HARP Chronic Disease Management Program

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HARP Chronic Disease Management Program
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Where We Have Come From?

• Didnt do it alone
• Formed a consortium to plan then implement
• Program evolved over the three years
• Nine Pilot Projects
• COPD, CHF, Falls Prevention, Diabetic Foot, Ed
  Care, COACH, ARION, Stroke, Integrated Disease
  Management
• Stroke was not mainstreamed
• ARION funded within Mental Health

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Mainstreamed Services

• July 2005 DHS Funded State wide HARP Chronic
  Disease Program
• DHS HARP Chronic Disease Guidelines
• July December Consultation with Staff and
  Internal External key Stakeholders
• Executive Endorsement of PIH HARP CDM Program
  Model and Structure

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PIH HARP CDM Governance Structure
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BUDGET

• 2006 2007 4250,000
• EFT 35.45 - 48 Staff

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Client Flow
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HARP Chronic Disease Management Program 2007
Falls Prevention
Diabetes Diabetes Co-management in General
Practice Diabetic Foot Service
Chronic Cardiovascular Disease Chronic Heart
Failure Heartwise Cardiac Coach
Integrated Service across acute community
continuum
Central Intake
Intensive Service Coordination Case
Management Psychosocial support Psychology
Chronic Respiratory Disease Melbourne Easy
Breathers Asthma Service Respiratory Outreach
Medication Management
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HARP CDM Service Components
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Chronic Respiratory Stream

• A comprehensive, multi disciplinary pulmonary
  rehabilitation program.
• Asthma Service

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Melbourne Easy Breathers Outcomes

• Evaluation of Easy Breather clients
• 65 achieved improved physical function
• 69 achieved reduced breathlessness
• Clients reported
• Improved self management
• Coping better
• Reduced anxiety and depression
• Reduced fatigue
• Improved confidence

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Chronic Cardiovascular Disease

• Multidisciplinary community care for people with
  Chronic Heart Failure
• COACH Coaching cardiovascular risk factors
  people post cardiac surgery

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CHF Outcomes
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CHF Outcomes
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Diabetes Service Component

• Endocrinology, Vascular, Podiatry, Specialist
  Nurse Wound Consultant and Allied Diabetic Foot
  Service
• Diabetes Co-Management Service Specialist
  Nurses and General Practitioner Diabetes Risk
  Management.

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Outcomes Acute DFU

• Before the DFU existed, audit of all RMH patients
  admitted with diabetic foot conditions showed
  that of these patients
• 20 had a minor amputation
• 10 had a major amputation
• Since the DFU was established, of a similar group
  of patients (Jan-Dec 2005)
• 8.8 had a minor amputation
• 2.2 had a major amputation
• 50 reduction in amputations

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Medication Management

• Outreach pharmacy support for HARP CDM eligible
  clients.

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Outcomes Community January December 2005

• Amputations
• 22 all patients had a history of amputation
  pre-HARP
• 1 of patients have required a minor amputation
  post-HARP
• Ulcerations
• 83 of patients had a history of ulceration
  pre-HARP
• 69 maintained ulcer free since HARP
• 50 with an ulcer healed
• ED presentations
• Reduced by 4 post HARP
• Inpatient admissions
• Reduced 12 post HARP

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Local outcomesChronic Disease Management

• 1,768 patients 2002-05
• COPD or CHS and/or chronic and complex
  conditions
• Comparison of actual use 6 months pre-
  post-enrolment
• 42 reductions in ED presentations
• 19 reduction in admissions
• 43 reduction in mean LOS (by 2.5 days)
• 32 reduction in median LOS (3 days)
• Equivalent to 2,730 bed-days over 6 months

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Falls Prevention Service

• Multidisciplinary community nursing and allied
  health Falls prevention service

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Local outcomes Falls Prevention

• 259 patients presenting to ED or admitted post
  fall.
• 75 reduction in severe falls related injuries at
  12 months
• 53 reduction in falls risk
• Improved static dynamic balance
• Improved Quality of Life (AQoL)
• Improved confidence to perform tasks without
  falling
• 46 reduction in ED presentations
• 67 reduction in hospital admissions
• 10 reduction in mean LOS (10 to 9 days)

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Psychosocial Service

• Psychologist counselling and support to enrolled
  HARP clients
• Acute and community support for frequent
  attenders to RMH emergency department

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Local Outcomes Psychosocial Program

• 79 people with complex psycho-social problems
• (homelessness, mental health, DA etc)
• Clients reported
• High satisfaction with service
• Improved integration and coordination of services
• Reduced anxiety
• Coping better
• Hospital usage
• 42 reduction in ED presentations
• 33 reduction in admissions
• Clients spent less time in ED when they did
  attend

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Referral

• See detailed eligibility handout.
• E-referral via iSOFT link to www.connectingcare.co
  m
• Need help?
• Ring 9319 9456
• talk to intake workers Xam Norma

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HARP CDM Clients Seen1 July 31 December 2006
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PIH HARP Key Activities January December 2007

• Integration of HARP and RMH Diabetes Services
• Statewide Diabetic Foot Best Practice Roll Out
• Review of HARP Intake location RMH Direct
  Access Unit
• Review of HARP Psychosocial Services and
  development of a model of care
• Implementation of DHS Comprehensive Assessment
• Tool Inter-Rai Pilot
• Development and implementation of HARP CDM Client
  
• Management System
• Implementation of VINAH reporting
• Greek Speaking COACH quality Service Improvement
  Initiative