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Aged Care Service Integration Project Greater Newcastle Cluster

Aged Care Service Integration Project Greater Newcastle Cluster. Ageing Population. Community Aged Care Services. CNC: staff consultancy & education – research – planning – clinical support CDNs – CQI projects CDNs –Assessment, cognitive screening ACCR completion Episodic case management

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Aged Care Service Integration Project Greater Newcastle Cluster

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  1. Aged Care Service Integration ProjectGreater Newcastle Cluster

  2. Ageing Population

  3. Community Aged Care Services • CNC:staff consultancy & education – research – planning – clinical support CDNs – CQI projects • CDNs –Assessment, cognitive screening • ACCR completion • Episodic case management • Carer support • Incidental counselling, education and information to PWD & carers • Support Geriatric medicine clinics • Support GP & practice nurse with diagnosis & management • LWMLP & carer support group • Advance Care Planning • Comprehensive assessment • ACAT ACCR completion • ACAT Delegation • ACAP MDS Reporting • Compliance with Commonwealth guidelines • Clinical support to staff • Monthly reporting • Project plan development and implementation • Monthly reporting • Education • Assessment, care planning, and management of the older persons presenting to E.Dept • Discharge Planning • Comprehensive Assessment • ACAT Completion ACCR • Monthly reports • Comprehensive Assessment • Completion of ACCR • Delegation • ACAP MDS reporting • Compliance with commonwealth guidelines • Community and Private Hospitals • Advance Care Planning • Guardianship • Elder Abuse • Clinical support • Chair Nurse Peer Review Meetings • Education and Research • Policy development and review • CQI • Project management • Competency development and review • Cognitive testing • Neuropsychology testing of referrals from Geriatricians, neurologists, psychiatrist. • Research • Education • Support to CDNs re cognitive testing

  4. High Demand for service:Rural

  5. High demand for service:Hunter

  6. Aged Care Service Aged Care Assessment Teams • Hunter Team • Rural Team servicing the rural regions Staffing: Clinical:24 FTEs Admin:7:1 FTEs • Allied Health and Nursing • Geriatricians:6 FTEs

  7. Integration Project Implementation • Involved: • Phased in approach • Change management • Staff participation • Team divided into geographical areas/teams • Re-Location to 7 Community Health Centres • Adoption of new IT system:CHIME program • Standardisation of work practices • Central Intake Service • Staff education • Additional equipment

  8. Current Problems: • Provider-focussed. • Fragmented services. • Limited understanding of service offerings. • Limited coordination between service providers. • Service gaps & overlaps Aged Care Service model within Community Health Services Aged Care Service The ideal service model aligns services to patient needs and provides timely support across the continuum of care. GPs DayCentres COPs Home Mods Nursing CAPAC Physio ACAT

  9. Inpatients / Outpatients Emergency Department Aged Care Service Community Nursing Allied Health CAPAC Chronic Disease Interagency Services Aged Care & Dementia COPS GPs Carers/Families Aged Care Service …to a patient-centred model that integrates health care services Acute Setting • New model: • Better alignment of services to patient needs. • Continuity of care, Seamless integration. • Location of services closer to the patient • Link with HAHS Dementia plan to better meet the needs of people with Dementia • Increase resources: Dementia Nurses to meet demands for case management/Care Coordination of people with Dementia • Flexible delivery modes Greater Newcastle Cluster Community Health Services Transitional Care Residential Care Specialists Teams

  10. Aged Care Service • Multidisciplinary Teams maintained within each Community Health Centre and consist of: • Registered Nurse • Community Dementia Nurse • Occupational Therapist • Social Workers/Welfare Worker • Geriatrician • Administration staff

  11. Community Dementia Nurses • Role • Comprehensive Assessment • Cognitive screening • Carer education and support • Counselling • Episodic case management • Assess for suitable and appropriate care options • Support Geriatrician Clinics

  12. Clinical Coordinator Role • Response to Priority One referrals • Allocation of referrals to ACAT and CDN clinicians • Delegation and response to priority assessments • Advise to service providers/health professionals • Assessment of and Problem solving of complex cases • Advice/Information regarding ACAP guidelines • Positions staffed from within team

  13. Clerical support provided at each Community Health Centre for the Aged Care Service Clerical Support • Clearly defined roles • ACCR processing • Customer service • Integration of medical records • Scanning of assessments and ACCRs into CHIME • Maintenance of resource information

  14. Access Referrals and enquiries to be managed by the Referral and Information Centre Referral & Information Centre:RIC Providing accurate and comprehensive information and assistance about community based services Client Carer GP Hospital Community Service Directory

  15. Access Referral and Information Centre GP Client Carer Hosp • ACAT RN seconded to the referral and Information centre • CHIME Program enabling electronic referral allocation to ACAT • CHIME business rules developed • ACAT referral acceptance criteria developed • Involved in the development of Aged Care intake templates • Staff receive referrals electronically • Staff have more available time for assessments • Referrers have improved access • Education provided to RIC staff and ongoing Enquiry Screening / assessment Referral Information provided Service request Other assistance Protocol / template Liaison with other services Allocate to service Allocate to clinician Service delivery

  16. Aged Care Facilities Residential Aged Care Facility 17% Other 6% Family &/carers Hospital 10% General Practitioner Family 20%% 35% GP Community Services Referral info for clients 17% Referrers Access Referrers have different needs Source of Referrals to ACAT Source: (1) CHIME, for 12 month period

  17. Standard Referral Management Process Community Aged Care Service Referral & Information Centre Intake managed by experienced clinicians with knowledge of community services and problem solving skills. Phone:49257990 Aged Care Assessment Teams Community Dementia Nurses Neuro-psychology Service specific intake templates, supported by information systems which enable managers/clinicians to prioritise patient needs without needing to call them for further information.

  18. Central Office maintained for …. Central Office Role • ACCR processing • Maintain RACF & Provider information • Management of waitlists • Management of enquiries for complex cases • Management of priority one referrals • Daily communication with RIC staff • Service to acute care hospitals

  19. Information Technology CHIME:The solutions supported by changes to information technology. Community Health Information Management Enterprise (CHIME): • Adoption of the CHIME program: improved integration with CH IT systems • All staff trained in the use of CHIME • Geriatricians trained to provide access to patient information • Geriatrician reports accessible on CHIME • Reports developed:Commonwealth reporting,Activity,home visit and waitlist management • Clinical documentation:Intake templates,GP Feedback letters,assessments and reporting • Access available to Acute Care Hospitals

  20. Wait times

  21. Wait times have been sustained

  22. Average Wait Times

  23. Benefits of Integration • Reduction in wait times • Efficiencies in travel times • Located closer to the population we serve • Improved collaboration with key health providers • Developed relationships with other service providers who share clients • Heighten awareness of ACAT assessments and role • Reduction in inappropriate referrals • Facilitated client discussion and information sharing • Common information/communication system promoting seamless information • Access to single electronic medical record (CHIME) • Opportunities for case conferencing • High staff satisfaction

  24. THANK YOU

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