Older Persons and Chronic Care Project Update

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Older Persons and Chronic Care Project - Update

• Anne Meller
• 19TH February 2008

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Project overview

• Overall aims and approach
• to improve aged and chronic care provision in
  SESIH such that services are consistently able to
  deliver safe and cost effective health services
  which reflect best practice models of care
• to focus on supporting patients as they journey
  across the community and acute care service
  interface
• four stage approach covering diagnostic,
  solutions design, implementation planning
  implementation support phases

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The OPaCC Project Methodology
We are Here
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Aged and chronic care services within Northern
Network

• Issues raised through diagnostic phase
• Siloed approach to chronic care. Difficulty for
  patients navigating system especially for those
  with multiple and complex health needs
• Variation in model of service deliver between
  chronic care programs
• Process for identification and management of
  patients at high risk of admission and ED
  presentation unclear
• Organisational infrastructure and IT capacity a
  significant barrier to communication and
  coordination

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Solutions design

• Area wide (SESIAHS) strategies
• Aged/chronic model of care
• Access and referral service model
• Network strategies
• Aged and chronic care program
• patient flow
• program coverage
• interface with ED
• Interface with developing access and referral
  service
• Care coordination and community interface (staged
  with access and referral service model)
• Other locally identified priority areas of focus

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Identified priority areas - Northern

• Identification and management of those at high
  risk of presentation or admission.
• Medication review /communication (post discharge)
• Improved Discharge admission communication for
  GPs
• Centralized waiting lists for services
• Enhancing GP practice capacity to participate in
  Chronic Disease Management (role trends with
  practice nurses).
• How can health and private providers work
  together?
• Increase utilization of self management models
• ED alternatives
• Community Transport

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Rationale for developing an Access and Referral
Centre

• Diagnostic report noted that
• health professionals, carers and patients all
  have difficulty in navigating the service system
• the ED often becomes the default service to
  support effective system navigation and access to
  required services
• lack of knowledge about appropriate service
  options means that patients are waiting for
  extended periods of time to access services
• extensive time and effort is involved in
  facilitating access to post-discharge support
• there are multiple and varying referral pathways
  to access programs which offer similar forms of
  support
• opportunity to better use scarce health and aged
  care resources through better targeting services
  to patient needs.

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What an Access and Referral Centre can achieve

• Coordinate access to NSW Health services in
  SESIAHS and support providers to work together
• Ultimately, make it is easier for patients (and
  their referrers) to navigate the service system,
  and enable more effective transition across the
  acute / community / aged care interface
• The service will offer
• easily identified contact points
• easily available alternatives to inpatient care
  and ED presentation
• streamlined processes for referral out to
  community services
• comprehensive and consistent provision of
  information to individuals seeking assistance

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Access and Referral Model
Service Group 3 ED / Admission

• Infrastructure Regimes
• Comprehensive Directory
• Staff
• Assessment Tools
• Referral Protocols

Protocol or Clinical Assessment
Service Group 2 Ambulatory Care/ admission
alternative PACS
Referral Point A

• Access Referral Service
• Information
• Risk Screenings
• Eligibility / POA
• Triage / Priority
• Intake (Stream 1)
• Service Streaming
• Referral Out (New Health)

Information Provision
Referral Point B
Intake
Referral Out
Service Group 1 Servie _at_ home
Health e.g. Comm Health/ACART
Non health e.g. Home Care
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Service groups

• Service types grouped into related groups to
  allow for consideration the full range of like
  service options which may address patient needs
  and risk factors.
• Service group 1 Supports to remain at home e.g.
  community health, general practice and non health
  community care services.
• Service group 2 Ambulatory care (attendance to
  receive services that are provided on an
  outpatient basis, in contrast to services
  provided in the home or to persons who stay
  overnight or are inpatients). E.g. Outpatient
  services, Ambulatory care services (differently
  titled in each Network).
• Service group 3 Inpatient care. E.g. Aged Care
  Precinct, EMU, ED, now MAU!

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Roles and functions

• Point of Contact
• Information provision
• Eligibility screening across multiple services
• Broad shallow assessment
• Start the process of clinical assessment
• Prioritisation
• Allocation to the right service group
• Intake (appointment scheduling)
• Admission to service group 3
• Assistance with referral to community services

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Northern Network Access and referral service -
NNARC

• Governance group in place
• Located at WMH
• Commissioning complete
• Protocols in progress
• Teams engaged
• Phasing in of services

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Service involvement and phasing

• A staged approach is being used for the
  development of the Access and Referral service
• In the first instance, the focus will be on NSW
  Health funded aged and chronic care services,
  accessed both within hospital sites and in
  community-based settings
• In later phases, there will be the capacity to
  add other services (including the non health
  community services (stream 1 services) such as
  those funded by DADHC or the Commonwealth)
• This may include an option for widening the
  target group into the future (e.g. alcohol and
  drug treatment or other related services in a
  similar fashion to the Hunter RIC and ACT
  Community Health Intake models)

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Involvement of community services

• Part of service group 1 supports to remain at
  home
• Provision of information about community services
• Support informed decision-making about which
  service the patient/carer/health professional
  should contact
• Have key waiting list information
• Referral-out
• Support for the discharge planning process
• Will support ward staff/NUMs to gain information
  about the best service type for the patient,
  available provider and waiting lists
• Envisaged that the service will free up discharge
  planners time to work with more complex patients

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Working with community services

• Creating a collaborative culture across the
  acute/community/aged care interface
• Collaboration as core business collaborative
  practice should be integrated into the day to day
  business
• Creating a culture of joint-work - fostering a
  spirit of cooperation, acknowledging the
  constraints and complexities
• Developing collaborative relationships
  recognising that it takes time and effort to
  develop trust and common understanding
• Use of networks - There are opportunities to
  develop a network of acute/community/aged care
  providers participating in the ARC so to foster
  an understanding of the agencies that are
  operating within the Network

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Risk Responsiveness

• Better identification and management of patients
  at risk of falls, cognitive impairment and
  medication mismanagement
• Governance group
• Screen at first presentation (pilot, tool,)
• Response pathways described
• Role of NNARC in supporting risk screening
• IT platform to flag risk track responses
• Identify service gaps/impact on pt transition
• Register of high risk patients linked to enhanced
  chronic care pathways

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Next steps

• NNARC-
• Service information for service via template
• Description, Eligibility, Ineligibility,
  Boundaries/ targets
• Alternatives, Priorities/ waiting
  lists/capacity, Referral protocols, Training
  required and available
• Risk Response
• Establish Governance group Northern network
• Refine Pilot tools
• Develop risk register of patients/clients

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Questions to audience ?

• HSNet utilisation?
• Service Information via NNARC
• Identifying client at risk?
• Pilot?
• Risk Register?
• Centralised Waiting or Vacancy Lists?

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Questions?
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Contacts

• Anne Meller
• OPaCC Project lead
• Northern Network
• 9369 0401(WMH)
• 9382 2984(POWH)
• anne.meller_at_sesiahs.health.nsw.gov.au