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Implementing integrated Multidisciplinary Models of Care. Debra Starr Integrated Service and Planning Manager. Integrated Coordinated Care How we are changing how we work. Aims and Objectives Strategy Past Pilots Results Overcoming barriers to implementation

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Implementingintegrated Multidisciplinary Models of Care. Debra Starr Integrated Service and Planning Manager

integrated coordinated care how we are changing how we work
Integrated Coordinated Care How we are changing how we work
  • Aims and Objectives
  • Strategy
  • Past Pilots
  • Results
  • Overcoming barriers to implementation
  • Current model of implementation
  • Current Pilots
  • Evaluation
slide3
AIMS
  • Stream-lined, coordinated service for those entering our system with complex and/or chronic diseases.
  • Client-centred approach using self-management models of care.
  • Services focusing on not just presenting issues, but risk prevention and holistic management of health issues.
  • Coordinated Care planning and discharge.

REACTIVE PROACTIVE

objectives of cbchs integrated coordinated care
Objectives of CBCHS Integrated coordinated care
  • Multidisciplinary Teams
  • Interdisciplinary Assessment
  • System Redesign
  • Consumers Active Partners
  • Processes/Evaluation/Quality
  • Training and Support
strategy
Strategy
  • Driver
  • Strategic Plan
  • Operational Plan
  • Team Planning
  • Identification of change champions

A PRIORITY FOR ORGANISATION

communication strategy
Communication Strategy

Client Information

Newsletter

Forum

Focus Group

Questionnaire

Client participation

Meetings

background pilots
BackgroundPILOTS

Pilot – PDSA Approach

Interdisciplinary Assessment

Learning's from the design and implementation of the tool

interdisciplinary assessment
Interdisciplinary Assessment

Patient and Carer Issues

Physical

Psycho-social

Cognitive

Functional

Interdisciplinary Assessment

Team Based Assessment

Health Needs Identification

Planning

Goals

Actions

pilot 2
Pilot 2
  • 6 month pilot study (2012)
  • Investigated the implementation of how an Integrated chronic disease model of care could be introduced into the Primary Health Service at CBCHS.
  • Involved 22 staff members.
  • Training provided on self-management of chronic disease
  • 3 multidisciplinary pilot groups
results
RESULTS

Understanding and confidence

Job satisfaction

Identification of client priorities

Collaboration, coordination a

resources

Multidisciplinary Teams

overcoming barriers to implementation
Overcoming Barriers to implementation
  • Discipline Specific Verses Multidisciplinary
  • Change ‘like the way things are’
  • We already work in an integrated model
  • Previous Pilots and getting staff on board
  • Confidence
  • Time, Wait Lists, Competing Priorities
  • Processes/tools/TRAK
evaluation
Evaluation
  • ACIC
  • PACIC
  • Audit
  • Focus Group
focus group results
FOCUS GROUP RESULTS
  • One holistic assessment reduced duplication/ better understanding of clients needs
  • Development of Tools: case discussion, care planning, discharge
  • Trust in other Services/ Job satisfaction
  • Collaborative care planning/joint consultations/case conference/home visits
  • Primary Clinician/Learn from others/peer supervision
  • Client outcomes Observed: less hospitalisation, increased confidence, independently attending appointments
vignette
Vignette

Before

After

  • Frequent non-attender
  • Doctor Shop
  • Not taking Medications
  • Lack of social support
  • Mistrust in health system
  • Reduced ability to manage conditions
  • Attending Appointments
  • Taking Medications
  • Has formulated Goals
  • Walking with an aid
  • Wearing shoes
  • Has council services
  • Has trust in health system
  • Increased Confidence
  • Improvement in health status
learning s
Learning's
  • Model of implementation takes time
  • Variable evidence suggests that some Health Professionals are on board and some are not.
  • Model and process have been implemented in a pilot with positive results
future developments
Future developments
  • The challenge ahead to further implement an Integrated coordinated system across all sites.
  • All Health professionals completing a interdisciplinary assessment on all clients entering our services.

Debra Starr

dstarr@cbchs.org.au