xx/xx/2011
Insert Council logo

Royal District Nursing Service Limited (RDNS) and municipal councils in the Melbourne metropolitan regions have had a long history of working together co-operatively and sharing clients. Together, they have been the major suppliers of Home and Community Care (HACC) funded nursing, personal care and other home based services. The Municipal Association of
Victoria (MAV) and RDNS first adopted a formal Strategic Alliance Agreement in 1999 and jointly developed the Service Delivery Protocol to improve role clarity and uniformity of practice between the councils and RDNS services, particularly in relation to providing home based personal care. Both of these documents have been reviewed and updated in light of a number of policy changes in the HACC program, in particular the Victorian HACC Program Assessment
Framework, 2007 and the newly defined roles for HACC Assessment Services undertaking
‘Living at Home’ assessments within an Active Service approach.
The purpose of these agreements is to re affirm the parties’ commitment to a constructive, cooperative working relationship and to provide a framework to govern the practices in the delivery of HACC services between RDNS sites and councils. The agreement and protocol is not intended to be legally binding.
The HACC Assessment, Referral and Service Delivery Protocol Agreement has been endorsed by the CEOs of both organisations in July,2011.
Both MAV and RDNS will continue to monitor the use of the protocol and use feedback from councils and RDNS sites to determine any review or changes needed.
1. Local area protocol scope and purpose
2. Principles
3. Initial enquiry and intake processes
4. Assessment processes
5. Referral processes for existing clients
6. Processes to facilitate co-ordinated care
7. Assessing and providing personal care
8. Identifying and managing risk for clients and staff
9. Maintaining trust and strong relationships
10. Information about Council
11. Information about RDNS
12. Protocol endorsement and review
13. Attachments

July 2011 Protocol
This protocol represents the current agreement about the working relationship and practices of the relevant RDNS site (refer to clause 10) and the relevant Council (refer to clause 11), and outlines arrangements between the organisations for the provision of referrals, assessment, care planning, co-ordination and service provision in the municipality, particularly in relation to frail aged people, people with disabilities and their carers, eligible for HACC and related services.
The protocol outlines practices for ensuring that clients receive the most appropriate home based assessment and personal care service to meet their needs, and that the appropriate level of health knowledge and multi –disciplinary approach is used to improve client outcomes, including:

Determining which organisation should undertake a Living at Home (LAH) assessment

Determining the most appropriate organisation and /or skills required for assessment and provision of personal care needs

Facilitating and streamlining the collection and sharing of client information and care plans to reduce duplication for clients using both services

Outlining a clear mechanism for working collaboratively and maximising efficiency

Producing a process for accountability in assessment, care planning and service delivery

Determining which organisation will provide the key worker role for clients needing interagency care planning and co-ordination

Ensuring that response times between referrals, assessment and service delivery is appropriate to client/carers’ needs and circumstances
(NOTE: This agreement is not intended not cover any commercial or contractual arrangements between council and RDNS - such as where council is purchasing the time costed services of a
Division 1 nurse from RDNS (Rally) in the role of a council assessment officer).
The protocol is based on the following principles:

Respect for the place of each organisation in providing HACC and related services

Acknowledgement of the skills and knowledge residing in each organisation
 Respect and trust for each organisation’s professional judgements and role within the scope of the assessment and service delivery framework

Commitment to best outcomes for clients

Respect for client self determination, choice, informed consent, privacy and confidentiality

Willingness to work together honestly and co-operatively, give professional feedback, jointly solve problems and settle any disputes

Provide services which meet the National Community Care Standards

Use the Victorian Service Co-ordination Practice manual to guide good practice processes to better achieve integrated service outcomes.
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July 2011 Protocol
Council and RDNS both act as points of entry to the HACC service system by receipt of an enquiry or referral through their intake or call services. Both organisations have written procedures, training and supervision processes to guide Intake staff and meet the Good
Practice Indicators outlined in the Victorian Service Co-ordination Practice Manual.
(NOTE: It is suggested that in reviewing this agreement both RDNS and Council also review their current conformity with the VSCPM Good Practice Indicators for referral, and service coordination.
)
For example: As part of the Initial Needs Identification, it is the responsibility of both organisations to:-

Accept an enquiry from any community member, their family or health professional

Screen the person for eligibility to the HACC service system

Determine if the needs being identified can be met from the services provided by the initial organisation

Determine if there has been a recent assessment undertaken by another service

Provide relevant information or advice to the client/referrer to ensure they are informed about the range of relevant services available and eligibility criteria, their rights and responsibilities in accessing services and the rationale for collecting their information and how it will be used

Accept the referral if appropriate, subject to referral being made by the client, or with their knowledge and permission, and explain the assessment process

Have a procedure for dealing with referrals for community members considered to be at risk, and in need of assessment and services, but from whom permission to make a referral has not been gained

Collect the information detailed on the Initial Needs Identification (INI) forms of the Service
Coordination Tool Templates (SCTT)

Determine what type of assessment is most likely to be needed (e.g. ACAS, LAH or service specific)

Determine which local HACC Assessment Service (HAS) would most appropriately undertake the initial assessment, if a LAH assessment is required

Refer on to the most relevant organisation for assessment , with the client’s consent, using the SCTT referral templates.
3.1 Considerations for determining at enquiry stage which HAS ( RDNS or Council ) undertakes the initial assessment
In determining the most suitable organisation to undertake the initial home based assessment the following considerations may apply. It is the responsibility of the organisation accepting that referral to further determine the degree to which a LAH and/or service specific assessment is required.
Based on sole or main service provider relationship

If the person appears to only need one HACC service, then the organisation providing that service should undertake the initial assessment, undertaking a LAH as well as service specific assessment if appropriate. e.g. if only domestic assistance is required then Council would undertake initial assessment, but if only nursing care is required then RDNS would.

If the person is likely to require services provided by both RDNS and Council, then both organisations will need to undertake service specific assessments, and if a LAH is
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July 2011 Protocol necessary, then either do a joint assessment, or discuss and agree which organisation is most appropriate or available.

If the person ‘s need for particular HACC services is not initially clear from the information available via phone intake, then the organisation taking the enquiry will undertake the initial home based assessment

If the person needs a HACC service not provided by either RDNS or Council, and a LAH is also indicated, then the HAS receiving the enquiry would undertake the initial assessment and make the referral for the service specific assessment.
Based on person’s health status and personal care needs, RDNS would undertake initial assessment if the person:

has unstable health and complex personal care needs

requires assistance with personal care tasks that appear to be beyond the scope of
C ouncil’s home support workers’ training and competency e.g. suctioning, or medication administration.

requires personal care services immediately or in a time frame that Council cannot deliver on and RDNS can (e.g. coming out of hospital over weekend)
NOTE: Refer to flow charts in Attachments – Attachment 1 and Attachment 2. and Referral
Process Attachment 3. Criteria for Identifying Unstable Health and Referral Tool - Attachment4 and 5.
4.1 Living at Home (LAH) assessment
In the absence of considerations that suggest one or other organisation is the most suitable for a particular person, both organisations agree to provide LAH assessments for those people first referred to them who require a LAH. If either organisation is experiencing high levels of demand that impact on their capacity to conduct LAH assessments in a timely way, then the other will be approached to provide assistance by taking additional referrals, if they have the capacity to do so at that point in time.
Both RDNS and Council are part of the local and sub – regional alliances for HACC funded
Assessment Services ( or will contribute to their development) and will work within the agreed arrangements of that protocol, and endeavour to meet the Good Practice Indicators for
Assessment and Care Co-ordination.
Indicators that suggest a LAH assessment is needed, to be used by both organisations, may include situations where:

Community care is likely to be needed on an on –going or longer term basis

There have been recent threats to or actual changes in functional capacity e.g. driving, mobility, personal care, shopping

There have been recent threats to or changes in care giving or partnering relationships e.g. carer ill health or stress, death of spouse

There are concerns about environmental or safety risks e.g. poor housing conditions

There are concerns over the level of socialisation or risks of social isolation
 Person’s needs and/or the reasons for referral are not able to be sufficiently clarified at initial enquiry/intake stage
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July 2011 Protocol

There are different viewpoints over what the person wants and what carers/other services/referrer believe is needed.

Client and/or carers are anxious and/or not well informed about options or what to expect from services

There are multiple clients in the one household with competing needs

Client does not, or may not have, capacity to make their own informed decisions, and there is no legally appointed guardian.
And:

Person has not had a recent home based assessment from another HACC assessment provider or health service e.g. ACAS, Transition Care, HARP, Palliative Care

Person has not had a multi –disciplinary assessment from a recent acute, sub acute or rehabilitation episode of in - patient care

Person is not case managed by another service provider e.g. Mental Health, CACP provider, Disability services.

Need for an ACAS assessment is not indicated i.e person doesn’t appear to have a need for ongoing case management support or access to specialist support services due to complexities in their health, social or family circumstances ( examples outlined in the
Guidelines for streamlining pathways between ACAS and HACC assessment services –
Improving the client journey . Department of Health,2011 page 5 – www.health.vic.gov.au/hacc/assessment.htm
)
NOTE: Suggest this list of indicators be reviewed annually and developed over time with practice experience.
4.2 Joint RDNS/Council assessment
In some cases both RDNS and Council will be providing services to a client or household, or the person’s health status and needs are unclear from the available information at Intake. In these instances it may be appropriate to conduct a joint assessment. The decision to conduct a joint assessment will be determined by discussion between Council and RDNS Intake or assessment staff, subject to client permission, and based on the identified needs, and the potential benefits to the client in regard to:
Where a joint visit will achieve:

Streamlined communication between all parties

Integrated multi
–disciplinary approach to assessment of need

Enhanced establishment of a care plan and agreement on goals

Reduction in multiple assessment, or intrusion for client

Effectiveness of the continuum and co-ordination of care

Efficient use of an interpreter

C onsideration for family member’s availability and time
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July 2011 Protocol
Council may refer an existing client of its’ HACC services to RDNS for a health based assessment or a nursing service, when the client:

has unstable or deteriorating health status

is requiring more assistance with procedures such as medications, foot care, wounds, incontinence management

needs supervision or management of chronic, unstable health conditions.
RDNS may refer an existing client to Council when they require additional HACC services as provided by Council (e.g. housekeeping, respite, transport, meals), or for personal care where
RDNS either retains a health monitoring role, or no longer needs to, as the person does not require a nursing service or supervision of personal care because their health has improved.
Both RDNS and Council agree to indicate, on referral to one another, and with the client’s consent:

if and when a LAH assessment has been done

to share all relevant assessment, OHS and care planning information, including the goals and care plan

whether care co-ordination is being provided and if this is continuing.
5.1 Determining the urgency of the referral
When a referral between RDNS and Council is made, it is the responsibility of the receiving organisation to indicate the time in which they can respond to the referral. Both RDNS and
Council will attempt to respond to the referral within the shortest possible time frame. An arrangement will be made between both organisations about the timeframe for handover from one service provider to the other.
Council and RDNS will endeavour to undertake assessment of urgent referrals within two days and routine referrals within seven days, as per the Good Practice Indicators in the Victorian
Service Co-ordination Practice manual, or negotiated based on Priority of Access guidelines.
NOTE: If this can’t be achieved routinely (i.e. for 95% of cases), then Councils and RDNS agree to specify the timelines that are achievable within current resources as part of this agreement and continue to review this issue and the impact annually, with view to making progressive improvements as resources allow.
If either organisation is unable to respond to an individual referral as per the agreed timeline standards, then an achievable timeline is to be discussed between the organisations, and the client advised.
6.
6.1 Fees
The HACC Fees Policy forms the basis of all fees charged for HACC services. Each organisation is responsible to negotiate fees for the services they provide, on an individual basis with the client according to each organisations’ fee policy. However, when both services are involved in the client’s care, or there are multiple services and expenses, then a negotiated arrangement for affordable fees is to be discussed between the organisations and client. It is not expected that any one organisation will bear the brunt of reduced fees and that where this is necessary it will be shared, but in a way that simplifies processes for the client. Where client
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July 2011 Protocol care is coordinated between RDNS and Council, both organisations will work collaboratively to minimise disruption and cost to the client. At the annual review of this protocol, Council and
RDNS agree to share their current fee levels and procedures and a process for identifying any joint clients who are in financial distress, and methods for simplifying fee payment for clients using multiple services.
6.2 Communication
Information relevant to changes in client need or worker risk will be communicated promptly between the services – by phone and/or encrypted email. Where a more detailed discussion is required to develop or review the care plan, either organisation can request a case conference, with the client’s permission.
6.3 Care co-ordination
Where a care co-ordination role is needed to implement the care plan, then the organisation doing the care plan would ordinarily assume this role. If there are factors which suggest the role should be done by another organisation, service or person, then this will be negotiated between organisations and with the client and carers.
The following extract from the Victorian HACC Program Manual 2003 (p 94) defines personal care:
“Personal care provides assistance with those tasks which a person would normally do for themselves but because of illness, disability or frailty they are unable to perform without the assistance of another person”.
Examples of personal care include:
 assistance (or supervision) with bathing, showering or sponging
 assistance with dressing and undressing
 assistance with shaving, hair care and grooming
 limited nail care, only following appropriate professional assessment*
 assistance with mobility (in bed and out of bed) such as to sit up, to turn, to stand and walk, to sit, to transfer to commode, wheelchair, chair or vehicle
 assistance with eating, drinking, cooking, preparation and service of food, preparation of special diets
 assistance with toileting
 assistance with prescribed exercise or therapy programs ** - fitting and use of appliances such as splints and callipers, or hoists
 assistance with hearing aids and communication devices
 monitoring self-medication
 escorting to medical and other related appointments.
* Foot care
“The competency unit CHCICS306A Provide basic foot skin and nail care in the CHCO8
Community Services Training Package will enable a Community Care Worker to undertake
HACC funded foot, skin and nail care as long as this is done in accordance with the HACC
Personal Care Policy relating to unstable health/complex care. The Community Care Worker must also have completed the relevant first aid and personal care competency units. If the Basic
Date: Page 7

July 2011 Protocol foot care skill set - community services focus, is completed the HACC Community Care Worker is also required to complete the relevant first aid competency unit before providing a HACC funded service.” ( Refer to DH Guidance, July 2010. www.health.vic.gov/hacc )
Exercise and Therapy programs
** “This assistance can be provided on a consumer-specific, non-transferable skills basis.
Personal care workers must not be taught a standard set of exercises or a therapy program to use across the HACC target group as this is outside the scope of a personal care worker’s role .” (Refer to: http://www.health.vic.gov.au/hacc/prog_manual/index.htm
)
If the client has a personal care need not included in the above examples of personal care, and there is any doubt about the competency of Council’s personal care workers to safely undertake the tasks, then Council may ask advice from RDNS via a secondary consultation or request for an assessment.
7.1
As per the Victorian HACC Program Manual, all Community Care or Support Workers employed by Council who undertake personal care will have an appropriate Certificate III level qualification with the relevant personal care and first aid competency units.
“As stated in the Victorian HACC Program Manual, all Community Care Workers who undertake personal care tasks funded by the HACC Program must adhere to the HACC Personal Care
Policy and must have an appropriate minimum Certificate III level qualification with the relevant personal care and first aid competency units. Where a Community Care Worker has completed a qualification without the relevant personal care and/or first aid competency units then they must complete these unit(s) before undertaking personal care tasks.
The relevant first aid and personal care competency units are:
HLTFA301B Apply first aid – with updates in accordance with the Australian Resuscitation
Council Guidelines; and either
CHC02 Community Services Training Package:
CHCHC302B Provide personal care in a home and community care environment or
CHC08 Community Services Training Package:
CHCICS301A Provide support to meet personal care needs or
CHCICS401A Facilitate support for personal care needs”
(Refer to: http://www.health.vic.gov.au/hacc/downloads/pdf/hacc_training.pdf
)
7.2 Council’s capacity to provide personal care staff to assist clients with medication
DHS Guidance, September, 2009.
“A person who needs assistance with medication is likely to have either complex care needs and/or unstable health. In such cases an appropriate process would include: assessment by a
Division 1 nurse or other health professional, determination if it is appropriate for a Community
Care Worker to assist with medication, training for the Community Care Worker specific to the needs of that particular person by a Division 1 nurse or other health professional, ongoing support for the worker from a Division 1 nurse or other health professional and development and implementation of a written care plan for that person (Please note all HACC clients should have a written care plan). Some people who require monitoring of self medication may also have complex care needs and/or unstable health and above process would also apply to them. “
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July 2011 Protocol
“Community Care Workers must have completed competency based medication training before assisting with medication. Staff, undertaking personal care tasks who have not completed this training can only monitor self medication as stated in the HACC Personal Care Policy in the
Victorian HACC Program Manual.
The relevant medication competency units are: either
CHC02 Community Services Training Package
CHCCS304A Assist with self medication or
CHC08 Community Services Training Package
HLTAP301A Recognise healthy body systems in a health care setting and
CHCCS305A Assist Clients with medication (Note prerequisite HLTAP301A) “
(Refer to: http://www.health.vic.gov.au/hacc/downloads/pdf/assist_medication_hacc.pdf
)
{insert or delete para} Council does have personal care workers trained in CHCCS304A /305A
Assist with self medication as part of, or in addition to their Certificate 3 level qualification in aged care/community care.
{insert or delete para} Council does have assessment or supervisory staff with nursing qualifications (Division 1 registration), who can determine if an individual’s medication assistance can be safely provided by Council ’s personal care staff, in consultation with the client’s treating or clinical health professionals.
{insert or delete para} Council does not have assessment staff with nursing qualifications
(Division 1 registration), and thus clients requiring assistance with medication will be referred to
RDNS to undertake the assessment and advise on the suitability of a Council personal care worker with CHCCS304A /305A training providing such assistance in those particular circumstances.
Council has procedures and work instructions for personal care staff involved in assisting with medication that meet the guidelines provided by the DHS in their Guidance, September, 2009.
{insert or delete para} Council does not have personal care workers trained in CHCCS304A
/305A Assist with self medication as part of, or in addition to their Certificate 3 level qualification in aged care/community care.
Thus clients requiring assistance with medication will be referred to RDNS to undertake the assessment and assistance.
Council staff, undertaking personal care tasks, who have not completed the unit CHCCS304A can only monitor self medication as stated in the HACC Personal Care Policy in the Victorian
HACC Program Manual.
7.3 Bathroom modifications to improve client functioning and safety for workers, family carers and client.
Where either organisation is providing assistance with showering or bathing, and modifications are required, it is standard practice that a referral is made for an Occupational Therapist assessment. If handing over a client’s personal care to Council, RDNS will provide any necessary instructions for the personal care worker/s to continue the established care routines and use of equipment, as part of the referral.
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July 2011 Protocol
8.1 Occupational Health & Safety assessment
Each organisation maintains responsibility for the occupational health and safety of their staff working in a client’s home.
An assessment of environmental and situational risks for both clients and staff will be undertaken at the first home visit. Both Council and RDNS agree to share written information from the safety assessments they have undertaken, at point of referral, which identify any risks to worker or client, hazards, ameliorating actions recommended or already undertaken. It remains the responsibility of each organisation to check this information and formulate their own actions and be responsible for their worker’s safety.
Where both organisations are involved in a client’s care, and there are concerns about safety of workers or clients, then they will work together, with the client, to resolve the issues. Neither organisation will withdraw a service on safety grounds, without first trying to resolve the issues and notifying the other organisation.
9.1 Practices which respect clients ’ privacy and confidentiality
RDNS and Council both agree that the client at all times has control over what information about them is communicated to others in accordance with the Privacy Act 1988 (Commonweath) and the Health Records Act 2001 (Vic).
Both organisations have policies and procedures relating to work practices that comply with the relevant privacy legislation, including:

recorded consumer consent for treatment/care provision and for information sharing

processes for the collection and transmission of personal information

processes for storage, maintenance and disposal of personal information.
RDNS and Council agree that clients have the right to control how their personal information is to be shared, and that appropriate information is provided to ensure clients can make informed decisions.
Each organisation will conduct induction and on –going staff training to assist their respective staff to understand their privacy obligations when handling all personal and health information.
9.2 Practices to improve sharing and learning
Both Council and RDNS agree to provide secondary consultations to each other’s assessment staff, as needed to support a more multi –disciplinary approach to LAH assessment.
RDNS and Council agree on a case conferencing procedure, both for client care planning and co-ordination purposes, and as well as a learning tool for furthering multi –disciplinary practice and inter –agency co-operation.
See Attachment 6: Case Conference template
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July 2011 Protocol
9.3 Developing and maintaining strong working relationships
Both organisations agree to:

Ensure existing and new staff are inducted re the practices outlined in the protocol

Support the induction of new staff from each organisation
– e.g. shared site and home visits, attendance at team meetings etc.

Share and update written information with staff and service contact names and details necessary for service delivery

Provide opportunities for relevant staff in each organisation to meet in person

Explore opportunities for staff from both organisations to share professional development
(e.g. PCP or regional HACC Training events, or be involved in the relevant professional development programs provided by each organisation and industry bodies)

To provide confidential, timely, honest and constructive feedback (manager to manager) about any client complaints or concerns over performance issues that are not adequately dealt with between the staff directly involved.

Make best efforts to resolve any dispute or grievance between them as quickly as possible.
If the issue cannot be resolved to the satisfaction of both parties, then the matter will be referred to the senior line manager(s) in both organisations for mediation and resolution.
List Council documents provided to RDNS as agreed, or include as Attachments :
For example:

organisation chart or list of names/positions in the HACC/ADS Services Unit/department

Intake /Assessment Policy/procedures

Priority of Access policy

Relevant information re HACC services eg annual report; ADS plan etc.

Web link to other reports/municipal information eg Community Profiles; Council newsletters;

Training/professional development opportunities
List documents provided to Council by RDNS site as agreed, or include as attachments:
For example:

Regional site /local area key staff details (e.g. RDNS internet site- About Us>About our
Locations> List of Locations )

Intake /customer service centre procedure

Annual report

Specialist clinical services available and how to access/refer

Training /professional development opportunities
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July 2011 Protocol
I confirm my Councils’ participation in and endorsement of this protocol .
Council:
Address:
## [Insert Council title]
## [Insert Council address]
Name:
Position:
## [Insert authorised signatory name]
## [Insert authorised signatory position]
Signature:
Date:
Review Date : ## [Insert date]
I confirm my RDNS site’s participation in and endorsement of this protocol .
RDNS:
Address:
Name:
Position:
Signature:
Date:
Review Date :
## [Insert RDNS site title]
## [Insert RDNS site address]
## [Insert authorised signatory name]
## [Insert authorised signatory position]
## [Insert date]
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July 2011 Protocol
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July 2011 Protocol
Yes
Is a referral required?
Obtain client consent
Notify CAO of planned assessment date
Determine appropriate SCTT for client
Complete SCTT
Send via encrypted email or fax SCTT details to RDNS
CSC
“Acknowledgement
Sheet” to be sent via encrypted email or faxed back with date of initial visit
Does RDNS need further info or want to request a joint visit?
No
No Yes
No further action required
Client admitted
& assessed
Contact CAO
RDNS will communicate outcome of assessment to CAO
Legend:
CAO
– Council Assessment Officer
CCR – Client Care Record
CSC – Customer Service Centre
SCTT
– Service Coordination Tool Template
Date: Page 14

Yes
July 2011 Protocol
Is a referral required?
Obtain client consent
RDNS to continue providing care, where appropriate and currently doing so up to first planned
Council visit
RDNS records acknowledgement details in client information system
Determine appropriate SCTT for client
Complete SCTT in RDNS client information system
Send via encrypted email or fax SCTT to Council
“Acknowledgement
Sheet” to be sent via encrypted email or faxed back by Council with date of initial visit
Attachment 2
Does Council need further info or want to request a joint visit?
No
No Yes
No further action required
Client admitted
& assessed
Contact CAO
Legend:
CAO – Council Assessment Officer
SCTT – Service Coordination Tool Template
CCR – Client Care Record
Date: Page 15
CAO communicates outcome of assessment to
RDNS by encrypted email or fax “Assessment
Outcome” sheet if requrested
RDNS record details in
Client Care Record

July 2011 Protocol
The organisation making the referral is responsible for completing the SCTT.
Referral from Council to RDNS
Council Intake/Assessment Officer
1. Telephone RDNS Customer Service Site (CSC) and give them the client’s details.
2. Send via encrypted email or fax appropriate paperwork (SCTT) to RDNS CSC.
CSC Operator
3. Arrange the initial assessment date with the client.
4. Notify the Council Intake/Assessment Officer of the planned date of the initial assessment.
RDNS Assessment Nurse
5. After the assessment visit, liaise with the Council Assessment Officer regarding the outcome of the initial assessment visit.
Primary Nurse
1. Send via encrypted email or fax appropriate paperwork (SCTT) to HCS
2. Telephone Council Intake Service on phone :# (insert number) if required for complex client.
Council Assessment Officer
3. If additional information or a joint visit is required, contact the primary nurse prior to the initial visit.
4. If appropriate, liaise with the primary nurse regarding the outcome of the initial assessment visit.
5. Notify the primary nurse of the date of the first planned Council visit.(for personal care service)
Note – with current clients, RDNS will endeavour to provide service to client until
Council confirms their commencement date.
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July 2011 Protocol
The following list of indicators is used as a guide to assess the existence of unstable health. A single factor does not necessarily indicate an unstable health status. The indicators are to assist in a judgement about the client’s overall health status and thus need for a health based assessment in relation to meeting personal care needs.
If the referrer/client does not seem clear about their health conditions and treatment, or if there is doubt about symptoms, diagnosis and management, impacting on need for assistance with personal care and daily living, then the client should be referred back to their General Practitioner or other health service for appropriate diagnosis and management of underlying health conditions, or RDNS requested to assist with such a referral, if they feel it is necessary, based on their further assessment.

Giddiness/falls

Loss of bladder or bowel control

Acute or chronic diarrhoea/constipation

Acute or chronic nausea/vomiting

Special dietary requirements/ limitations e.g. percutaneous endoscopic gastrostomy
(PEG) feeding regimes

Pain

Difficulty with breathing/advanced respiratory disease

Terminal or life threatening illness in palliative care stage

Recent changes in sensory status e.g. vision or hearing

Apparent fever/persistent excessive coldness

Wound (surgical/non-surgical)

Persistent bruising and/or skin integrity break down

Significant recent changes in medications

Multiple (more than 5) and frequent use of medications ( 3 times per day or more)

Several recent hospital or respite admissions

Progressive deteriorating chronic illness

Any procedure requiring insertion into the body (e.g. injections)

Disoriented/ confusion/memory loss - undiagnosed and/or leading to unco-operative behaviours re personal care

Very limited mobility - bed bound or needing assistance with transfers
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July 2011 Protocol
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Describe condition and details Present Not present
Has been investigated or being treated by:
Poor mobility -
Client is bed-bound or needs assistance with transfers
Giddiness/falls (describe frequency)
Requires further investigation/ assessment
Loss of bladder or bowel control
(onset/duration)
Diarrhoea/constipation(acute/ chronic)
Nausea/vomiting (acute/ chronic)
Special dietary requirements eg: percutaneous endoscopic gastrostomy
(PEG) feeding regimes
Pain (state location onset and duration)
Difficulty with breathing/advanced respiratory disease (indicate if using
Oxygen)
Disoriented/confusion/memory loss
Disoriented and unco-operative or aggressive - other difficult behaviours
Terminal or life threatening illness in palliative care stage
Date: Page 18

July 2011 Protocol
Client requires foot care -
has circulatory problems or
diabetes.
Apparent fever/persistent excessive coldness
Wound (surgical/non-surgical)
Persistent bruising and/or skin integrity break down
Requires review of medications - because_(state reason)
Requires supervision of medication multiple and frequent use , or changing of medications, or seems unable to manage self medication
Several recent hospital or respite admissions
Progressive deteriorating chronic illness
Date: Page 19

July 2011 Protocol
Case conferences to refine care plans may be useful where client needs are complex or several key services need to be involved to combine information and advice and clarify options. Agreement between organisations about the process and format for requesting and presenting a case conference can facilitate understanding and participation by all parties. As a learning tool, case discussion can be also very useful for addressing system problems or improvements and professional development.
Example:
1. Agency requesting/organising case conference
2. Presenter
3. Facilitator
4. Invitees
5. Location /time
Name and position of person presenting
Name and position of person facilitating the discussion

List all people/positions/agencies to be invited

Confirm time and place of case conference

Ensure location is suitable and comfortable for client/carers e.g. re hearing, fitting everyone in etc.
6. Client /carer names and address
7. Client involvement and consent
8. Purpose of case conference (outcome wanted)
9. Status of case conference
10. Summarise key issues for discussion
11. Reach agreement re plan of action

Confirm that client knows about the proposed case conference and its purpose, who is to be involved and why, and has given their informed consent in writing

Clarify if client and carers will be present or not

Cases presented for learning purposes/system improvement should not use actual client names/identifying information, unless necessary to achieve objectives
 developing a care plan
 care plan review and co-ordination
 professional development/shared learning
 system improvement
 decision forming – contributes to decisions, but decisions made elsewhere
 decision making – expected to reach agreement re action in the meeting

Summary of situation and presenting issues

List key points for clarification/discussion

Take notes of action plan as agreed and circulate to participants (including client if not present)
Date: Page 20