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Implementing Transitional Aged Care Model of Care

Transitional Aged Care Model of Care  (1.05M)		Planning Where are you now?		Preparing Make it happen		Operationalise Make it stick
Governance		Identify Leaders Develop a Process Map Establish a Steering Committee		Develop a Governance Plan Develop service agreements with partners Establish and mobilise team Develop Key Performance Indicators (KPIs)		Monitor KPIs Provide regular updates and reports
Patient Journey How do patients flow through the hospital		Map Patient Journey		Identify changes that need to happen to improve the patient journey Document 'new' patient journeys Include the perspective of carers and/or family members		Regularly map patient journeys to monitor their experience
Policies and Protocols		Review current policies, processes and protocols Identify gaps and strengths of current policies, processes and protocols		Develop policies and protocols Develop patient selection criteria		Implement and monitor compliance with new protcols
People Understand who the staff are, how they function and what role they play in the patient journey		Stakeholder Analysis Develop staff profile		Engage geriatricians, GPs, ACATs, allied health and community service providers Develop position descriptions  Develop competencies and an educational program for staff		Develop a review process
Resources		Survey current resources Identify resources needed to establish and maintain Transitional Aged Care		Deliver required resources		Monitor resource use
Communication		Develop communication plan		Implement the communication plan		Feedback and review process