Inter-Agency Care Planning

The EICD / Darebin Community Health perspective

Carolyn Hines

Manager – Chronic and Complex Care Program

Today’s presentation

• The Early Intervention in Chronic Disease (EICD) program model (Health Wise)

• Health Wise and inter-agency care planning

• Issues and challenges

• The way forward

Background• Care planning at DCH

- Some discipline-specific care planning for internal use only

- Inter-agency care planning is limited - Specific to certain programs eg HARP

• HARP- Austin Health, St Vincent’s, Northern Health - Inter-agency care planning occurs to varying

degrees• Early Intervention in Chronic Disease (EICD)

- Health Wise- Care planning is in development stage

LEVEL 4

LEVEL 3

LEVEL 2

LEVEL 1

Levels of Chronic and Complex Care

Primary Prevention for whole population

eg Go For Your Life

HARPPeople with chronic conditions / complex

needs who use, or are at risk of using,

hospitals frequently

EICiD People with chronic conditions / complex

needs who do not use, or are at low risk of

using, hospitals frequently

Inten

sity

Health Wise Program

Model

INITIAL APPOINTMENTComprehensive assessment: Self Management (Flinders tools); Clinical risk screening;Care planning: Healthy Living Plan; Care Coordination: Referrals;

REFERRALS - SCTT Internal; GP’s; Self referral; Local

council; External health professionals;

INTAKEAppointment with Key Worker

SELF MANAGEMENTIndividual: Key Worker– goal setting and care planning;

Group: BHSMP

Refer to

HA

RP

TARGET POPULATIONDiabetes; Heart Failure; COPD;

CLINICAL 1:1

Counselling; Diab Ed; Diet; OT; Physio;

Podiatry;

CLINICALGROUP

Diab Ed; Exercise; Emotional Wellbeing;

Smoking Ces’n;

Recall SystemAnnual review – client and GP notified

Gen

eral Practitio

ner

Referral Acknowled-

gement

Report

Reports as required

Annual Review

Key Worker role

• Comprehensive assessment - general chronic disease screening, self management assessment (Flinders), Client Survey (DHS)

• Preparation of a Healthy Living Care Plan based on self management needs / goals (Flinders)

• Further appointments with KW for 1:1 self management; referral to other services (internal or external) as required

• The main point of contact for client and GP • Extent of involvement with each client will vary according to

needs

Healthy Living Care PlanFlinders Care Plan V9 April 06

Client Problem Statement: This Problem interferes with my daily activities 0 1 2 3 4 5 6 7 8 does not slightly definitely often severely

Client Goal/s: My progress towards achieving this goal 0 1 2 3 4 5 6 7 8100% 75% 50% 25% no success

IDENTIFIED ISSUES [INCLUDING SELF

MANAGEMENT]

MANAGEMENT AIMS

INTERVENTION WHO IS RESPONSIBLE

DATE REVIEWED

PROGRESS (eg no progress, some

progress, completed)

Sign Off - PatientI ……………………………………(patient name) agree that the information contained within this care plan is true and correct and currently reflects my needs for the forthcoming year. Additionally, I consent to this information relevant to my care will be released to my health providers.

Signature: ………………………………….. Date: ………/………/………Sign Off - DoctorI ……………………………………(GP name) agree that the services prescribed within this care plan are true and correct at the time of development but are subject to review based on the patient's needs and / or my professional opinion as the responsible Medical Practitioner. Provider No:[ ] [ ] [ ] [ ] [ ] [ ] [ ] Date: ………/………/………

Care Plan Review Date: ………/………/……… Signature: ………………………..… MBS ITEM: GP Management Plan - 721

Team Care Arrangements - 723

INITIAL APPOINTMENTComprehensive assessment: Self Management (Flinders tools); Clinical risk screening;Care planning: Healthy Living Plan; Care Coordination: Referrals;

REFERRALS - SCTT Internal; GP’s; Self referral; Local

council; External health professionals;

INTAKEAppointment with Key Worker

SELF MANAGEMENTIndividual: Key Worker– goal setting and care planning;

Group: BHSMP

Refer to

HA

RP

TARGET POPULATIONDiabetes; Heart Failure; COPD;

CLINICAL 1:1

Counselling; Diab Ed; Diet; OT; Physio;

Podiatry;

CLINICALGROUP

Diab Ed; Exercise; Emotional Wellbeing;

Smoking Ces’n;

Recall SystemAnnual review – client and GP notified

Gen

eral Practitio

ner

Referral Acknowled-

gement

Report

Reports as required

Annual Review

The HARP / EICD interface

The GP / EICD Interface

Health Wise and inter-agency care planningFocus will be:• General practitioners• HARP programs and other external organisations /

programs• Internal service providers

- Maintain communication - Streamline client care

Health Wise and inter-agency care planning (cont)Progress to date:• Working group has been established with staff from

EICD project the DCH Medical Practice (GP, Practice Nurse, Chronic Condition Practice Coordinator)

• Started investigating care planning options- Service Coordination Plan - HARP

Community Care Plan

Coordinator: GP: Other care provider:

Phone: 9290 6615 Phone: Phone:

Fax: 9290 6650 Fax: Fax:

Client’s address and phone number (if different to usual):

Participants and Service Provider Details

Name Position Contact Details Date

Helen Glouftsis Cardiac Nurse 9290 6615

Community Care Plan

UR NO:Surname: Given Names: DOB: Sex:

Authority to proceed with care planThe purpose of this care plan has been explained. I/my carer, give permission for its preparation and for the discussion of my medical history and diagnosis, with the providers listed above.All participants are to retain confidentiality.I/my carer have been asked if any medical/personal information should be withheld from other participantsI am aware that my GP will bill me in their usual way for their participation and that a Medicare rebate is available for this service

Signature: Helen Glouftsis Date: Client / Carer / Verbal (please circle)

Community Care Plan

UR NO:Surname: Given Names: DOB: Sex:

Client Summary

Principal diagnosis and other significant health issues:

Medications:

Aims and outcomes:

Goal Task/recommendation Review date & person responsible

1.

2.

3.

4.

5.

Issues / challenges• Multiple options available• Multiple views about the ideal care plan• Terminology - medical care plans, service coordination

plans, community care plans…………. • Commitment to self-management - need to incorporate

client-centred goals• Don’t want to reinvent the wheel!

What do we need?• We can’t do it alone!• Small EICD project managers network but cuts across

different regions • Regional approach (state-wide)

- Support and leadership from DHS- Bring service providers / Divisions of General

Practice together to establish definitions, common needs, standard care plan format/s

- Strategy to promote the “why” and “how” to agencies / staff