R-CAT provides nursing care, assessment and treatment in the community to enable patients an earlier or more supported transition from hospital to home or to help avoid an admission to hospital. The care is coordinated by a Specialist Nursing team who liaise with a wide range of providers and professionals such as Home-based Support Services, District Nursing, Aged Residential Care, Allied Health and Gerontology Services. R-CAT can be used along with other services already provided by POAC. If your client is at risk of admission to Auckland City Hospital, our team may be able to support them at home. What to expect Your patient will be seen either in the hospital or at their own residence within a 2 hour framework; short term nursing care will be planned with links to other community services being explored. How to access the service The service accepts referrals from Primary Care, Aged Residential Care, St Johns Ambulance and hospital teams. Contact Details Please call our Care Closer to Home Community Services no. 0800 631 1234 ADHB R-CAT Service FAQ.pdf (PDF, 471.8 KB)

A team of experienced nursing staff based in the community providing a wide variety of nursing care in the home, including palliative care and leg ulcer services at Greenlane Clinical Centre, with the goal of promoting optimum health and independence for clients. District Nursing includes generalist and specialist knowledge and skills as well as knowledge of community resources which may be needed to complement care. The staff function independently and interdependently in assessing needs, monitoring, delivering and evaluating care. What to expect? You will be allocated a primary nurse, but from time to time you will see other nurses. If you are able to attend a clinic you will be requested to do so. The clinics operate an appointment system to ensure you are not kept waiting. If you aren’t able to attend a clinic the nurse will contact you following referral to arrange a visiting time at your home. Referral Expectations Please use e- Referrals to refer to the appropriate service. Referrals are triaged by a multidisciplinary team and actioned by the appropriate community team. Alternatively please phone our contact centre 0800 631 1234

Gerontology Nurse Specialists will provide nursing assessment, advice, education and support to those people living within the community with age related needs and complex medical conditions. The team have a great relationship with Aged Care Providers and work with other teams in the community to provide seamless care across the acute and community continuum. The team help to support a number of schemes within the community and can help to navigate cares for older people living at home. What to expect The Gerontology Nurse Specialists will provide assessment for those patients with complex medical needs that require specialist nursing input, for people over 65. We can also provide advice for Residential care facilities and GPs. How to access the service E-referrals (GPs) Contact Details Phone: 0800 631 1234 Building 17 Green Lane Clinical Centre

The service provides nursing assessments including management and supplies for people from the age of four with bowel and bladder problems. A full assessment of your conditions may include: bladder pattern analysis bladder scan bowel assessment. A treatment plan for continence problems may involve: bladder retraining ongoing education/study days appropriate product recommendation bowel management programmes recommendation and regular review of postal supplies education and support to you and your carers referral on to other specialist services such as Urology. What to expect We will conduct a full assessment and then work with you to develop a plan to ensure your continence needs are met. If you are able to attend a clinic you will be requested to do so. The clinics operate an appointment system to ensure you are not kept waiting. If you aren't able to attend a clinic the nurse will contact you following the referral to arrange a visiting time at your home. How to access the service Referrals accepted to this service from: GPs Primary Care Self-referrals and from acute settings Referrals accepted to this service include: Assessment for urinary & faecal incontinence Bladder retraining programs Bowel management Advice on continence aids including purchasing information Education for clients/carers Education for health professionals Assessment for supply of continence aids for clients with irreversible continence problems. Contact Details 0800 631 1234. FAQs How long will I need to wait for an assessment? We aim to see clients within 8 weeks. How do I get continence supplies? A detailed assessment needs to be undertaken to determine whether continence supplies are required. How can I get a referral to the service? Your GP or other healthcare professional known to you can refer via electronic referral.

The Ostomy service provides specialist nursing advice, assessment, support and supplies to people of all ages who have a stoma. A stoma is a surgically created opening in the body e.g. the abdomen that requires the use of a colostomy, ileostomy or urostomy bag. What to expect We will conduct a full assessment and then work with you to develop a plan to ensure your continence needs are met. If you are able to attend a clinic you will be requested to do so. The clinics operate an appointment system to ensure you are not kept waiting. If you aren't able to attend a clinic the nurse will contact you following referral to arrange a visiting time at your home. How to access this service Access to the Ostomy service is by referral from the hospital or GP. Referrals can be made by e-Referral, mail or for urgent cases via the telephone. Contact Details 0800 631 1234.

Occupational Therapists are experts in function. Occupational Therapists assess the level of functional ability of clients who, through a temporary or permanent illness or disability, cannot safely or independently carry out roles and meaningful occupations, in looking after themselves (self-care), participating actively in life (leisure), and contributing to their community (productivity). This service provides comprehensive assessment in the home and the implementation of interventions for what are often complex functional problems i.e. practical advice and strategies, alternative adaptive techniques, provision of assistive equipment (often customised) and home modifications. Occupational Therapists act in an advisory capacity for other A+ services around the design of home modifications for people with disabilities and consult for therapists when a client's living situation has multifaceted functional issues impacting on discharge planning. Occupational therapy also offers a home based rehabilitation service for clients with newly acquired neurological disabilities. This team provides sessional / goal orientated treatment programmes devised within a multidisciplinary team. What to expect The Occupational Therapist will visit you at your home and undertake an assessment of your: home environment function (physical and/or cognitive) ability to perform activities of daily living needs and those of your caregiver(s). In discussion with you the therapist will identify areas of limitations and strengths and work with you with appropriate treatment goals. How to access the service Referrals accepted for this service: Advice regarding the practical implications of living with disability or illness Problem solving to improve abilities and safety Teaching of adaptive techniques Advice and assistance with essential home modifications Recommendations for and provision of essential equipment (therapists are accredited assessors enabling them to access Ministry of Health funding for essential equipment and home alterations). Referrals not accepted for this service: We are not able to accept 'equipment only' referrals when no assessment is required. ACC clients Please refer directly to ACC as they can organise for a private Occupational Therapy assessment. Contact Details Phone: 0800 631 1234 FAQs Can I have mobility equipment e.g. walking frame, wheelchair for outings to access the community? The Ministry of Health do not provide funded equipment for outdoor mobility. This will need to be funded privately. Can I have equipment/services for a short term need regarding a relative coming to stay for a holiday? Equipment will need to be hired and funded privately by the family.

Speech Language Therapists provide assessment, treatment and management for adults with communication and/or swallowing problems. The aim of the input is to help clients reach and maintain their potential. To achieve this therapists work closely with clients, their family / whanau, caregivers and other health professionals. Clients may be seen in their own homes, at an outpatient clinic or if required at a rest home, private hospital or retirement village apartment. Services offered: - Individual home based treatment - Strategies to help the client to communicate/swallow - Alternative communication systems where appropriate - Communication group programmes - Education sessions for individuals and family members - Referral to the Volunteer Stroke Scheme for help with communication practise. Speech Language Therapists work closely with associations such as Volunteer Stroke Scheme, Stroke Foundation, Parkinson's Society, and Motor Neurone Disease Association. What to expect On receipt of the referral you will be contacted either by phone call or letter to indicate when you can expect an appointment. All our referrals are prioritised in terms of urgency. Your Speech Language Therapist will contact you by phone to arrange your initial appointment. You may find it helpful to have a family member or support person with you during an appointment. Appointments usually last up to an hour. On the first visit, the therapist will ask you questions to ascertain the nature and extent of your difficulty, and to establish your goals for intervention. If you have a swallowing difficulty, the therapist may need to see you eating and drinking as part of their initial assessment. Following the initial assessment a plan for intervention will be discussed with you and your family members/carers. The number of sessions will vary depending on your needs and situation. If your first language is not English, then an interpreter may also be present during the sessions. How to access the service Referrals are accepted from your GP or from clients themselves. If you are in a residential care facility a referral by a registered nurse would also be accepted. All relevant information needs to be included in the referral. If the referral is made by anyone other than your GP, then the GP may be contacted for a medical update. Referrals accepted for: Swallowing problems: e.g. difficulty swallowing; poor saliva control; choking; food sticking in throat; suspected aspiration of food or liquids. Communication difficulties: receptive problems i.e. difficulty in understanding the spoken or written word; expressive problems i.e. speech production, verbal and written language production. Diagnostic groups: progressive neurological conditions e.g. Parkinson's disease, motor neurone disease, multiple sclerosis, Huntington's disease, dementia; acute neurological conditions e.g. stroke. Oncology diagnosis e.g. cancer affecting oral cavity, or brain metastases. Contact details 0800 631 1234 FAQs How often/how many times will we go to see the client? Frequency and the length of time patients will be seen will be determined by their individual needs.

Community Health Social Workers provide assistance to individuals and families with health-related personal, emotional and social issues. This service is available to adults, 18 years and over, with a long term physical illness or disability; a terminal illness or diagnosis of cancer; or who require short term support and assistance related to a recent health issue or diagnosis. This excludes referrals which are specifically related to Mental Health and Alcohol and Drug issues. To read more about ‘Needs Assessment’ for people 65 years and over with long term disabilities, please refer to Needs Assessment & Service Co-ordination by clicking here. Services offered: Counselling in the areas of decision making, grief and loss, relationships, problem solving and adjustment to change. Support and information for caregivers. Assistance to address issues of neglect or abuse. Information and support regarding financial and accommodation issues. Liaison and advocacy with other health professionals, community groups, Work & Income (WINZ), and Housing New Zealand. Referral to other appropriate services. What to expect Community Health Social Workers are trained and skilled at assisting individuals and families to deal with a range of problems and issues which may be affecting their health and wellbeing. We can support you to identify your needs, to set goals and put you in touch with the available resources and services which may help you to achieve your goals. Our interventions will be short term and goal directed. All Social Workers are registered under the Social Workers Registration Act 2003. How to access the service Referrals are accepted from GPs, other health professionals and self-referrals. All referrals are prioritised on the basis of urgency. On receipt of the referral you will be contacted by phone or letter to let you know when to expect an appointment. Following this, a staff member will phone you to make the initial appointment to visit you in your home. You may find it helpful to have a family member or support person with you during an appointment. On the first visit the Social Worker will talk with you in order to ascertain the nature and extent of your issues or concerns and the services we offer which will best meet your needs. With your agreement we will develop a plan for follow up services which may include support, counselling, advocacy, mediation, information, and liaison with other social service agencies. This service accepts referrals for: adults, 18 years and over, with a long term physical illness or disability; a terminal illness or diagnosis of cancer; or who require short term support and assistance related to a recent health issue or diagnosis. This excludes referrals which are specifically related to Mental Health and Alcohol and Drug issues, which should be sent to the relevant specialist services. For a ‘needs assessment’ for people 65 years and over with long term disabilities, please refer to Needs Assessment and Service Co-ordination by clicking here. All received referrals are prioritised on the basis of urgency. On receipt of the referral we will contact the patient by phone or letter to let them know when to expect an appointment. Contact Details Adult Community Service Referrals Office: 0800 631 1234 Referrals can be sent by appropriate health professionals through the e-Referral system. FAQs How long will it take to see a Social Worker? Social Workers are allocated files on a priority basis. Whilst you may feel that your case is urgent, this may not be as urgent as other referrals received. As a general rule most new cases are seen for the First Specialist Assessment within a 2-4 week period. Will I be able to choose my Social Worker? No, Social Workers are allocated cases within specific localities and do not generally move between set geographical boundaries. Special needs are considered on a case by case basis by the Practice Supervisor.

Physiotherapists are based in the community and provide care to adults who are homebound and unable to attend any other physiotherapy clinic. Physiotherapists are experts in movement and function. Our service involves assessment, rehabilitation and education. Our aim is to work with you, to achieve optimal physical function in the home. Adult Community Physiotherapy is unable to provide services for clients who are registered for their conditions with ACC. What to expect Physiotherapists are trained to help you reach an improved physical activity level and quality of life. We have emphasis on teaching you self-management skills, rather than interventions that are dependent on the physiotherapist. By providing you with knowledge, advice and support we can help you to understand and manage your condition. Our physiotherapy assessment with you will involve asking questions followed by specific physical testing. We work closely with other health providers and agencies outside of ADHB . You will to be notified by letter if there is an interval before your initial assessment can be scheduled as all our referrals are prioritised in terms of urgency. How to access the service Referral from your health care provider is required. Contact Details Phone: 0800 631 1234

The Community Rehabilitation Service is a home based or clinic rehabilitation service for all age adults following a stroke or an acute event. Rehabilitation aims to maximise the benefits of recovery as well as assisting to compensate for any persisting difficulties. The team is coordinated by a nurse and can include a physiotherapist, occupational therapist, speech & language therapist, psychologist, rehabilitation technical instructor and a therapy assistant. Early Supported Discharge Early Supported Discharge is for patients with intensive therapy needs who have recently been discharged from hospital. It is an intensive, home-based rehabilitation service for patients with mild to moderate disability who require rehabilitation focused visits at least daily. The service is for stable patients and helps to ensure rehabilitation is delivered at home, reducing the need to be in hospital unless medically necessary. Our aim: To work in partnership with the client within their home and community to: Identify and work towards personal goals Return to work goals Develop support strategies for the client and their caregivers Develop links with community support networks, e.g. Stroke Foundation What to expect An initial multidisciplinary focused assessment to identify goals and disciplines that may be required. An individual’s plans and goals are reviewed regularly during the rehabilitation period. If long term needs and supports are identified, the appropriate referrals are made prior to discharge. A discharge letter is sent to the client and GP. Contact Details Phone: 0800 631 1234 FAQs How long is the rehabilitation programme? The programme runs between 4-12 weeks. Do I attend an outpatient clinic? If you cannot access our clinic, we can see you in your home. Community Rehabilitation Brochure.pub (PUB, 266 KB)

The supported discharge service is a short term, home based support service for patients who are new to home based support. This includes help such as personal care and domestic assistance for patients while they recover at home. Long term support needs are determined once patients have recovered from an illness. The service ensures rapid access to home care support and more accurate assessment in the community so the patient's needs are met in the right place, at the right time. We provide: Short term assistance with showering, basic housework and other tasks identified by your assessor equipment to improve your safety assessment for Meals on Wheels referral to long term if required. What to expect? To best understand your needs, an assessor will visit you at home and complete an assessment. This may be done on a computer. your Assessor will let you know what assistance can be provided. the Carers allocated to you are employed by Auckland District Health Board. They are closely supervised by a Home Service Assessor. your needs will be reviewed, and changes made if necessary.

The dietitians in Adult Community Service assess and treat adult clients (over the age of 16) with nutrition related disorders. Dietitians provide nutritional support to clients, their family and caregivers by: explaining the role of food in disease management helping clients to make choices about foods which suit them and their lifestyle. What to expect You will be seen in your own home or at a clinic at the Greenlane Clinical Centre. First assessment appointments may take up to an hour and follow-up appointments will generally be around 30 minutes. You are encouraged to invite carers, family or whanau to be present during sessions with the dietitian. What will the dietitian do? Assessment: - ask questions about your meal patterns, food choices and lifestyle. This will include questions about the type and amount of food and drink that you have - measure your height and weight if needed - the dietitian may also ask you to keep a written record of what you eat and drink. Education: - work with you and your family/whanau to provide a personalised nutrition plan - explain any recommendations made and why they are needed - provide written information about these recommendations. Support: - monitor your food and fluid intake and suggest ways to improve your health - provide follow up appointments as required - with your consent, we refer you to other services as you require (for instance – physiotherapists, district nurses) - talk to you and your family/whanau about other groups and health professionals that can provide ongoing support when you no longer need to be seen by the dietitian - send a summary of your nutrition care to your GP and/or referrer. What do you need to do? Dietitians provide information and support to help you to choose the best foods for your health. To do this you and the dietitian need to work together. You can help by: - telling us as much as you can about the foods you choose and the amounts that you eat and drink - asking about things that you don’t understand - trying the changes that are suggested by the dietitian - telling us about how the changes are going and if you are managing them - telling us if you have difficulty understanding the written and/or the spoken information that we give. How to access the service Call our Base team on 0800 631 1234. Contact details Contact Adult Community Services base team on 0800 631 1234. You may need to leave a message and a dietitian will return your call when they are available. FAQs What information is required for Screening Dietitian Referrals? Medical history Medications Current weight Well weight +/- presence of oedema Amount of weight loss (if any) and time period (if available) Appetite and factors affecting food intake e.g. nausea, constipation, swallowing problems Social support Alerts e.g. cognition, dentition problems Relevant biochemistry