Team, St Vincent’s Hospital- Sydney

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2:00 Integrated care across hospital, primary care and residential aged care facilitiets

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9:10 KEYNOTE Transitioning patients into long-term solutions • Planning transfers early to guarantee services will be available • Improving post-transition handover to avoid premature hospital readmission • Ensuring fluid continuity of care and creating a stable environment Lynelle Hales, Chief Executive Officer, Sydney North Health Network

9:50 KEYNOTE Effectively transferring care of complex consumers: A whole of health system problem to solve • The challenges of transferring care of the complex patient in the private sector • Understanding the barriers to effective service integration that allows true consumer centred care • The opportunities for a whole of health sector approach to effective consumer centred care Natalie Sullivan, Executive Director, Brighton and Continuing Care, Cabrini Health


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Transfer of Care for Complex Consumers 10:30 Morning tea 11:00 Nursing in Aged Care: The Politics and the Possibilities • Trends in aged care since privatisation • The pivotal role of registered nurses in aged care • Integrated and quality consumer-centred care

4:30 PROBLEM SOLVING SESSION Each table will be given a complex case and will have the opportunity to come up with an innovative transition programme. Complex cases: 1. Barbara, 75, tripped in the shower, broke her hip and has received a hip replacement. Barbara is on the pathway to recovery but is afraid of going back home alone. 2. John, 92, is affected by dementia. He lives with his wife, Rose, who has limited mobile capacity. He wants to stay in his home but his wife and children cannot take care of him. 3. Anne, 84, is starting to feel old age creep up on her. She has few friends, no children and isn’t very wealthy.

Brett Holmes, General Secretary, NSW Nurses and Midwives’ Association

11:40 ROUNDTABLE In this interactive session, delegates join the table that will be discussing the topic of greatest interest. Each discussion topic will be facilitated by an expert speaker. Topic: What makes high quality clinical handovers and referrals? Facilitator: Lynelle Hales, Chief Executive Officer, Sydney North Health Network Topic: Strategies to drive collaboration Facilitator: Walter de Ruyter, Service Manager, UnitingCare Ageing NSW-ACT and Former Director of Nursing, Shoalhaven District Hospital Topic: Tools for monitoring client outcomes Facilitator: Danielle Ballantine, Chief Executive Officer, Northside Community Forum Inc.

12:20 Engaging with art for a healthier ageing population • Demonstrating the efficacy of arts in community health • Improving health and wellbeing within the ageing population through creative activities • Implementing arts and health programs to assist complex consumers Margret Meagher, Founding Executive Director, Arts and Health Australia and Member, NSW Government Ministerial Advisory Committee on Ageing

1:00 Lunch 2:00 KEYNOTE The impacts of the aged care reforms on the complex consumer • Reviewing reforms implemented over the last 2 years • www.MyAgedCare - what we have seen on the ground • Catering for complex consumers under the new system Illana Halliday, Chief Executive Officer, Aged & Community Services NSW & ACT

• How to see the older person as the consumer and not just the service recipient • How Northside Community Forum sees the consumer at the centre and how this forms part of everything we do • Maintaining Consumer Directed Care regardless of the complexity spectrum Danielle Ballantine, Chief Executive Officer, Northside Community Forum Inc.

3:20 Afternoon tea CONTINUITY OF CARE AND USE OF TECHNOLOGY 3:50 Assistive technology and dementia: A review of current products and clinical guidelines • How assistive technology can assist the person with dementia • Presentation of various low tech and high tech products and their applications for use • Clinical guidelines and considerations for clinicians and management when considering using assistive technology for people with dementia and their carers Daniel Calleja, Senior Clinician Occupational Therapist and Behaviour Consultant, St Vincent’s Health Hospital Melbourne - Dementia Behaviour Management Advisory Service

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POST-CONFERENCE WORKSHOPS DAY THREE: THURSDAY, 3RD DECEMBER 2015 WORKSHOP A: 9:00AM-12:30PM Tools to improve quality of life through consumer-directed care Ensuring consumer directed care (CDC) is about empowering patients over the services they receive and letting them have their say on their quality of life. Clearly, improving the quality of services for complex consumers has never played such a central role in aged care, especially considering Government has declared that CDC will be extended from exclusively home and community to residential aged care providers as well. During this workshop, you will be given tools to: • Help consumers continue taking charge of their lives • Adhere to consumer directed care with complex consumer • Improve service delivery for older people • Prepare for transition of CDC to residential aged care facilities Carmen Barnard, Registered Nurse & Discharge Planner, Spencer Clinic Carmen has been working in the area of mental health nursing since 2009. She has been working in the area of transitional care planning since 2012 and is currently studying a Bachelor of Nursing with Honours by Research looking at staff perceptions of transitional care in the acute psychiatric inpatient setting.

2:40 INTERACTIVE WORKSHOP SESSION Tools to strengthen Consumer Directed Care

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5:20 Closing remarks from the Chair and conference adjourns

12:30PM-1:30PM Lunch WORKSHOP B: 1:30PM-5:00PM How to ensure successful handover for viable long-term solutions Although there is a National Safety and Quality Health Service standard on Clinical Handover, it is commonly believed that the moment of handing over a consumer’s case is the time when gaps and confusion can appear and that it becomes easy for health and aged care professionals to fall through these gaps. Attend this workshop to improve your clinical handover, but also better prepare consumers for the next steps towards their long-term solutions.

Learn how to: • Develop tools to make information accessible • Improve communication and multidisciplinary planning • Know, respect and apply patient’s wishes • Include patients and carers in clinical handover processes James Everingham, ACC&R Service Manager, Aged, Chronic Care & Rehabilitation, Sydney Local Health District James Everingham has a Bachelor of Social Work and began his career as an ACAT assessor at the Canterbury Aged Care Assessment Team before moving into a social work role at Royal Prince Alfred Hospital on the geriatric ward for several years. James then moved back into community work, taking on an assessor role at the Camperdown ACAT and then a Senior Social Work role at the Concord ACAT.


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Transfer of Care for Complex Consumers REGISTRATION FORM — AGE04 EARLY BIRD DISCOUNTS

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