2. To facilitate patients and families understanding their care and to work in partnership with wider communities to ensure adopting a ‘Home First’ philosophy, striving to facilitate a discharge home for older person it is possible and appropriate.
3. The CNSp. Mater FIT will focus on assessing and promoting the health and function of older people living with frailty, assisting them in preventive and rehabilitative processes as appropriate and timely manner as a member of the Mater FIT. The CNSp. will link with other practitioner’s and services such as primary care, respite day services and home support providers and will also support, empower and enable family/carers.
4. He/she will provide early access to Comprehensive Geriatric Assessment (CGA), frailty related assessment and intervention as part of Mater FIT to implement a model of care with the outcome of ensuring older persons are assess and supported in accessing an appropriate care pathway.
5. To provide a seamless integrated service with multidimensional and multidisciplinary input for older persons as they transition through the continuum of care.
6. Deliver quality evidence-based education to ED and MMUH staff on frailty related topics.
7. Participate and contribute to, education, research, and service improvement initiatives with ED staff.
8. For patients who require admission to the acute hospital, intervention and discharge planning is commenced within the acute floor with the aim of reducing overall length of hospital stay. This will include assisting with discharge home visits for patients on an as required basis.
9. Contribute to the reduction of Patient Experience Time (PET) by managing complete episodes of care and communicating assessment findings promptly to the Emergency Medicine (EM) teams.
10. Integrated working with EM team and Acute Medicine teams to enhance patient care.
11. Communicate appropriately with in-patient medical teams, nursing teams and HSCPs involved in the care of patients seen by Mater FIT through good documentation, and clear recording of patient goals and plans of care on CGA document.
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