The Geraint family have been liaising regularly with the health care team in the hospital to facilitate the transfer of Jason back to his local community. His rehabilitation, medical, and social care needs need to be identified and addressed before the transfer to ensure his local community can support Jason and his family.
Background
Inter-Hospital Transfer and Rehabilitation
You have been assigned as the case manager for Jason at the Tabletop Hospital, and this requires you to facilitate his transfer back to the Tabletop Community so they can arrange his home-based rehabilitation in a remote community.
Assessment
Jason has an amputated right arm, fractured legs, and brain injury sustained from his motor vehicle accident (MVA), and he will require extensive rehabilitation and habilitation. He currently has difficulty with his communication including both speech and thinking process and will require ongoing treatment and assessment to rebuild his functional skills. He has also been experiencing bouts of depression concerning his injuries and needs to re-train for future employment.
Glenauire hospital has a limited time frame for inpatient rehabilitation so Jason will be transferred to the Tabletop community before he has fully recovered. The goal of ongoing care is to maximise Jason’s level of function and help him transition from hospital to independent living in the community. His rehabilitation may last from a few months to years, depending on the type and severity of the disability. Participation in social and community activities will be an important goal for Jason as he transitions back into the workforce.
Situation
Jason’s inter-hospital transfer is being planned and organised by a social worker and a nurse at the Glenaurie Hospital in the Rehabilitation Ward. Over the last two weeks, limited communication concerning the transfer has occurred; also bed shortages, incomplete documentation of the rehabilitation and nursing treatment plans, and staff shortages have exacerbated the delay. This problem has been escalated to nursing and medical management who have expressed frustration directly to you about the situation.
The transfer will be by air ambulance, and the case manager at the Tabletop hospital will coordinate the process. Arrangements for the transfer include:
- Contacting Jason’s family
- Locating an available community rehabilitation team in the Barringfield area and communicating the rehabilitation plan that includes teaching Jason self-care(dressing/showering/meal preparation). If there is no community based-rehabilitation team available, Jason will have to stay at the Tabletop hospital and receive rehabilitation there.
- Contacting the admitting medical and nursing staff and communicating the medical record and treatment plan if Jason is transferred to the hospital.
- Booking the air ambulance
- Liaising with the Social worker and Psychologist
Additional issues related to the transfer and Jason’s ongoing care include
- The complexity of Jason’s wound care and medications
- Need for mental health support for Jason, his girlfriend, and his family
- Payment of inter-hospital transfer (Glenaurie Hospital and Tabletop Hospital are arguing over who pays for the transfer; NSW Health policy states the transferring hospital pays for the inter-hospital transfers, except where the patient is being discharged home rather than to the hospital but this depends on the availability of a community rehabilitation team).
- Unresolved Workers Compensation claim; Jason’s workplace have not admitted liability and are not paying Jason lost wages
- Ongoing financial support for Jason through the National Disability Insurance Scheme (NDIS)
You are unsure what needs to happen in arranging the transfer and have approached your line manager for support and guidance, however, the line manager has not returned your emails or calls, so no arrangements have been initiated. Furthermore, the nurse caring for Jason believes his care is too complex for home care. Communication goes back and forth between you and the line manager, the nurse, Tabletop Hospital Health Service Manager, and Glenaurie Hospital Rehabilitation Unit Social Worker without resolution.
At this point, you phoned Jason’s mother Maureen to find out if the home arrangements are progressing. She informs you that Jason is already on his way via air ambulance to Tabletop Hospital and will arrive within the hour. You confirm this with Glenaurie Hospital staff then inform your line manager so preparation can be made for Jason’s arrival.
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