How we can enable you to better manage

CA-7

 

Care Assess is a private health care organisation, specialising in health assessment and coordination of community care. We employ registered nursing health professionals as our care coordinators in order to provide clinical care for our clients with multiple and/or complex care in the community (living at home).

We adopt a multi-disciplinary team care approach to care coordination, as care coordinators draw on the health professional training of allied health staff such as occupational therapists, exercise physiologists and social workers.

We use a best-practice case management model to deliver clinical coordination of support and care for our clients, which is distinguished by the following features.\

Care Assess’ Care Coordinators:

  • Are a single (but not the only) point of contact – our care coordinators work in partnership with clients and their family or carer as a single point of contact regarding their care. Our Care Coordinators are also a central point of contact for other service providers.
  • Adopt a ‘life strengths’ approach – every client has strengths that is the focus of the interaction between our Care Coordinators and consumers; we aim to maximise the physical, social and psychological wellbeing of clients to achieve their optimal level of independence and assist in their participation in the community commensurate with their capacity and choice.
  • Specialise in increasing collaboration – Our care coordinators work collaboratively with other service providers and professionals involved with our clients to ensure the best possible outcomes for that person.
  • Ensure services are individualised – consumer focused support ensures each person receives the appropriate level and type of support according to their needs, culture and budget constraints, working towards jointly agreed goals.
  • Ensure continuity of care – consumers have a right to expect continuity of service over time between services in order to meet their individual needs.
  • Facilitate flexibility – support can be delivered in a way that suits individuals’ needs and varied according to the changing needs of the individual.
  • Span boundaries – Our care coordinators draw upon all available resources, both formal and informal to provide support in the most cost effective manner.
  • Focus on appropriate services – they ensure diversity is respected and catered for, for example cultural preferences and special needs.
  • Are creative – our Care Coordinators work “outside the square” to find innovative ways to meet needs.
  • Increase empowerment – our care coordinators ensure consumers are supported, through the provision of information, to manage their own affairs as far as possible.
  • Uphold confidentiality and safety – Care Assess protects privacy and ensures quality and safety is maintained at all times in accordance with legislative requirements and minimum standards.

Provided below are a few examples of how a Care Assess’ care coordination services can be used effectively to provide community-based rapid response services providing urgent care for people when their health or independence rapidly deteriorates, including effective alternatives to hospitalisation.

Coordinated community care in a crisis

  • We know that people with complex needs can deteriorate rapidly at any time, in or out of hours, and when this happens, clients need effective and speedy support from health professionals who understand their individual circumstances and conditions.
  • People need to know who to call in a crisis and they need to do it quickly (within and outside of usual hours).
  • Community-based health professionals, such as nurse care coordinators, are able to assess a client’s level of risk, coordinate access to out-of-hours advice and in-home support services when needed.
  • Community-based providers such as Care Assess, with available health professionals and capacity, can rapidly respond in a crisis with a team approach, including out of hours – providing quick assessment of clients’ individual care and support needs where appropriate.
  • Home care providers are perfectly placed to stabilise the situation and put together a care plan that avoids an unnecessary trip to hospital or to long-term residential care.

Improved advance care planning

  • All end-of-life care services should provide informed choice and control to people, including the ability for people to remain at home during their end of life stage if possible.
  • We know that early involvement in planning end-of-life care increases people’s choice, control and support, and the likelihood of them being able to die at home if wanted.
  • Care Assess can provide support for General Practitioners and/or other health professionals in initiating advance care planning as soon as they suspect that a patient may be approaching the end of life.
  • We know that ongoing assessment of patients’ physical, mental, social and spiritual needs will better enable clients to make goals and enable health professionals to make referrals to community-based palliative care services or other relevant health and home care professionals as needed.

Providing home-based end-of-life services

  • Care Assess has available nursing personnel that can provide comprehensive end-of-life care services, including health professional primary care and emotional support.
  • Care Assess follow a personalised care plan, and clients and their carer(s)/family have as much involvement in that plan as they are able to provide.
  • Clients receive regular communication, assessment and management of their symptoms, and are provided with psychological, social and spiritual support as well as physical.