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