SESIH Redesign Update Older Persons and Chronic Care Project

1. SESIH Redesign UpdateOlder Persons and Chronic Care Project Paul Preobrajensky Manager Redesign Program 19 September 2007

2. Older Person and Chronic Care Project Objective This project aims to improve aged and chronic care provision in SESI such that services are consistently able to deliver safe and cost effective best practice models of care. The project will support the older patient as they journey between the acute, community and aged care service interface.

3. Session Objectives • Description of the Extending Care Choices strategy – the key platform for reform for SESIH and • Describes the relationship of the Service Delivery Framework to this program. • Describe the service Delivery Framework key Elements and Focus Areas for service delivery • Introduce the Year 1 strategies

4. Extending Care Choices

5. Extending Care Choices The Extending Care Choices strategy maps the pathway through key initiatives designed to enhance and strengthen care in the community, through to the ultimate goal of a regional health hub

6. Extending Care Choices • The three key projects under the Extending Care Choices strategy are: • Older persons and Chronic Care Project; • Primary and Community Care Enterprises (PACE); and • HealthOne Initiative.

7. Service Delivery FrameworkThe First Key Outcome of OPaCC & PACE The key solution platform developed in the solution design phase was the Model of Care. The Model provides a vehicle for change – providing a framework to improve the system response to patient need through better integrated and coordinated services. The Model of Care is the leading platform for delivering the Extending Care Choices strategy and as such, though the implementation planning phase, has been developed and progressed into an Area Service Delivery Framework (the framework) providing the blueprint for the AHS going forward. .

8. Eight Key Elements of the Service Delivery Framework • Population approach, risk stratification, target populations; • Delivery system design; • Evidence based guidelines and care pathways; • Clinical information systems; and • Measurement of outcome and feedback (individual and system level). • Primary care focus – prevention, early intervention, risk identification/ response. • Self management, motivated partner. and • Multidisciplinary care management and service provision.

9. Nine Key Focus Areas – AHS Measurement of the Framework • CAPAC (Community Acute/ Post Acute Care) • Chronic Disease Management Program • Primary and Community Health • Self Management • Primary Care Integration • Primary Prevention • Access and Referral • Risk Response • Strategic external relationships

10. Example

11. Implementing the Service Delivery Framework • The key focus for the implementation planning phase was to develop an understanding of how the service delivery framework should and could be implemented across the AHS. • This required articulation of the required elements and focus areas at a service provision level across the Area. • prioritise elements and focus areas at a service provision level; • the systems and processes required to operationally support the functional requirements; and • the timing priority for implementation. The plan takes a three year view identifying expectations for implementation across the following periods: • year one – period ending 30 June 2008 • year two – period ending 30th June 2009 • year three – period ending 30th June 2010.

12. AHS Responsibility

13. AHS Responsibility cont.

14. Network Implementation Plans • Access and Referral Centre • Risk screening and responsiveness • Immediate opportunities of components of the service delivery framework • Solutions relevant to Calvary

15. Access & Referral • Purpose: • Provide a point of access for patients and others (GPs, community health, VMOs, ED) into area health services • Provide information on services to support improved system navigation for patients and other stakeholders • Streamline service access pathways • Support more effective resource allocation decisions • Provide a focus on alternatives to hospital • Support discharge processes for referral to home / community with services Service Group 3 • Infrastructure Regimes • Comprehensive Directory • Staff • Assessment Tools • Referral Protocols Protocol or Clinical Assessment Referral Point A Service Group 2 Third door • Access & Referral Service • Information • Risk Screenings • Eligibility / POA • Triage / Priority • Intake (Stream 1) • Service Streaming • Referral Out (New Health) Information Provision Referral Point B Intake Referral Out Service Group 1 Health e.g. TACT / SAFTE/ QRP Non health e.g. Home Care

16. Risk Response Purpose: • Early identification of older people and those with chronic disease who may be at risk of hospitalisation if intervention is not provided • Early intervention and prevention • Hospital avoidance The capture of consistent data on risks and service responsiveness will support improved practice and service planning. The guideline: • identifies three areas of risk for screening and monitoring; • identifies when and where risk screening should occur and how it should be responded to; and • details requirements for data capture and information sharing to inform practice and future service planning. Risk indicators for screening • Falls - defined as unintentionally coming to rest on the ground, • cognitive functioning – dementia, delirium, depression; and • medication management – the ability of a person to manage their medication and self medicate.

17. Risk Response cont. How should identified risk be responded to? • Identification of risk against the three indicators must be responded to in the following way: • Response Level 1:If appropriate and a core service responsibility, the service provides a response directly; • Response Level 2: If not core business but risk is identified, the service refers the patient to another service or program or advises the patient of other service alternatives, • Response Level 3:If not core business but potential risk is identified, the service advises the patient’s General Practitioner directly in writing of the identified risks or potential risks as part of discharge from that program or service with recommended actions for the GP. • Eg: The clinic may suggest referral to a falls clinic or a more comprehensive geriatric assessment. • Response Level 4:If not core business and risk is identified, the service investigates an appropriate referral but, after investigation, determines there is no suitable service then this is noted as “no suitable service available” in the data base and the patient’s GP is advised directly in writing.

18. Risk Response cont. • The implementation plan therefore focuses on ensuring that: • those services that currently screen are aware of intervention pathways and services available in response to identified risk; • the response to identified risk is documented to support more effective service planning and responsiveness; • providing a pathway forward to ensure services not currently screening are supported to undertake this process over time; and • in the longer term working with our community sector partners to introduce common risk screening.

19. Immediate opportunities of components of the Service Delivery Framework Northern Network Implementation Plans - Year 1 • Implementation plan for Aged and Chronic model of care • Increase community nursing capacity to support chronic disease self management • Risk register for COPD and Heart Failure • Improve integration ED and chronic care programs for patients with COPD and Heart Failure • Increase the efficiency of hospital and community transport operation • Access & referral Service • Risk Responsiveness

20. Immediate opportunities of components of the Service Delivery Framework Central Network Implementation Plans - Year 1 • Person Centres Planning • Access & referral Service • Risk Responsiveness Calvary specific Solutions • Implementation of the Rehab system (electronic referral to rehab) • Implementation of Jonah progressing • Broad forward direction for CRAGS agreed • Falls program

21. Immediate opportunities of components of the Service Delivery Framework Southern Network Implementation Plans - Year 1 • Aged, Community and Chronic Stream, structure and workload review • Supporting projects • Advanced Care Directives/ ongoing life management • GP engagement model • Aged care nurse Practioner role • Chronic disease management program • Access & referral Service • Risk Responsiveness

22. Performance Measurement Framework • There are two types of performance monitoring required: • Monitoring of the progress of implementation of activities against the implementation plans; and • Monitoring of the success of the solutions in improving services for older people and those with chronic disease. Using KPI’s against each of the 8 Areas of focus

23. KPI’s Framework - Example

24. Next steps

25. Presenter’s contact details Paul Preobrajensky Manager Redesign 0412 915 340 Paul.Preobrajesnky@SESIAHS.health.nsw.gov.au