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“ Through the Eyes of the Client ”. Service System Redevelopment. From the client’s perspective From the service providers perspective. Client Journey Experiential Study. Presenters:

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service system redevelopment

“Through the Eyes of the Client”

Service System Redevelopment

From the client’s perspective

From the service providers perspective

Client Journey Experiential Study


Lyn McKay, Service System Redevelopment Coordinator, FMPPCP Julie White, ICDM Support Officer, FMPPCP/ICDM , Peninsula Health Community Health

what am i going to get out of this session
What am I going to get out of this session?
  • An understanding of the:
    • Client Journey processes & challenges that went into the undertaking
  • Information about:
    • planning a service system redesign approach
    • A general framework for the project
    • Methodologies & tools used
    • Strategic outcomes
  • System Wide
  • Systematic
    • Start broad
    • Finish targetted
  • Well developed implementation plans
  • Use of robust project management approach/tools
  • Practical/doable – delivering tangible results at the end
  • Factual information – not just ‘intuition’
the study
The Study
  • Documents and analyses the experiences of the service system from the perspectives of both:
    • Clients
    • Service Providers
  • Provides a comparative
study objectives
Study Objectives
  • Empower clients to:
    • navigate the service system
    • manage their needs across the continuum of care
  • Identify gaps/areas and changes needed to improve the client journey & outcomes
  • Enable improvements to be made in the health system across the FMP catchment
  • Central Focus (in keeping with the SSR Plan)
    • Aging
    • Anxiety & Depression
    • Dementia
client inclusion criteria
Client Inclusion Criteria
  • Primarily between the ages of 50-80
  • Multiple agency involvement
  • Multiple co-morbidities
  • Met the profile for the anxiety & depression/dementia focus of the study
  • CALD group
  • Indigenous person
  • Family carer or have a personal/family carer
  • Relevant and current experience of the health system
  • Ability/assisted capacity to express how they think the system could improve
study scope
Study Scope
  • 147 Clients
  • 87 Services / PCP Member agencies
client sources
Client Sources
  • Brotherhood of St Laurence
  • Frankston Senior Citizens
  • Seagull Day Club – Frankston
  • Baptcare
  • Positive Aging Group, Frankston City Council
  • Access & Mobility Group, Somerville
  • Greek Women’s Group, Rye
  • Indigenous Group, Hastings
  • Villa Maria (home visits) - case managed clients
  • Telephone Interviews – Peninsula Support Services
  • Age Strong
study inclusions
Study Inclusions
  • Assessment of:
    • Access/intake
    • Exit/discharge
    • Assessment and care planning
    • Referral
    • Care coordination
    • Self management
    • Chronic disease
    • Capacity of organisations – limitations to go beyond presenting issue or service programs
    • Communication between providers
    • Strengths and weaknesses of client journey processes for client feedback and quality improvement
  • Clients
    • Focus groups
    • Questionnaires
    • Open group discussion
    • Individual client interviews
  • Service Providers
    • Questionnaire – via Survey Monkey
Supported by
    • clear governance structures
    • Use of System Frameworks
      • Victorian Service Coordination Practice Manual
      • Wagner Model
    • Project management processes & tools
clients were asked about

ServiceProviders were asked about:

Clients were asked about:
  • Client demographics
  • Managing their condition
  • Getting into services
  • What has been done to manage their condition
  • Their experiences of the health system
  • Service provider demographics
  • Service provider client demographics
  • About structures & processes
  • Service accessibility
  • Assessment & Care Coordination
  • Referral & feedback
  • Client pathway information
key themes
Key Themes
  • Service Access
  • Listening, noticing & follow up
  • Effective Communication between Services & Clients
  • Carers – Involvement
  • Waiting times and time management
  • Social Groups
  • Case Management
key findings
Key Findings
  • Clients expect to:
    • be able to access the services they require in a reasonable period of time
    • receive help and be looked after
    • be given information appropriate to their situation

"QUESTION: Do you feel you have been given sufficient information about your condition/ illness to manage it?

medically yes-well informed / practically-NO"

Clients’ Best experiences of the system were those that:
    • involved timely responses to clients’ concerns
    • related to particular programs where the leader provided friendly/appropriate service tailored for the individual client’s needs
Clients’ Worst experiences of the system were those that included:
    • slow responses/lack of timeliness
    • apparent lack of concern/interest in individual client
    • service providers not taking the time to listen or pay proper concern to the client needs and issues
most important to clients
Most Important to Clients
  • Being treated with decency, courtesy, respect
  • Receiving timely follow through
Being listened to

‘Really heard’,

important factor
Important Factor
  • Being involved in social & worthwhile activity together

(social inclusion)

who do clients go to as a priority
Who do clients go to as a priority?
  • GP
  • Hospital
  • Pharmacists
  • Community Health
  • Local Government
of interest
Of Interest
  • Many clients did not see that they actually had a ‘condition’
  • Raises issues about the terms used in consultation with clients
key findings service providers
Key Findings Service Providers
  • Lack of awareness - internal processes for identification of clients with dementia, depression or anxiety.
  • More work required to further integrate/streamline access to services for clients.
Many service providers are unsure about, or do not know if their organisation has a monitoring/reminder /recall system
Wide range of timeframes for practitioners seeing clients from when clients first access services
  • There is evidence of a lack of clarity by service providers around what is ‘Client Focused Care’
Diverse communication practice exists between service providers and GPs.
  • Extensive service provider practice variations between referral timeframes & transmission of referral acknowledgements.
Perception (by Service Providers)
  • monitoring of client risk at presentation is supported by consistent practice across service providers regarding:
      • effective communication of timeframes
      • eligibility and prioritisation across services

…….in accordance with good practice

example care plans
Example Care Plans

Service Providers Responses

Are your clients actively involved in developing their treatment/care plans?


Client Responses

Have you been actively involved in developing your treatment/care plan(s)?


Client’s Responses

Do you have a treatment/care plan(s)?

If Yes, do you have a written copy of your treatment/care plan(s)?

“My ex-wife may have it. There is a written contract but I don’t have it”

“My own plan - I belong to a Bushwalking Group and walk 10 km /week”

example consent
Example - Consent
  • Most service providers ask for clients consent to share personal details & information –

Client perception

- they (52%) had not been asked to give consent prior to service providers sharing their information with other services


Service Providers Responses

Client’s Responses

what did we learn
What did we learn?
  • Processes always take longer than expected
  • Analysis of data & information - generally more complex than often anticipated in early stages of project/data collection phases
  • Timelines need to be realistic and flexible
project evaluation
Project Evaluation
  • Governance/Leadership
  • Planning and scoping
  • Stakeholder engagement
  • Risk management
  • Resource management
  • Quality management
  • Reporting
  • System-wide/organisational change management
  • Impact evaluation
  • Outcomes/achievements evaluation
  • Learnings dissemination
outcomes impacts of the client journey study
Outcomes/Impacts of the Client Journey Study

Informed the development of numerous service improvement initiatives such as:

Development & piloting of Broader Needs Assessment tool through the PCP

“Working Together for Better Diabetes Care” Catchment planning initiative

Informed individual agency service planning

Informed Medicare Local discussions & included in MLO submission

Project Review -lessons learned log
  • Being used for SSR planning – identification of key work priorities for remainder 2011-2012
  • PCP strategic planning evidence base
  • Service providers using for QI purposes
  • Benchmarking resource for various entities
back to the future
Back to the Future


  • Address findings - prioritising
  • Developing & implementing models of care, access, etc. - client focussed care
  • Affect appropriate change at all levels of organisation & the system
  • Resourcing

Lyn McKay

Tel: 9788 1544


Julie White

Tel: 9784 7764


Copies of the Client Journey Report available at: