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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

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inter agency care planning the eicd darebin community health perspective

Inter-Agency Care Planning The EICD / Darebin Community Health perspective

Carolyn Hines

Manager – Chronic and Complex Care Program

today s presentation
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
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
slide4

Levels of Chronic and Complex Care

HARP

People 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

LEVEL 1

Intensity

LEVEL 2

Primary Prevention for whole population

eg Go For Your Life

LEVEL 3

LEVEL 4

key worker role
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 plan
Healthy Living Care Plan

Flinders Care Plan V9 April 06

Sign Off - Patient

I ……………………………………(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 - Doctor

I ……………………………………(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 

slide8

The GP / EICD Interface

The HARP / EICD interface

health wise and inter agency care planning
Health Wise and inter-agency care planning

Focus 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
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
issues challenges
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
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