New social work intervention to help avoid complex complications

Janice Morgan is helping elderly patients avoid complications by proactively identifying and establishing care plans for those at risk in the community.

A unique new social work position at Community and Oral Health (COH) is having an immediate and lasting impact on reducing patients’ risks of developing longer-term complex health complications.

COH Complex Care Coordinator Janice Morgan said it was important to manage patient supports and ongoing health care needs proactively to ensure that long-term risks were mitigated.

“The complex care coordination role is putting interventions in place to help the elderly and people with a disability before their situation gets to a critical state,” Janice said.

“I have been proactively helping clinicians with their caseloads by supporting them to navigate through and find the extra supports and care required for a patient who is heading home or into the community.

“It is important that those in need, like the elderly and people with a disability don’t fall through the cracks, and that unnecessary bed days or readmission are avoided.

“By identifying patients in advance, we can get the necessary packages and supports in place to avoid complications that can lead to frequent and lengthy hospital admissions and health interventions in the community.”

Janice actively consults and works closely with COH clinicians across all its bedded and home visiting services and has helped more than 100 clients so far.

“Interventions include increased supports prior to Support at Home package assignments, additional disability supports or accommodation while awaiting National Disability Insurance Scheme (NDIS) outcomes,” she said.

“We can also fund interim supports to reduce the risk of hospital admission for those waiting for access to other services or increased NDIS supports.”

One example of the value of the role is a middle-aged patient who was diagnosed with an intellectual impairment and at extremely high risk of recurring hospitalisation, if home supports and monitoring weren’t put in place.

“We introduced interim supports by way of health monitoring, a thorough environmental clean and regular domestic assistance, plus support with ongoing wound care through Long Stay Rapid Response funding,” Janice said.

“We also ensured that the patient had access to long-term support through the NDIS.

“Through this intervention, for this patient alone, an estimated 165 hospital bed days were avoided, as well as seeing great long-term patient outcome where the patient was living independently safely.”