inner north west chronic disease & service coordination workshop chronic disease & service...

Inner North West Chronic Disease & Service Coordination

Workshop

Chronic Disease & Service Coordination Progress Across Our PCP Catchment

Presented by Emily HookeSeptember 14th 2011

Inner North West PCP• Significant Pockets of Disadvantage

• 3-7 % are public housing tenants(higher in Yarra with 11% public housing)

• High rates of unstable housing(129 per 10,000)

• Over 1200 Aboriginal & Torres Straight Islanders

• 34 – 48% speak a language other than English at home

• 20% have poor English language proficiency

Source: Australian Bureau of Statistics, Socioeconomic Indexes for Areas(SEIFA), 2006.

Chronic Disease in the Inner North WestChronic Disease Prevalence Source: National Health Survey (NHS) 2007-08. Inner North West Estimate for 2009Condition PersonsArthritis 60,062Asthma 43,083Hypertension 36,266CHD & Stroke 20,979Diabetes Type 2 13,258Cancer 6,011

Burden of Disease Source: Australia’s Health 2010, Health Across Life Stages www.aihw.gov.au/publications/aus/ah10/11374-c06.pdf15 – 24 yearsMental Illness25 – 39 yearsMental Illness, specifically Anxiety & Depression40 - 54 yearsMost people have at least one chronic health condition55-64 years Chronic Disease represents the highest burden of disease

Avoidable Hospital Admissions Source: VHISS, Ambulatory Care Sensitive Conditions1 Diabetes 2. Cardiac Disease 3. Dental Conditions 4. Kidney Disease

Inner North West PCPVision To ensure that - healthcare is equitable, regardless of circumstance or disadvantage - the health service system is easily navigated - the best care is provided at the best place and time, including prevention,

screening and early intervention

Key Deliverable Areas:

Partnerships Service Coordination

Integrated Health

Promotion

Integrated Chronic Disease

Management

Victorian Service Coordination Practice Standards

Victorian Service Coordination Practice Manual 2009

• Provides a vision for Victoria’s Service Coordination and Practice

• A Reference GuideConsumer Outcomes & Good Practice IndicatorsConsumer PathwaysTools & Resources

• Covers

Initial ContactInitial Needs IdentificationAssessmentCare Planning Referral

Available online at : http://www.health.vic.gov.au/pcps/downloads/sc_pracmanual2.pdf


For Initial Needs Identification (INI).......


Good Practice Guide 2009Provides Good Practice Guidelines for

Initial ContactInitial Needs IdentificationAssessmentCare Planning Referral

Available online at http://www.health.vic.gov.au/pcps/downloads/good_practice.pdf


Continuous Improvement Framework 2009 Supports organisations to monitor and improve service coordination implementation and practice Forms the basis for the state wide Service Coordination & ICDM Surveys Based on PDSA (Plan, Do, Study, Act) cycles of improvementAvailable online

http://www.health.vic.gov.au/pcps/downloads/continuous.pdf


Service Coordination Tool Templates 2009 Suite of templates Supports Service Coordination Practice Standardised format for collection and sharing of

consumer information Formalised documentation of consumer consent

SCTT 2012 Revision Project• Improvements based on working group feedback• SCTT 2012 will be piloted prior to implementation

Available online:http://www.health.vic.gov.au/pcps/downloads/sctt_user_guide09.pdf

Wagner Chronic Care Model

Service Coordination & ICDM Survey

• Annual Survey • Supports review of Service Coordination & ICDM Practice & identifies

areas for improvement• Survey Questions mapped to the Accreditation Standards

QIC Standard (6th Edition) ACHS – EQuIP 5 Standard• Agencies can benchmark against previous results• Enables PCPs to deliver targeted partnership strategies• 3 Levels of Results are reported:

Agency PCP Catchment

Victoria• All PCP member agencies engaged in Service Coordination/ICDM are

encouraged to participate• Several minor changes to the 2011 Survey

Service Coordination & ICDM Survey

• The Surveys went live on 1st September 2011

• Information is available at:

www.health.vic.gov.au/pcps/coordination/cqi.htm

• The Surveys will close on the 31st of October 2011

http://www.health.vic.gov.au/pcps/coordination/cqi.htm

2010 Service Coordination & ICDM Survey

Where we are doing well...• Service Coordination principles and standards integrated into

policies, position descriptions• Service Coordination principles integrated into consumer feedback

systems• Provision of information to consumers in response to an enquiry• Initial Needs Identification conducted within 7 days of Initial Contact• Care Coordination Plans for clients with multiple and complex needs• GP provided with copy of Care Plan (where one existed)• Referral acknowledgements sent within 7 days of receipt of non-

urgent referrals

2010 Service Coordination & ICDM Survey

Common areas for improvement.....• Service Coordination template Tools (SCTT) in client referrals• Timely review of care plans• Referral acknowledgements sent within 2 days of receipt of urgent referrals• Evidence that consent form has been completed for all relevant referrals• Documentation of Assessment meets Victorian Service Coordination

Practice Standards• Intra-agency care plans meet VHA criteria• Feedback to GPs has been documented• Clinical care protocol/pathways/decision support tools demonstrate

delivery of best practice and continuity of care • Documentation of self management support including health behaviour

change• A formalised quality improvement system for ICDM is in place

2010 Service Coordination Survey ResultsPart A: Service Coordination

Part B: ICDM

2010 Service Coordination Survey ResultsPart B: ICDM

Much work is already underway...

Resources to Support This Work

• Checklist: Monitoring Organisational Chronic Disease Management Quality Initiatives www.health.vic.gov.au/pch/downloads/icdm_checklist.doc

• ICDM Status Report (2010)http://docs.health.vic.gov.au/docs/doc/Status-Report-2008-10

• ADMA Clearing Househttp://clearinghouse.adma.org.au/

• PDSA Improvement Methodology http://www.health.vic.gov.au/pch/gpp/pdsa_overview.htm

Tools That Assess Organisational Systems

• Assessment of Chronic Illness Care (ACIC)MacColl Institute for Healthcare Innovation (USA)www.improvingchroniccare.org/index.php?p=ACIC_survey&s=35

• The Audit & Best Practice for Chronic Disease: Systems Assessment Tool(ABCD SAT)––Menzies School of Health Research (NT, Australia)‑ www.health.vic.gov.au/pch/downloads/app11_systems_assess_tool.doc

• Organisational Skills Analysis Tool: Chronic Disease CareGill and Willcox (Vic, Australia)www.gillandwillcox.com.au

Tools That Assess Consumer Experience of Chronic Disease Care

• Patient Assessment of Chronic Illness Care (PACIC)

MacColl Institute for Healthcare Innovation (USA)www.improvingchroniccare.org/index.php?p=PACIC_Survey&s=36

Tools that Assess Specific Components of Chronic Disease Care

• Self-Management Assessment Tool for Community Health OrganisationsGill and Willcox (Vic, Australia) www.gillandwillcox.com.au

• Service Coordination & ICDM Survey Department of Health (Vic, Australia)

www.health.vic.gov.au/pcps/coordination/cqi.htm

inner north west chronic disease & service coordination workshop chronic disease & service...

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