New program links the elderly with primary health services

A close up photo of two women
Beverley Watts and Clinical Nurse Specialist Deb Jones
February 23, 2018

A new pilot program at Rockingham General Hospital (RGH) is helping patients connect with the right support from primary health care providers following discharge from hospital.

The Aged Care Transition program, funded by the WA Primary Health Alliance (WAPHA), is a first for the Rockingham community and aims to fill a gap between the hospital and primary health services.

RGH Clinical Nurse Specialist Deb Jones has more than 30 years aged care experience and is leading the project.

“The Aged Care Transition program is designed for vulnerable older patients, with complex health care needs, who require health care and social support following hospital discharge,” Deb said.

“A distinguishing factor of the program is that visits are made to the patient’s home following their discharge from hospital. 

“By seeing a patient’s home environment, how they move in it and the support they have helps me to identify their real needs and decide on how these can be met,” she said.

Anchorage resident, Beverley Watts, credits her wellbeing to the program. Beverley had been in and out of RGH due several health concerns, the latest a carpal tunnel injury from her 20 years as a cleaner.

“After one surgery, I was sent home to wait for my next surgery for severe stenosis of the back.

“When I got home, I had no support and didn’t know how I was going to make it through. My partner has emphysema and I am his carer – I couldn’t help him and he couldn’t help me.”

“I was in such a black hole. I didn’t know what to do or where to go.”

Beverley was referred to the Aged Care Transition program by one of the geriatricians at RGH.

Due to their situation, crisis care was provided for Beverley and her partner, to tie them over until her next hospital admission. There was also liaison with Silver Chain, Beverley’s pharmacist and GP to facilitate the care plan she had been given at RGH.

“It was such a miracle, we had carers staying overnight, which is the most frightening time to be left alone,” an emotional Beverley said.

WAPHA regional manager Jody Niven said the service is focused on improving the patient’s journey from hospital back to the community.

“It is all about re-connecting people with the right primary health care and support services, so it’s fantastic to see people such as Beverley benefiting,” Ms Niven said.

Deb said her role was to connect patients with their community-based primary health services.

“This reduces stress for patients and helps them keep on top of their health problems, well and out of hospital,” Deb said.

“Discharge plans from hospital can be complex and often include follow up tests, appointments, changes to medications and commencement of new care services.

“Navigating health and social services and reconnecting with primary health care providers can be a challenge for older patients and can be a daunting process.”

The results of the pilot program will be evaluated later this year.