What is the Out of Hospital Care Program?

The NSW Health Out of Hospital Care (OHC) program offers patients across NSW access to short term non clinical home care packages. These are the ComPacks, Safe and Supported at Home (SASH) and End of Life (EoL) packages.

These packages can support patients being discharged from hospital or people who are receiving treatment from LHD outpatient or community teams. Packages are available for up to six weeks at a time and can be repeated for patients who require further support

What is provided?

Case management

Each patient is allocated a Case Manager who will be their main contact. The Case Manager will meet with or telephone the patient to discuss their needs. They will co-ordinate and monitor service provision according to identified needs and goals.

The following services may be provided depending on the patient’s assessed needs:

Domestic assistance

Cleaning, washing and assistance with mopping

Personal care

Assistance with bathing, oral care, grooming & dressing

Meals

Assistance with meal preparation

Transport

to medical and other appointments

Social support

Accompaniment to: appointments, shopping, paying bills

Respite

In-home respite for family/carers

OHC cannot provide intensive levels of home care on a permanent basis.

When to choose Out of Hospital Care

NSW Health OHC should be used when:

• a patient requires immediate access to case management and home care for a safe discharge home or to prevent an admission or readmission to hospital
• services are not in place or cannot be immediately accessed through other programs
• no informal support options such as family or friends are available for the patient.

Who is eligible?

OHC can be accessed by patients of all ages who are either inpatients in a NSW Health Public Hospital or have been referred by a NSW Health Community Health Service or Team.

Patients eligible for the program may suffer from acute or chronic health conditions, disability or terminal illness that impacts on their ability to manage their activities of daily living and therefore puts them at risk of unnecessary hospitalisation.

Who is not eligible?

A person who resides in a residential aged care facility and is requiring home care services to be provided in that facility.

Who can refer?

Clinicians from LHD in-patient, community and out-patient teams can refer. These may include, but are not limited to Palliative Care, Community Nursing, Chronic Care, Outpatient Therapy, Mental Health and Aged Care Assessment Teams.

How to refer?

Once a patient has been identified and screened by key staff, LHD local referral protocols will need to be followed. This may be:

• a direct referral to the Service Provider using the OHC referral form
• a direct referral via the Service Provider’s Intake Portal
• a referral via the LHD centralised intake service.

When do I refer?

LHD staff are encouraged to make referrals as soon as possible.

• If the patient is in hospital refer as soon as the patient’s discharge destination and estimated date of discharge is known.
  
• If the patient is not in hospital a referral should be made as soon as agreement with the patient/family is confirmed.

Funding

OHC is a State funded initiative and is managed in conjunction with LHDs by the NSW Ministry of Health Out of Hospital Care (OHC) Team.