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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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Presentation Transcript
slide1

Aged Care Service

Integration ProjectGreater Newcastle Cluster

community aged care services
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
aged care assessment teams

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
integration project implementation
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
slide10

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

slide11

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

aged care service
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
community dementia nurses
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
clinical coordinator role
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
clerical support provided at each community health centre for the aged care service
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
referrals and enquiries to be managed by the referral and information centre

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

referral and information centre

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

referrers

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

standard referral management process
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.

central office maintained for
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
chime the solutions supported by changes to information technology

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
benefits of integration
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