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Innovative Multidisciplinary Care Model for Rural Aged Care Services

This document outlines a unique care model implemented by Jo Varley and the CNC team for the Lower Mid North Coast Cluster in May 2010. Covering an area of 10,000 square kilometers, including Taree and Forster/Tuncurry, predominantly rural farming communities face limited services. The model integrates interdisciplinary team services and a centralized intake process, enhancing collaboration and service delivery. While the approach benefits clients by enabling cross-referrals, challenges include travel for assessments and clinic setup in small towns. The transition to a digital system in 2008 streamlined processes, ensuring better management of referrals and statistics.

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Innovative Multidisciplinary Care Model for Rural Aged Care Services

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    1. A DIFFERENT MODEL OF CARE Prepared by Jo Varley CNC / Team Leader Lower Mid North Coast Cluster May 2010

    2. Lower Mid North Coast Cluster 10,000 square kilometres. Area takes in 2 major centres Taree and Forster / Tuncurry. Mainly rural farming area. Small towns with limited services.

    3. Organisational Chart

    4. Service Network. ACAT and Geriatricians

    5. Multidisciplinary service

    6. The Benefits. Each client no matter what program they are in has the opportunity to receive interdisciplinary services. Ability to cross refer and discuss within team leading to a more collaborative approach. Each discipline is able to provide discipline specific services as well as a generic Aged Care focus. Close working relationship with other community services. Outreach clinics for small communities.

    7. Disadvantages The amount of travel that the service does to do assessments. Challenges of setting up clinics in small towns. (Need a travelling road show). The time wastage with no shows. 6 degree’s of separation (eg I may be related to you?)

    8. Centralised Intake Process

    9. Central Intake Within The Team Provides our service with: One point of contact for all referrals A standard referral process for all referrals. The opportunity to discuss complex referrals prior to making the decision of who to refer to. Coordination of referral process into the 3 arms of the service reducing risk of multiple referrals.

    10. 2008 The Big Change In 2008 this service went from using a paper based system to CHIME. We took the opportunity to review and redevelop our processes for management of programs, referrals and assessments. This has resulted in flow charts that allow for staff movement between programs as needed.

    11. Statistics over Time 2008

    12. Statistics over Time 2008

    13. Referrals by Source.

    14. Referrals by Area.

    15. Conclusion Even though these ACAT services are in Hunter New England Area Health Service: The needs of the communities must be taken into account. The demographics must be considered. Staff needs need to be considered.

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