Lara (83) has lived alone for the past 25 years. She was admitted to hospital after falling in her driveway.
Although she claimed she had been there only a short time before help arrived, her family and medical staff felt she may have been there overnight.
Lara was referred to a SIHI aged care clinician 5 days after her fall.
The referral stated, ‘family and patient have decided she needs full low level residential care and does not want to go home’.
Lara’s presenting health problems
- Lara had massive bruising and grazes from her fall.
- She was frail, not eating properly, had lost weight and was worried about her sense of balance.
- She didn’t want to go home as she was extremely frightened of falling again.
Recent history related to presenting problems
Lara had no personal duress alarm even thought she was elderly, frail and living on her own.
With an alarm, she would have been able to call for help much sooner.
While in hospital, Lara just wanted to rest in bed most of the day.
She needed constant reassurance and support for the activities of daily living (for example, washing, dressing and eating).
Transitional Care Manager’s testimonial
“This client transfer was the most comprehensive and inclusive I have seen.”
Key principles for SIHI primary health highlighted by this case
There are many elderly people living on their own in the Wheatbelt who have falls and need rehabilitation to enable them to return home safely.
With the current level of services available locally, many people have no option but to stay in a hospital or a residential high care facility (nursing home). This limits their opportunity to recover and return to living independently in their community.
Role of the SIHI funded primary health nurse practitioner in this case
- Lara has her needs assessed by the SIHI Aged Care Clinician.
Intervention: The SIHI Aged Care Clinician assessed Lara and classified her as a priority 1 for rehabilitation, to help her regain her confidence and independence in activities of daily living. After rehabilitation, Lara could choose to return home with community-based support or move into permanent residential care.
Outcome: The local rehabilitation service was full.
- The SIHI Aged Care Clinician identifies treatment options that suit Lara’s needs and family situation.
Intervention: The SIHI Aged Care Clinician looked for other local options, but none really suited Lara’s needs. The SIHI Primary Health Integration Coordinator suggested a Transitional Care Program.
Outcome: There is no Transitional Care Program in the Wheatbelt, but there is one in the south west, near where Lara’s daughter lives. It had places available.
- Lara and her family choose their preferred treatment option.
Intervention: The SIHI Aged Care Clinician talked with Lara and her family about her local treatment options and the Transitional Care Program. They opt for Lara to be assessed for the Transitional Care Program.
Outcome: To save travel, the SIHI Aged Care Clinician tried to arrange Lara’s assessment via videoconference. Unfortunately, the Transitional Care Program did not have videoconference facilities on site.
- Lara benefits from Telehealth videoconference facilities.
Intervention: The SIHI Aged Care Clinician arranged for them to use the videoconference facilities at their local hospital in the south west. She also sent them Lara’s physiotherapy, occupational therapy and speech pathology reports and her pathology test results.
Outcome: Lara was assessed via videoconference. The Transitional Care Manager agreed that the program would suit Lara’s needs.
- Lara and her family access a treatment option that suits their situation.
Intervention: Lara was discharged from hospital 2 days later and her daughters shared the driving to take her to the south west. She was admitted to the Transitional Care Program the same day.
Outcome: Lara is staying with her daughter and receiving in-home rehabilitation through daily physiotherapy, occupational therapy, dietary improvement, meal preparation, social support and other services based on Lara’s needs. Lara will be able to choose where she wants to live once she finishes the program.
WA Country Health Service