Continuity of care

June 24, 2019 · Our Stories

Born in Spain, Rita and her husband, Jim, moved to Australia when their first child was a baby.

Their second child was born in Australia. When the children were young they spent a further 10 years living in Spain before settling permanently in Australia. Rita and Jim wanted their children to feel part of the Spanish culture, so they celebrated traditional holidays, and spoke their first language at home.

Rita is 78 yeas old now and living with cancer.  Jim cares for her at home with help from their daughter. During a recent hospital admission, Jim told the nurses that it was getting harder to manage at home.

To support Rita to remain living at home and Jim to continue caring for her, the hospital referred them to our Health independence Program (HiP). Following an assessment, the HiP complex care coordinator identified relevant home support services, talked to the couple about their options, and coordinated referrals and assessments. Being
unfamiliar with aged care services, the family said having a care coordinator helped to reduce their stress and they could be confident that Rita was getting what she needed.

The care coordinator arranged for an assessment through the Commonwealth Home Support Program (CHSP, My Aged Care).

The CHSP arranged for Rita to receive home care services through the council including personal care, home help and for Jim to have weekly respite. The couple received these services and the Care Coordinator talked them through what they needed to do and how to set up a routine for care in their home.

Rita’s cancer advanced and her specialist introduced Palliative Care Services to manage her symptoms. One day the Palliative Care Nurse noticed that Rita was developing a pressure sore. She referred Rita to occupational therapy for pressure care.

We prioritised Rita to access the service because she was receiving palliative care and had a pressure sore which carries a risk for serious infection and can be very painful.

The occupational therapist conducted a pressure care assessment because treatment must be tailored to the individual or the area can get worse. From the assessment, the occupational therapist identified that Rita was experiencing high levels of fatigue between her cancer treatments. As a result, she spent a great deal of time sitting, which would contribute to the development of her pressure sore. She was also in some discomfort and in pain. Rita and the family agreed that reducing her pain and pressure risk was an important care goal.

Medications can affect fatigue and mobility so the occupational therapist, with Rita’s consent, spoke with the palliative care doctor about her medications. The occupational therapist measured Rita’s weight, height and chair size to decide what pressure care cushions might suit her best.

They trialled a few pressure cushions with Rita until she found one that could be tailored to the way that she sat, provide the best pressure relief and reduce her pain. She also showed Rita, Jim and their daughter how to position the cushion so that it provided the best support to prevent further pressure. The palliative care nurse met with the occupational therapist as she was finishing her home visit. They talked to the family about using cream to prevent the skin from breaking.

The occupational therapist let the family know that they should call her if the pressure sore seemed to be getting worse or was not healing. The care coordinator was also able to liaise with a second daughter living overseas in Spain. She reassured her about how her mother’s health care was being provided in the changed aged care system in
Australia and who, on the team, could best answer her more specific questions.