Sandra Petrie
Clinical Screener
Care Coordination
Aim:
To increase awareness of issues surrounding discharge
to home-based health care services
Objective:
Refresh knowledge of discharge planning process
Increase knowledge of referral to home based
health care services in Canterbury
Increase insight and understanding of the
implication of poor discharge planning
What information do you need when a patient
comes into your service?
When do you receive this information?
Care Coordination Centre (CCC)
In Canterbury, ALL referrals for nursing services
including: hospital discharges for ACC District Nursing
care; Rural DN; palliative care equipment; falls
prevention … and non ACC short term (<8 wks) home
based support services go through Canterbury CCC
Canterbury; Capital and Coast; Hutt Valley
Their work includes:
Clinical screening of referrals - meet criteria;
legibility;
all necessary information
 Allocate client to provider
Home Based Service provided by Access,
Healthcare NZ and Nurse Maude in Christchurch
Generalist care
Home based support:
 •District nursing
 Domestic assistance
 • Catheter management
If patient has a Community
 • Continence management
Services Card and no able bodied
 • Diabetes care
person at home, they may be
 • Medication management
eligible
 • Palliative care
 Personal Assistance
Generally eligible for 3 showers per  • Wound care/compression
 • ACC
week up 45 minutes and will be
reviewed after about 6 weeks. Aim
to continue rehabilitation and
Early supported discharge/ Community
reduce needs
Rehabilitation Enabled Support Team
(CREST)
Specialist Community Services in Canterbury
Acute Demand
Cardio thoracic
Continence management
and products
IV
Methadone
Paediatric outreach and
Palliative care
Respiratory care
Specialist Palliative care
Stomal therapy
Wound
Home based health care
Referral criteria
 Requires a home visit by a nurse in order to maintain a state of wellbeing.
 Is unable to access general practice or clinic for care due to mobility,
finance, or transport barriers.
 Has no suitable person (relative or friend) to administer care in the home.
Exclusions
 In residential care.
 If currently receiving CREST services any district nursing needs are referred to
the CCCC by the CREST coordinator. Where possible, the CCCC ensures
continuity of any previous district nursing provider. For other district nursing
needs (outside of CREST) refer via CCCC.
The referral guidelines for Community nursing and Specialist nursing services
are available on Health Pathways at
http://www.healthpathways.org.nz/
Discharge planning
When to start?
What can patient /family do
for themselves?
Who is the best person to
manage on-going care?
What fits with patients
lifestyle?
What does the patient want?
Do they really need
additional services – just in
case?
What can be done prior to
discharge?
What can be done before discharge?
• Assessed for equipment
• Many patients could manage without home based support i.e. showering
if a shower stool is provided on discharge
• If a patient needs pressure relieving equipment up to discharge- they will
need it at home
• Medications arranged
• Up to 50% of patients discharged to community miss doses of medication
immediately after discharge including warfarin, high dose steroids.
• If a dose due within an hour of discharge, please administer before they
leave
• Providers can be contacted for case discussion
• Send referral to CCC and request nurse contact the
• Dept./ward, if complex case
• What information do community providers need when a patient comes
into their service?
• When do they need to receive this information?
Include this information in your referral:
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Date of referral and Name of referrer
Date when the service needs to start.
Patient condition and diagnosis
Reason for referral
Specific condition details, i.e. Catheter insertion date and details, wound
treatment chart
Current Medications and the name of community pharmacy. Medication
Chart if required
The patient's preferred provider: - specific provider may only be available
for some conditions. - providers currently working with the patient e.g.,
home support service providers, CREST.
Information regarding barriers preventing the patient's accessing to other
services e.g., general practice.
Known risks that the nurse may encounter when making a visit e.g., home
detention, security while in ED or hospital, unsafe home environment,
history of violence, undesirable associates
Discharge Summary
General points:
 Send referral before the patient leaves the ward.
 Referral can be sent several days before discharge- it is easier to cancel a
visit that set up the service late in the day
 If you send a referral late in the day to start that evening or early the
following morning, especially for a large package of care - this may be
declined
 Ask if a patient has a current or preferred provider.
 Ask if they want to change current provider if returning to service.
 If a patient contacts ward after leaving saying they can’t manage- send
urgent referral
 Medication management: if supervision to ensure taking on time etc., …
 No blister pack required
 If need assistance taking medication: blister pack needed and yellow card
 If prescribed medication , including cream, eye drops, etc., to be given :
 Medication chart needed.
 Be specific of reason for referral - “ just pop in” or “check following
discharge” is not appropriate
Effects of discharge planning/referrals
 Delayed discharge from hospital
 Confusion
 Deterioration in condition
 Insufficient equipment- shower stool, pressure
relieving equipment care = cannot be given
 Insufficient information-patient has to repeat
themselves; key information remains unknown by
provider.
 Readmission to hospital
 Delayed visit-missed health care: meds, wound care;
catheter care;
 Disconnected care
Seamless care requires
• Professional courtesy
• Patient centred approach
I will ask you
nicely … please
fill in your
referrals correctly
or else: