sesih redesign update older persons and chronic care project paul preobrajensky manager redesign...

SESIH Redesign Update

Older Persons and Chronic Care Project

Paul PreobrajenskyManager Redesign Program

19 September 2007

Older Person and Chronic Care Project Objective

This project aims to improve aged and chronic care provision in SESI such that services are consistently able to deliver safe and cost effective best practice models of care.

The project will support the older patient as they journey between the acute, community and aged care service interface.

Session Objectives

• Description of the Extending Care Choices strategy – the key platform for reform for SESIH and

• Describes the relationship of the Service Delivery Framework to this program.

• Describe the service Delivery Framework key Elements and Focus Areas for service delivery

• Introduce the Year 1 strategies

Extending Care Choices

Extending CareChoices Strategy

Older Persons

& Chronic

Care

PACE

AHS wide Responsibilities

for implementation

Network Implementation

Plans

Performance Measurement Framework


•CAPACS•Chronic Disease

Management•Self

Management•Primary

Prevention•Primary Care

Integration •Primary & Community

Health •Access & Referral

•Risk Response•Strategic external

relationshipsHealthOneInitiative



Older Persons

& Chronic

Care

PACE


for implementation


Plans

Performance Measurement

Framework


Framework


Management•Self







The Extending Care Choices strategy maps the pathway

through key initiatives designed to enhance and strengthen care in the community, through to the

ultimate goal of a regional health hub



Older Persons

& Chronic

Care

PACE


for implementation


Plans


Framework


Framework


Management•Self







The three key projects under the Extending Care Choices strategy are:

•Older persons and Chronic Care Project;

•Primary and Community Care Enterprises (PACE); and

•HealthOne Initiative.

Service Delivery FrameworkThe First Key Outcome of OPaCC & PACE

The key solution platform developed in the solution design phase was the Model of Care.

The Model provides a vehicle for change – providing a framework to improve the system response to patient need through better integrated and coordinated services.

The Model of Care is the leading platform for delivering the Extending Care Choices strategy and as such, though the implementation planning phase, has been developed and progressed into an Area Service Delivery Framework (the framework) providing the blueprint for the AHS going forward.

.

Primary care focus - prevention, early intervention, risk identification/response

Evidence based guidelines & care pathways

Self managementMotivated partner

Multidisciplinary care management & service provision

Delivery system designMeasurement of outcome &

feedback (ind. & system level)Clinical information systems

Elements of service model Service focus

Univ

ers

al a

ccess

Primary prevention and health promotionEg. Smoking, Nutrition, Alcohol and Physical Activity – SNAP , general practice, Area and national response

Acute/sub-acute services – out of hospital into the community/ sub-acute response

Eg. CAPAC, PACS, ambulatory care, HITH, SAFTE (HaH)* GP relationship/engagement* Level 3 (disease management service) relationship/engagement

Established disease management services – increased care planning and action planning - Dementia, Diabetes, Heart Failure, Respiratory

Medium term goals

Eg. RCCP * Utilise hospital allied health with GPs, * Combined with GP + community health relationship/engagement, * Level 4 (acute

services) relationship/engagement

Primary care management + Elective preventive services Eg. * Disease management service relationship/engagement (access next level service), * quick response service access

for acute patient need, *Pulmonary rehab, cardiac rehab (6 week programs), Quit smoking Services,

* GP and community focused (MBS enhanced primary care funding)

Acu

ity o

f need

Levels of patient status and need

Level 1 – PopulationMaintain wellnessAvoid risk exposure

Level 2 – Older people and population with long-term condition/sAssistance to manage and maintain health status. Planned care management with service escalation pathways.

Level 3 – Exacerbation/ additional assistance requiredPlanned diseases and condition management with escalation and de-escalation action plan/s

Level 4 – Acute exacerbations / acute intervention

Service Delivery Framework - Older Persons and Chronic Care – SESIAHS (v1.1 10092007)Population approach – Community focused – Target health & quality of Life – Least acute / least invasive - Patient needs fluctuate

Population approach Risk stratifcation

Target population/s

Eight Key Elements of the Service Delivery Framework

• Population approach, risk stratification, target populations;

• Delivery system design;• Evidence based guidelines and care

pathways;• Clinical information systems; and• Measurement of outcome and

feedback (individual and system level).

• Primary care focus – prevention, early intervention, risk identification/ response.

• Self management, motivated partner. and

• Multidisciplinary care management and service provision.

Primary care focus - prevention, early intervention, risk identification/response

Evidence based guidelines & care pathways

Self managementMotivated partner

Multidisciplinary care management & service provision

Delivery system designMeasurement of outcome &

feedback (ind. & system level)Clinical information systems

Elements of service model Service focus

Univ

ers

al a

ccess

Primary prevention and health promotionEg. Smoking, Nutrition, Alcohol and Physical Activity – SNAP , general practice, Area and national response

Acute/sub-acute services – out of hospital into the community/ sub-acute response

Eg. CAPAC, PACS, ambulatory care, HITH, SAFTE (HaH)* GP relationship/engagement* Level 3 (disease management service) relationship/engagement

Established disease management services – increased care planning and action planning - Dementia, Diabetes, Heart Failure, Respiratory

Medium term goals

Eg. RCCP * Utilise hospital allied health with GPs, * Combined with GP + community health relationship/engagement, * Level 4 (acute

services) relationship/engagement

Primary care management + Elective preventive services Eg. * Disease management service relationship/engagement (access next level service), * quick response service access

for acute patient need, *Pulmonary rehab, cardiac rehab (6 week programs), Quit smoking Services,

* GP and community focused (MBS enhanced primary care funding)

Acu

ity o

f need

Levels of patient status and need

Level 1 – PopulationMaintain wellnessAvoid risk exposure

Level 2 – Older people and population with long-term condition/sAssistance to manage and maintain health status. Planned care management with service escalation pathways.

Level 3 – Exacerbation/ additional assistance requiredPlanned diseases and condition management with escalation and de-escalation action plan/s

Level 4 – Acute exacerbations / acute intervention

Service Delivery Framework - Older Persons and Chronic Care – SESIAHS (v1.1 10092007)Population approach – Community focused – Target health & quality of Life – Least acute / least invasive - Patient needs fluctuate

Population approach Risk stratifcation

Target population/s

Nine Key Focus Areas – AHS Measurement of the Framework


Older Persons

& Chronic

Care

PACE


for implementation


Plans


Framework


Framework


Management•Self







• CAPAC (Community Acute/ Post Acute Care)

• Chronic Disease Management Program

• Primary and Community Health

• Self Management

• Primary Care Integration

• Primary Prevention

• Access and Referral

• Risk Response

• Strategic external relationships

Example

Implementing the Service Delivery Framework

• The key focus for the implementation planning phase was to develop an understanding of how the service delivery framework should and could be implemented across the AHS.

• This required articulation of the required elements and focus areas at a service provision level across the Area.

• prioritise elements and focus areas at a service provision level;

• the systems and processes required to operationally support the functional requirements; and

• the timing priority for implementation.

The plan takes a three year view identifying expectations for implementation across the following periods:

• year one – period ending 30 June 2008• year two – period ending 30th June 2009• year three – period ending 30th June 2010.

AHS Responsibility


Older Persons

& Chronic

Care

PACE


for implementation


Plans


Framework


Framework


Management•Self







CRU and PASDU

ECC Governance Committee

Evaluation strategy


Executive with Network Leads support

Development of roll out plans

CRU – PASDU

Area Communications

Communication strategy


Area Performance Unit

Network Performance Unit

CRU Unit

Relevant Work Programs

Performance monitoring

Chief Information Officer

IT Service Planner

CHIME Team

Information Technology support

ECC Governance committeeGovernance and Accountability

ResponsibleGovernance

CRU and PASDU


Evaluation strategy


Executive with Network Leads support

Development of roll out plans

CRU – PASDU

Area Communications

Communication strategy


Area Performance Unit

Network Performance Unit

CRU Unit

Relevant Work Programs

Performance monitoring

Chief Information Officer

IT Service Planner

CHIME Team

Information Technology support

ECC Governance committeeGovernance and Accountability

ResponsibleGovernance

AHS Responsibility cont.

Network Implementation Plans


Older Persons

& Chronic

Care

PACE


for implementation


Plans


Framework


Framework


Management•Self







•Access and Referral Centre

•Risk screening and responsiveness

•Immediate opportunities of components of the service delivery framework

•Solutions relevant to Calvary

Access & Referral

Referral Point A

Referral Point B

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

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

Information Provision

Protocol or Clinical Assessment

Service Group 3

Service Group 2

Third door

Intake Referral Out

Service Group 1

Non health

e.g. Home Care

Health

e.g. TACT / SAFTE/ QRP

Purpose:•Provide a point of access for patients and others (GPs, community health, VMOs, ED) into area health services•Provide information on services to support improved system navigation for patients and other stakeholders•Streamline service access pathways•Support more effective resource allocation decisions•Provide a focus on alternatives to hospital•Support discharge processes for referral to home / community with services

Risk Response

Purpose:– Early identification of older people and those with chronic disease

who may be at risk of hospitalisation if intervention is not provided– Early intervention and prevention– Hospital avoidance

The capture of consistent data on risks and service responsiveness will support improved practice and service planning. The guideline:– identifies three areas of risk for screening and monitoring;– identifies when and where risk screening should occur and how it

should be responded to; and– details requirements for data capture and information sharing to

inform practice and future service planning.

Risk indicators for screening– Falls - defined as unintentionally coming to rest on the ground, – cognitive functioning – dementia, delirium, depression; and– medication management – the ability of a person to manage their

medication and self medicate.

Risk Response cont.

How should identified risk be responded to?• Identification of risk against the three indicators must be

responded to in the following way:

– Response Level 1: If appropriate and a core service responsibility, the service provides a response directly;

– Response Level 2: If not core business but risk is identified, the service refers the patient to another service or program or advises the patient of other service alternatives,

– Response Level 3: If not core business but potential risk is identified, the service advises the patient’s General Practitioner directly in writing of the identified risks or potential risks as part of discharge from that program or service with recommended actions for the GP.

– Eg: The clinic may suggest referral to a falls clinic or a more comprehensive geriatric assessment.

– Response Level 4: If not core business and risk is identified, the service investigates an appropriate referral but, after investigation, determines there is no suitable service then this is noted as “no suitable service available” in the data base and the patient’s GP is advised directly in writing.

Risk Response cont.

• The implementation plan therefore focuses on ensuring that:– those services that currently screen are aware of intervention

pathways and services available in response to identified risk;– the response to identified risk is documented to support more

effective service planning and responsiveness;– providing a pathway forward to ensure services not currently

screening are supported to undertake this process over time; and

– in the longer term working with our community sector partners to introduce common risk screening.

Immediate opportunities of components of the Service Delivery Framework

• Implementation plan for Aged and Chronic model of care

• Increase community nursing capacity to support chronic disease self management

• Risk register for COPD and Heart Failure

• Improve integration ED and chronic care programs for patients with COPD and Heart Failure

• Increase the efficiency of hospital and community transport operation

• Access & referral Service

• Risk Responsiveness

Northern Network

Implementation Plans - Year 1


Older Persons

& Chronic

Care

PACE


for implementation


Plans


Framework


Framework


Management•Self








• Person Centres Planning



Calvary specific Solutions• Implementation of the Rehab system (electronic referral to rehab)

• Implementation of Jonah progressing

• Broad forward direction for CRAGS agreed

• Falls program

Central Network



Older Persons

& Chronic

Care

PACE


for implementation


Plans


Framework


Framework


Management•Self








• Aged, Community and Chronic Stream, structure and workload review

• Supporting projects– Advanced Care Directives/ ongoing life management– GP engagement model– Aged care nurse Practioner role– Chronic disease management program



Southern Network



Older Persons

& Chronic

Care

PACE


for implementation


Plans


Framework


Framework


Management•Self









Older Persons

& Chronic

Care

PACE


for implementation


Plans


Framework


Framework


Management•Self







There are two types of performance monitoring required:

• Monitoring of the progress of implementation of activities against the implementation plans; and

• Monitoring of the success of the solutions in improving services for older people and those with chronic disease. Using KPI’s against each of the 8 Areas of focus

KPI’s Framework - Example

Next steps

Establish Governance structures

2007/08 2008/09 2009/10

Implementation of Plans

Year 1 Strategies Year 2 Strategies Year 3 Strategies

Project Team Supported ECC Driven

6 month Evaluation 12 month Evaluation 12 month Evaluation

Executive Endorsement

Network Briefings

Establish Performance Management Framework

Including

Baseline & impact analysis

Rollout Plans for

Services in AHS

Review indicators and targets to ensure

appropriate

Review indicators and targets to ensure

appropriate

Rollout Plans for

Community Sector Partners

Presenter’s contact details

Paul Preobrajensky Manager Redesign

0412 915 340

[email protected]

mailto:[email protected]

sesih redesign update older persons and chronic care project paul preobrajensky manager redesign...

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