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15-16 June - Broadbeach

Restoring Health – A Coordinated Chronic Disease Management Model of Care Presenter: Silvio Pontonio Hospital: Aphrodite. 15-16 June - Broadbeach. KEY PROBLEMS. 2001 Complex chronic conditions being managed in isolation Minimal coordination of care across these sectors

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15-16 June - Broadbeach

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  1. Restoring Health – A Coordinated Chronic Disease Management Model of CarePresenter: Silvio PontonioHospital: Aphrodite 15-16 June - Broadbeach

  2. KEY PROBLEMS 2001 • Complex chronic conditions being managed in isolation • Minimal coordination of care across these sectors • Emergency demand pressures (statewide and local to SVHM) • Evidence in literature that health outcomes (QOL and function) could be improved using chronic disease management strategies

  3. INNOVATIONS IMPLEMENTED Developed chronic disease management program … “Restoring Health” • Improved health outcomes • effective coordination of patient and carer needs • acute, subacute, primary care sectors • quality of life, health and wellbeing • Decrease avoidable hospital demand (HARP) •  emergency dept presentations •  inpatient admissions •  length of stay

  4. POST ACUTE / FUNCTIONAL COMMUNITY OUTPATIENTS OUTREACH RESTORATION SUPPORT RH Community Nurses Multi - disciplinary exercise Community maintenance Rapid access RH and education rehabilitation programs: exercise programs (CRC’s) Outpatient Clinic RH Community Allied Health Patient and Carer support • Pulmonary Rehab • Heart Failure Rehab • Diabetes Rehab Links with: groups Links with: Better Health Self St. Vincent’s at Home § St.Vincent’s Clinics § Management Course (HITH/HACC) PAC § Links with: RDNS § Community Health § Other chronic disease Community Health § § Local Government § Local Go vernment rehabilitation programs § Other § NESB Peer - Led Better § Health Self Management Course GP Review Carer care plan Restoring Health Client Contact Person EMERGENCY/ INPATIENT Referral and recruitment Optimal medical management Evidence based coordinated disease management Self management strategies Discharge and care planning processes Health Information Professionals provision CALD requirements identified INNOVATIONS IMPLEMENTED

  5. Feb 2003 – Dec 2004 48%

  6. Feb 2003 – Dec 2004 66%

  7. HOW WE DID IT Project Started: February 2003 Staffing: Multidisciplinary - acute / community Funding: HARP – 1.2 million/annum Duration: 3 year project … mainstream Key Reasons for Success: • Contact Liaison Role – “the glue” • Integrated Team – shared vision, goals & care delivery • Program Components– evidence based, flexible & variety • Infrastructure – IT, evaluation, marketing • Collaboration and Consultation – all stakeholders

  8. LESSONS LEARNT • Recommendations: • start with a contained referral base • foster a “real” team not just a “virtual” team • all chronic disease management under the one umbrella • develop and improve on links to existing services • What we would do differently: • IT Project Manager and IT $ from beginning • Commence with fewer agencies – consolidate partnerships and then potential to expand as indicated • Establish KPIs for collaborating agencies

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