Community – Older Adult Discharge Supports:

CCT 2 Home

• Metro Wide
• Contact:
  • Ext. 77926
• Indications:
  • OT home visiting service to support discharges from SCGH ED
  • Patient must be discharged directly from ED
  • Patient at risk of re presentation to ED
  • Patient requires CCT2home service (OT home visit, environmental review, education, equipment provision ,falls interventions, liaison with GP) in order to be discharged home safely

Rapid Assessment and Intervention Service (RAILS)

• SCGH / OPH catchment
• Contact:
  • E-referral via Rehabilitation & Aged Care [GERI] / General Geriatric Medicine [GGEM]
• Indications:
  • Community Geriatric MDT to support early discharge and prevent re presentation (Nurse, OT, PT, SW)

Rehabilitation in the home (RITH)

• Metro Wide
• Contact:
  • E-referral via Rehabilitation & Aged Care [GERI] / General Geriatric Medicine [GGEM]
  • Ph: RITH intake officer: 0410 333 825
• Indicaitons:
  • Home visiting MDT to support rehabilitation goals post d/c (PT, OT, SW, Diet and Speech therapy)
  • Consent to RITH & Live in RITH catchment
  • Be medically stable & cannot receive hospital discharge service
  • Have an accessible and safe home environment
  • Be able to actively participate in goal-oriented rehabilitation
  • Require allied health services which cannot be provided in an OP setting

Frailty Rapid Access Clinic (FRAC)

• SCGH / OPH catchment
• Contact:
  • E-referral via Rehabilitation & Aged Care [GERI] / General Geriatric Medicine [GGEM]
  • Phone 0466 938 848 (Mon – Thur 9am-4pm, Fri 9am-12 midday)
  • Frail Rapid Access Clinic (FRAC) – Referral Tips – 04/2020
• Indications:
  • Comprehensive Geriatric Assessment within two weeks of discharge. Follow up of investigations and treatment response
  • Risk of re-presentation to hospital due to geriatric syndromes (Falls, Cognitive Impairment, Pain)
  • Cellulitis/UTI on oral antibiotics
  • Mild delirium
  • Vertebral fractures/pain (not needing orthopaedic input/ brace)
  • Leg oedema/mild heart failure for titration of diuretics
  • Postural hypotension
  • New medications with need for monitoring of response and side effects

Homelink

• Contact:
  • Phone 1300 884 421 / Ext. 74838
• Indications:
  • Early Supported Discharge for Delirium (ESD – D) – daily nurse review and specialist OT home visiting service
  • Trial of Voids
  • Complex wound care Prolonged IV abx