Northern Beaches ComPacks

This project is funded by NSW Health to provide a time limited (6 week) package of case managed community support services on discharge from public hospitals. Assessment occurs while the client is still in hospital, to allow liaison with hospital staff to provide for a coordinated discharge process. The case manager works with the client to provide linkage and referral to mainstream community services when the package is complete.

The aim of ComPacks (together with the hospital clinical team) is to provide:

• Community assessment and case management of targeted people being discharged from public hospitals with the purpose of rapidly assembling individualised community care packages which are designed to meet each person's assessed clinical and support needs.

WHO IS ELIGIBLE FOR COMPACKS?

To be eligible for case managed services through ComPacks, people will:

• Be assessed as requiring two or more community services on discharge, and
• Require ComPacks support to facilitate discharge
• In addition people may be eligible if they are:
• Assessed as having clinical needs capable of being jointly met in the community by a ComPacks and a clinical team such as Community Acute/Post Acute Care
• Referred from Emergency Departments if the ASET (Agedcare Services Emergency Team) has assessed them as having in-home care and support needs rather than a need for inpatient care

The following groups are not eligible for ComPacks:

• Current CACP recipients (except where additional short term support is required)
• People needing more than 56 hours of service per calendar month
• People waiting for nursing home placement
• People waiting for Attendant Care funding

WHO CAN MAKE A REFERRAL?

Hospital staff who refer an inpatient to ComPacks include social workers, discharge planners, discharge liaison service, continuum of care coordinators, ASET case managers.

HOW DOES IT WORK?

• A case manager will take a referral and ascertain eligibility for the service.
• A case manager will visit the person, preferably in hospital, to discuss their individual needs through a comprehensive assessment process.
• In consultation with the person and if appropriate, their family, carers and involved health professionals, the case manager will develop a care plan.
• The care plan may include services such as:
  • personal care
  • domestic assistance
  • meal preparation
  • social support
  • transport to appointments and recreational activities
  • respite for their carer
  • Centre-based day care

(These services may be provided by other government agencies, or by private providers).

• The coordinator will provide a Service Agreement, including rights and responsibilities of the client, complaints procedures and information regarding privacy and confidentiality policies.
• The coordinator will arrange the services agreed to in the care plan and will monitor and adjust the services according to the changing needs of the client.
• Experienced direct care workers will be used to provide the services to the client
• The coordinator is the contact for the client and carer and will liaise with other service providers regarding changes to the assistance required.