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Hospital Discharge Support (HDS)

HDS is a short-term, goal oriented and Allied Health-led reablement service for patients discharged from public hospital beds, aiming to support successful discharge and prevent unnecessary readmission.

Referral criteria

Eligible:

  • Current inpatient, consent to referral.
  • 18 years old and above
  • Patients must have a new functional need which requires Personal Care as part of the service.
  • Achievable reablement goals and ability to engage in the program.

Not eligible:

  • Private patients in private hospitals, or private wards in public/private partnership hospitals.
  • Patients with NDIS funding.
  • Patients in receipt of, or waitlisted for, a Home Care Package.
  • Needs that exceed the capacity of the service

Geographical availability

Metropolitan WA:

  • All metropolitan areas

Country WA:

  • South West
  • Great Southern

Cost

No cost to client.

Length of program

Maximum of 6 weeks.

Post-program options

For clients aged >65 years:

Make a Referral for:    

  • CHSP Restorative Care Services
  • CHSP Occupational Therapy
  • CHSP Physiotherapy

 Make a Referral to the Aged Care Assessment Team (ACAT) for:  

  • Home Care Packages (HCP)

For clients aged <65 years:


How to refer
  1. Check referral eligibility criteria.
  2. Call 1300 300 122  whilst client is still an inpatient and ask to speak to our Allied Health Liaison during business hours, or Ambulatory Liaison Nurses after hours.
  3. Provide referral details over the phone.
  4. Supporting documentation will be requested from the discharging hospital/referrer:
    • Medical discharge summary
    • Allied Health handover
  5. Send supporting documents either via:

If the client is a hospital inpatient and already in receipt of a Home Care Package provided by Silverchain, please call us on 1300 300 122, or speak with the HCP Coordinator directly to discuss your client’s Allied Health needs on discharge.


Transition Care Program (TCP)

TCP seeks to optimise function and independence of older persons after a hospital stay. TCP is goal-oriented, time limited and therapy focused. TCP aims to avoid the need for longer term care and delay clients moving into an aged care facility.

Service may include:

  • Low-intensity Physiotherapy, Occupational Therapy, Podiatry, Social Work, Speech Pathology and Dietetics.
  • Nursing support
  • Personal care
  • Support with daily living activities
  • Support attendance at activities which reduce social isolation
  • Case management

Referral criteria

Eligible:

  • Valid ACAT assessment, consent to referral.
  • Age >65 years (>50 years for Aboriginal and Torres Strait Islander people).
  • Inpatient in a public or private hospital, medically stable and ready for discharge.
  • Have realistic and functional goals.
  • Able to begin TCP as soon as they leave hospital.
  • Client may be considering residential care and is being discharged with TCP so that Allied Health can maximise function and wellbeing prior to move to residential.
  • Existing HCP clients may take leave from the HCP during the TCP program.

Not eligible:

  • Clients in the community.
  • Clients who just need a service or are unwilling to actively engage in working towards their goals.

Geographical availability

Country WA:

  • Great Southern

Cost

A daily fee may apply. A fees assessment will be conducted to determine what the client will be required to contribute to their care.

Length of program

12 weeks.

Clients can take a maximum of 7 days leave from the TCP for hospital and social reasons, whilst remaining on the program. However, should the client remain on leave for >7 days they will be discharged from the TCP. 

Clients admitted to hospital for >7 days may be referred onto TCP using their existing ACAT assessment providing it falls within 4 weeks of the original TCP approval date. Past these 4 weeks, the client must be re-referred by the hospital for an updated ACAT assessment.

Post-program options

For clients aged >65 years:

  • RAS or ACAT referral via MAC for CHSP Restorative Care Service, Occupational Therapy or Physiotherapy.
  • ACAT referral for Home Care Package

For clients aged <65 years:


How to refer
  1. Check eligibility criteria.
  2. Admitting hospital contacts ACAT for ACAT assessment.
  3. TCP clients are discussed at weekly MDT and flagged with Allied Health Team Lead in the region. The Team Lead will determine if referral can be accepted. Once accepted, supporting documentation will be requested from ACAT (referrer):
    • TCP referral
    • National Screening Assessment Form (NSAF)
    • MAC Support Plan
  4. Supporting documentation will be requested from discharging hospital:
    • Medical Discharge Summary
    • Allied Health handover
  5. Send supporting documents either via: