Reference no: EM133559020

Case Study: Edith Holman is an 87-year-old woman who lives alone in her three-bedroom single-storey house in country Victoria. Her husband died 10 years ago and her only son and daughter-in-law live a 30-minute drive away. Edith is independent and manages well by herself. She says she has some good friends and states that her neighbours are generally helpful. However, following a series of cerebral vascular accidents (CVA) Edith was admitted to the medical ward of the local hospital. Edith confided to her daughter-in-law that her biggest worry was being placed in an 'old people's home'. Once her medical condition was stabilised, Edith was transferred to the rehabilitation ward. While there the staff assisted her to obtain an optimum level of health, functioning and wellbeing, thus maximising her ability to return to her own home following discharge. Prior to being discharged home, Edith met with a number of health professionals whose aims were to assist her in her transition to home. This multidisciplinary team also helped Edith to identify the resources required to help her manage at home. Their goal was to come up with a plan of action and forward referrals where required. It was also arranged for Edith to meet with the Community Nurse Liaison Officer.

Question 1: Who should be involved in creating the plan for Edith and what are there roles in the delivery of her care?

Edith has a partial left-sided hemiparesis and during her stay in the rehabilitation, the ward has learnt to mobilise with a walking frame. Her medical conditions are now controlled by medications and she is no longer considered at immediate risk of further CVAs. She has been medically cleared for discharge home. The occupational therapist has visited her home and made a number of recommendations for changes that will improve her safety. This includes the erection of handrails in her bathroom and toilet and alongside her home entrance steps. Edith has been approved for Home and Community Care support and has been recommended to receive a Community Aged Care Package (CACP). A registered provider of these packages meets with Edith to help establish her care needs. It is subsequently assessed that for Edith to remain within her own home she will need assistance with showering, meal preparation and housekeeping.

Question 2: How can patients access aged care packages and who provides these incentives?

Question 3: Who makes up the ACAT team and how do they assess patients?