The primary clinical purpose or treatment goal of maintenance care is support for a patient with impairment, activity limitation or participation restriction due to a health condition.
Following assessment or treatment the patient does not require further complex assessment or stabilisation. It is not intended that maintenance care should substitute other forms of non-acute care. It should emphasise a restorative approach to care post-treatment.
The aim of maintenance care is to support patients who have ongoing care needs but no longer require an acute admission.
Currently the majority of transfers occur following a hospital episode of care but are not restricted to this. Appropriate patients who are frail or have complex care issues may access the program from the community, and potentially avoid an acute hospital admission.
Maintenance care aims to reduce inappropriate long stays in acute and subacute beds and improve patient flow. While the program’s intention is to give people more time to meet goals or improve function, it should still be considered a short-term care episode.
Maintenance care patients
Maintenance care patients have clinical issues generally associated with ageing or disabilities and complex social issues that require a multidisciplinary approach to assessment and planning. Patients should be considered for maintenance care if they:
- are medically stable
- would benefit from goal-oriented, time-limited and therapy-focused care, in support of completing their restorative process and optimising their functional capacity
- are being assessed for long-term care arrangements
- are not considered appropriate for alternative programs such as TCP and HIP
- would benefit from a package of services that include at a minimum, case management, low intensity therapy and nursing assistance or personal care.
Elements of the service model
Health care service delivery must be coordinated and is always based on an individualised care plan containing negotiated goals with indicative timeframes.
The maintenance care service model includes:
- an emphasis on restoration of function, early discharge planning and coordination of community-based services to support patients on discharge
- evidence of a multidisciplinary care plan in the patient’s record that identifies goals of the clinicians, the patient, carers and family
- an assessment of functional ability, both on admission and discharge; the RUG-ADL is currently mandated by the department for assessment of all care episodes.
Setting of service
Maintenance care can be provided in a variety of settings. These include dedicated inpatient beds, the community, the patient’s own home or in another setting such as residential care.
Consideration should always be given to providing care for the vulnerable older person in the least restrictive setting that will promote independence and reduce the risk of functional decline and adverse events often associated with admission to hospital.
The physical environment
With a focus on restoring function, patients should be encouraged to be as physically active as they can. The physical environment should be one that encourages independence and considers the older person’s needs. It should capitalise on their strengths and abilities while protecting them against harm.
Enhancing interactions with family and carers is essential, so private spaces and communal areas should be available. Patients are expected to be dressed and remain as active as possible during the day. Access to outdoor spaces may be considered therapeutic.
Location of services
In Planning the future of Victoria’s subacute service system: a capability and access planning framework (2012), a service capability framework defines the scope of practice and expectations for Level 2 services which are not designated to report a geriatric evaluation management or rehabilitation program. Given the practical difficulties smaller health services would have in providing the necessary resources to provide a formal subacute service, a restorative approach to care is emphasised.
Maintenance care services are located across rural and regional Victoria at the following health services.
Barwon - South Western Region:
- Colac Area Health
- Portland District Health.
- Gippsland Southern Health Service.
- East Grampians Health Service
- Stawell Regional Health.
Loddon Mallee Region:
- Swan Hill District Health
- Kyabram & District Health Service
- Maryborough District Health Service.