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Integrated Coordinated Care How we are changing how we work

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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Integrated Coordinated Care How we are changing how we work

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

  2. 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

  3. 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

  4. Objectives of CBCHS Integrated coordinated care • Multidisciplinary Teams • Interdisciplinary Assessment • System Redesign • Consumers Active Partners • Processes/Evaluation/Quality • Training and Support

  5. Strategy • Driver • Strategic Plan • Operational Plan • Team Planning • Identification of change champions A PRIORITY FOR ORGANISATION

  6. Communication Strategy Client Information Newsletter Forum Focus Group Questionnaire Client participation Meetings

  7. BackgroundPILOTS Pilot – PDSA Approach Interdisciplinary Assessment Learning's from the design and implementation of the tool

  8. Interdisciplinary Assessment Patient and Carer Issues Physical Psycho-social Cognitive Functional Interdisciplinary Assessment Team Based Assessment Health Needs Identification Planning Goals Actions

  9. 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

  10. RESULTS Understanding and confidence Job satisfaction Identification of client priorities Collaboration, coordination a resources Multidisciplinary Teams

  11. 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

  12. System re-design

  13. New pilotIntegrated Health Team (IHT)

  14. Evaluation • ACIC • PACIC • Audit • Focus Group

  15. 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

  16. 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

  17. 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

  18. 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

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