CONTINENCE REGIONAL VIC SERVICE POLICY AND PROCEDURE
Our Mission
Our aim is to assist in improving the quality of life for children, adolescents and adults with associated incontinence. Our services are provided by qualified and experienced Continence Nurses Consultants.
Our Vision
To inspire hope and contribute to health and well-being by providing the best care to every patient through integrated clinical practice, education and delivery of evidence-based practice care.
To deliver Excellence in healthcare, putting people first. Providing high quality care that is:
• Respect for the Individual
• Pursuit of excellence
• Contribution to the Community
Goals and Objectives:
This service operates under the following principles:
• Person and family-centred care
• Quality, evidence based and timely services
• Equity of access to services
• Coordination and integration
• Promote choice and decision making
• Promoting health independence
The Key Goals and Objectives are:
To ensure each participant accesses supports that promote, uphold and respect their legal and human rights and is enabled to exercise informed choice and control.
The provision of supports promotes, upholds and respects individual rights to freedom of expression, self-determination and decision-making.
Each participant accesses supports that respect their culture, diversity, values and beliefs
Each participant is supported by the provider to make informed choices, exercise control and maximise their independence relating to the supports provided.
To comply with Health & Safety regulations. Identification of risk and preventing harm to consumers and workers.
Best practice through promotion of continuous improvement and risk management.
Actively involve consumer participation in care planning, provide choice and decision making in all aspects of their Continence care needs.
To improve access to effective, efficient, evidence-based programs for continence management and care for all people within the Regional Victorian Region.
To coordinate the holistic care for clients requiring continence management in the community setting which promotes independence and improves quality of life
To ensure that the management of each participant’s information that it is identifiable, accurately recorded, current and confidential. Ensure that each participant’s information is easily accessible to the participant and appropriately utilised by relevant workers.
To ensure the continence management plan for each participant is streamlined through the provision of a consistent standardised way for practitioners to identify consumer needs, identify appropriate services, make referrals, provide feedback, communicate and coordinate care, leading to improved operational efficiency.
Prescription of continence products:
The Continence Nurse provides client assessments, prescriptions and clinical justification for continence products for the following funding bodies:
• National Disability Services (NDIS)
• Department of Veteran’s Affairs (DVA)
• Transport Accident Commission (TAC)
• Aged Care Level 3 & 4 Packages
NDIA: These clients require assessment and reviews as determined by client carer and case managers, generally yearly
Clients receiving funding for continence products will require re-assessment based on their funding requirements. This ensures their ongoing supply of the most appropriate products.
DVA & TAC: These clients will require a review assessment every 2 years or as requested if changes occur.
Liaison, Monitoring and Review
All clinicians liaise with the client/carer and relevant community services to provide holistic care and advocacy on behalf of the client/carer to ensure effective outcomes and continuity of care.
This is done by:
• Acting as a point of contact for clients/carers on general issues
• Planning for consumer needs and initiation of supports and services for clients/carer in consultation with the client/carer and other service providers
• Ensuring the client/carer is aware of all options and is able to make informed choices
• Liaison and communication with other service providers
• Supporting effective communication between the client and the client’s carer network
• Conducting planned reviews, reassessments and proactive monitoring of the client
• Planning and attending all relevant discussions, goal setting and case conference meetings
• Monitoring completion of care plans and setting of goals in conjunction with the client
• Reviewing the care plan/active goals with the client, including discussion regarding discharge from the service
Triage process
• Referral received via email to info@continenceregionalvic.com.au
• Referral received via Continence Regional Vic email or Website and clinician personal CRV emails
• Referral received via Continence Regional Vic phone or any of the clinician’s personal phones
• When referral received collect details: Full Name; address; DOB; contact name and details; NDIA No. Medical background and diagnosis. Copy of plan if available and all other information, if possible, to be sent via email to Continence Regional Vic email
• Funding details to be obtained ie : self-managed – Plan Managed – Agency Managed – Check to ensure adequate funds in clients plan before booking the assessment time.
• Triage is determined by urgency, medical history, disadvantaged and complexity of care
• Urgent referrals will be prioritized
• If a client has seen a nurse before and requests the same nurse – which provides continuity to of care, then referral is allocated as requested.
• Priority is to ensure continuity of care; participants are able to receive support from the clinician of their choice or preference, they have the right to choose where the assessment is conducted and who will be present.
WAIT TIMES
Where possible we endeavour to see clients within 1 -2 weeks dependent on their situation, geographical location and the urgency of the assessment.
Initial Assessment:
Initial assessment appointments for new clients will be arranged. The time allowed for the assessment and ongoing support will be determined in consultation with family, carers, support coordinators and the client at the initial contact.
All clients are assessed and reviewed in their home or care facility.
To support and empower clients to participate in the assessment process, the clinician will explain:
• Rights and responsibilities
• The assessment processes
• Why information is being collected and how it will be used or shared
• Complaints and Feedback systems and processes (“Right to Complain “)
• Risk Management and Incident process
• Choice and Decision making
• Consent to share information
• Access to / a copy of NDIA Participant Welcome Pack
A comprehensive continence assessment will be conducted using:
• NDIS Service agreement signed by the client / carer / representative
• Home Risk Assessment
• Admission assessment
• Care plan summary
• Clinical Justification and Continence Assessment Report
A comprehensive assessment is undertaken by the Continence Nurse Consultant. The type of assessment will depend on the purpose of the referral and the clinical judgement of the client’s needs. Ongoing support and re-assessment may be required if there is a significant change in medical or functional status or the client, their care needs are ongoing or they have been on the program for an extended period of time.”
Clients who require education on their health conditions will be provided with information that is receptive to, and guided by the client’s needs, learning style and their capacity to understand information (taking in to account issues such as preferred language and visual or cognitive requirements)
Based on assessment outcomes the client may be given educational material:
Other relevant information/ fact sheets may be sourced from the following websites.
• www.bladderbowel.gov.au
• https://www.continence.org.au/
When the initial assessment is completed, the clinician will discuss the findings with the client / carer / representatives. Their care options for support services, including those provided by other service providers will be outlined. If a referral is required to another service, the clinician will complete this on the client’s behalf. The consumer is encouraged to actively participate in all decision making.
With the client’s consent written assessment feedback will be given to other relevant service providers involved in the client’s care (including specialist, GP)
Care Planning:
All clients will have a Care Support Plan completed following the first visit based on the client’s goals and assessment outcomes. The Care Support Plan will include client goals, self-management strategies, carer needs, and ongoing proactive monitoring, review date and appropriate recommendations from evidence based clinical guidelines.
The Care Support Plan also references where applicable any supporting documentation which may include social profile, assessments, service plans, support plans, GP (General Practice) plans, advance care plans, emergency management plans, screening or risk alerts. The client will receive a copy of the Care Support Plan / Report.
Ongoing support provision:
Based on the full range of identified client issues, needs and circumstances one or more of the following options will be discussed with the client:
• Ongoing support from the Continence Regional Vic clinicians
• Referral to another service provider if recommended
• Referral for a funding package, aids or equipment
• Provision of assessment outcome report to relevant funding body to meet requirements.
• Discharge from service
Client Review
Client review appointments are available and determined by the clinician or requested by the client. Some client reviews may take longer based on their needs and circumstances some case reviews will be conducted via phone. Review appointments will be based on needs and individual assessment. The client’s Care Support Plan will be used to guide the review process. This will be updated during each session. Any specific information the client was asked to collect (bowel chart, diet diary) will be evaluated and discussed with the client.
To ensure continuity of care for clients who have Case Managers, an updated client report can be is sent to the Case Manager after each appointment upon request.
To promote care coordination and the best client outcomes, reports will be sent out to other service providers in the client’s care following the initial assessment and then as required. The client will need to consent to share any information.
Cancellation Policy:
As per NDIS Guidelines July 2020 the following charges for cancellations are as follows;
Cancellations from 1 July 2020
A short notice cancellation (or no show) is now defined as when a participant has failed to provide:
Two clear business days’ notice for a support or service which is 8 hours or
less in duration and less than $1,000
When claiming a cancellation, providers should request a claim of 100% of the
negotiated price
Discharge:
Clients will be discharged when/if:
• They have reached their goals set out in the Care Support Plan and no longer require support from the Continence Nurse
• The client would benefit more from another service provider taking over
• They are not participating in agreed change management strategies (per Care Support Plan)
• The client does not wish to engage in the service
• The client has left the district
• The annual request for review is completed
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Continence Regional Vic Pty Ltd is a registered NDIS service provider delivering comprehensive continence assessments, investigation, education and management advice for Continence Care across all ages. The service operates across regional Victoria. We are based in Geelong but offering services across Regional Victoria stretching from Geelong to Swan Hill in the North, Bendigo, Ballarat and Shepparton.
The service will deliver safe and quality support services to individuals and their carers and families with disabilities. We offer services to clients that are supported under TAC as well as clients who choose our service to support them with their own individual continence challenges that are not funded through a government scheme.
Our aim is to bring courteous home and care support to our clients who struggle on a day-to-day basis managing bladder and bowel incontinence, toilet training challenges and other challenges related to continence management. We are fully qualified and well experienced qualified Registered Continence Nurse consultants with a wealth of experience this field.
We are committed to removing DIS from DISABILITY to make you ABLE to do anything you want. No matter what type of support you expect from us, we have the capacity to provide support. We provide a wide range of NDIS support services tailored to meet the needs of people with disability of all ages and needs, as well as carers. We are serving the NDIS participants residing across Regional Victoria.