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:
  • 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

Dr James Wheeler
Dr James Wheeler

Emergency Physician, SCGH, WA, Australia

Articles: 466

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