CQ Health’s Transition Care Program (TCP) is supporting the safe discharge from hospital to home for patients over the age of 65.
This is a vital service, supporting early discharge and freeing up hospital beds for those in need. There are 32 places available for the 12-week home rehabilitation program, and 118 patients have been referred so far this year.
Patient Desma Clarke can’t speak highly enough of the program, which has allowed her to return to her own home after spending time at a private hospital in Rockhampton following a fall when she broke her femur.
Senior Social Worker Beth Ford visited Desma on her first day home from hospital. She also has visits from an occupational therapist and a physiotherapist.
She has transport provided to exercise appointments, as well as help with social services including shopping and a haircut, showering and cleaning.
“I’m very impressed with the very professional manner of the staff, including Beth. They’re very friendly, but professional and that’s important. You feel very relaxed with them straight away.”
Desma lives alone and could not have returned home without support.
“I’m probably doing more because I’m here by myself. It’s been wonderful just knowing they are coming. They’re evaluating all the time how much I’m improving, or not improving, to plan future days and weeks. They’re always asking if there’s anything else they can do for me.”
Beth is pleased to provide this service to local seniors. The team also has clinical nurses, allied health assistants, and personal care workers.
Nurse Unit Manager Grace Hinder says the multi-disciplinary team has made excellent gains for patients and provides a valuable service keeping patients from requiring re-admission to hospital or early placement to a nursing home.
“They’re a great team that works well together and they enjoy getting to know and helping their patients. We’ve had people who have left hospital rehabilitation unable to walk, but within the 12-week program of intensive physiotherapy we’ve got them walking again.”
Referrals to TCP come from hospitals – Rockhampton (including Hospital in the Home) Mater, Hillcrest, Capricorn Coast, Mount Morgan, and there is a team in Gladstone. People coming onto TCP must have rehabilitation goals.