The purpose of this RFT is to assist the Northern Local Health District identify suppliers to provide the Transitional Aged Care Services on an overall best value for money basis.

Depending on the clients assessed level of need, transition care will offer eligible older people several or all of the following:

• Therapy (e.g. physiotherapy, occupational therapy, social work, speech pathology, dietetics and podiatry) to maintain physical and cognitive functioning, and to facilitate improved capacity in activities of daily living

• Personal care (including meals, medication monitoring and prompts)

• Nursing support

• Domestic assistance (including household tasks, laundry, meals)

• Carer respite

• Transport to medical appointments (including accompanied assistance)

• Shopping assistance (including from list or accompanied assistance)

• Case management

Scope:

Optimising Independence and Well-Being

Assessment process: Care Planning is focused on optimising independence and well-being and includes a goal-oriented plan for the client that:

• Responds to the identified needs of the client and targets those which optimise independence while taking into consideration the psycho-social needs of the client.

• Improves the client’s functioning by promoting independence and monitors improvements in consultation with the client, carers/families, clinicians, and therapists.

The Transition Care service demonstrates its service:

• Provides a coherent and integrated case management process that enables clients to meet their goals.

• Actively promotes self-management and self-sufficiency by providing interventions that support clients to make the most of their capacity and achieve their full potential.

• Encourages clients to seek support from carers/families, community groups and others to foster their independence.

• Assists clients to achieve an optimum level of independence and well-being so that their care needs are minimised over the longer term.

Multidisciplinary Approach and Therapy Focused Care

Assessment processes include:

• Assessment of the care recipient’s transition care needs by the multi disciplinary team (MDT) at the beginning of the care episode.

• The use of validated assessment tools deemed appropriate by the clinicians/therapists. The Modified Bartell Index (MBI) is mandatory for the Australian Government subsidy payments at the entry and the exit point of the transition care program. PROMS and PREM assessments to be implemented as directed by NSLHD.

The Care Planning process demonstrates that:

• A goal-oriented physical and cognitive programme is developed by the Case Manager, in consultation with the care recipient or representative, carer and family prior to the commencement of therapy or treatment.

• Hospital discharge information is incorporated into the initial care planning process.

• Clients’ goals are delivered in accordance with the care plan using an integrated case management approach.

The multi-disciplinary approach to the planning and review of client care demonstrates that:

• Documented procedures and protocols are in place to support the MDT in the care and review of clients

• Care plan reviews/case conferencing includes those members of the MDT involved in the client’s treatment and occurs at pre-determined intervals.

• Care is informed by discussions with and between the client’s GP, and other appropriate medical professionals, as indicated. 

Seamless Care

Assessment Process:

• Recognise and incorporate hospital assessment, care planning and discharge arrangements, including ACAS assessments and approval recommendations

• Enable staff of the receiving transition care services to meet and assess the care needs of the client where possible

• Provide verbal and written handover when a client moves between TACP services e.g. transfers from the Northern Sydney Transition Care Unit (NSTCU) to TRANSPAC community.

The Transition Care service works within an integrated system of care with other organisations by:

• Effectively coordinating the client’s needs and goals between services

• Keeping the client and/or their representative well informed prior to moving to a new service

• Facilitating access to ongoing care and service provision post discharge from the program, as required.

The Transition Care service develops systems for the safe discharge of clients to prevent re-admission to hospital, including:

• Providing Transition Care service discharge care planning to any subsequent care organisations

• Providing appropriate discharge documentation to be given to the client specifying:

- Length of stay in Transition Care

- Destination post Transition Care

- Goals which the clients agree have been achieved or haven’t been achieved with reasons for non-achievement

- Client, carer and family education and support to improve functioning following discharge from the program

- All contacts for ongoing services and equipment purchase information to be provided to the client on discharge from Transition Care, with supplier contact details

- An up-to-date list of prescribed medications

- Other follow-up arrangements/referrals such as information for the clients’ GP, which is the responsibility of the client and/or their representative.

Requirements

Mandatory requirements

Social procurement (Aboriginal Procurement Policy) *

Community and social services

Category and estimated value is subject to social procurement.

If you are successful in winning this opportuntity you will be required to submit quarterly reporting, do you agree?

Response type

Radio button (Yes/No)

Social procurement (Shorter Payment Terms Policy) *

Community and social services

Category and estimated value is subject to social procurement.

If you are successful in winning this opportuntity you will be required to submit quarterly reporting, do you agree?

Response type

Radio button (Yes/No)

Social procurement (SME Policy) *

Community and social services

Category and estimated value is subject to social procurement.

If you are successful in winning this opportuntity you will be required to submit quarterly reporting, do you agree?

Response type

Radio button (Yes/No)

Opportunity requirements

1. mandatory response schedule

Please provide your response in attcahed documents namend "NSLHD_2311059 - RFT PART C -Tender Response Schedule 7" and NSLHD_2311059 - RFT Part C - Tender Response_v1.6"

Response type

File upload (Multiple)

Response templates

Please see attached files in the link for more information