The Community Assessment and Referral Service is a small team of community nurses based in the emergency department of the RBWH. The nurses identify high risk elderly patients who present to the hospital and provide comprehensive assessment of their functional and discharge requirements to ensure a safe and effective discharge to independent community living.
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Screening and identifying high risk elderly patients as soon as practical after their presentation to the emergency department
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Liaise with general practitioners, community service providers and the emergency department team to facilitate appropriate continuity of care for patients at high risk to ensure their needs are being met across all health settings and to ensure early referral when required
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Complete comprehensive geriatric and functional assessment and initiate discharge planning of high risk patients presenting to the emergency department
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Provide safe and effective discharge from the emergency department with appropriate follow up as required
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Provide support, information and education to patients and families
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Promote an increased awareness of the specific care needs of older people and other people at risk amongst staff working in the emergency department
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Advocate for the appropriate care and management of aged patients in the emergency department
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Act as a resource person for issues relating to discharge planning, community service provision and care of the aged.
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