Complex Care Coordination Service Profile and Case Study
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1 Complex Care Coordination Service Profile and Case Study Central Coast Local Health District Prepared by Alison Austen Complex Care Coordinator Ongoing and Complex Care August 2011
2 Central Coast Local Health District Wyong Gosford Long Jetty Woy Woy Population Total persons Gosford 166,626 ( 53%) Wyong 149,362 (47%) Total 316,008 GPs
3 Care Coordination and health coaching delivers effective health management, enabling clients to stay in control of their health. NSW Health funding under the Severe Chronic Disease Management Program enabled Central Coast Local Health District to enhance chronic disease management services.
4 Complex Care Coordination For the most complex patients & their carers, overwhelmed by health issues Very High Risk for experiencing acute event 2.3% Complex conditions-need one to one help Modular Rehabilitation Including exercise and education. Disease-specific and generalist multidisciplinary expertise available High Risk 14.7%. Frequent presenter or recently experienced major health event. Self Management Support Individual & group basis. The Better Health Self Management Program assists patients to develop their personal goals and maintenance skills to optimise their health. Prevention Wellness Promotion -55% Lower risk 28% Chronic Health Condition. Self management skills important in optimising health in the long term. Segmentation of Population Aged 65+ in NSW 932,000 Model based on Kaiser Permanente and Wagner Chronic Care Model Models
5 2010/11 enrolment target met with 1080 clients ever enrolled and 1019 current as June Year 2010/ / /13 Target Enrolments 856 1,395 2,389
6 Patient Profile SCDMP HIE Lists 518 patients reviewed from the DOH HIE Lists 1-3 Male 56% Female 44% Average Age - 79yrs (Range 49yrs 102yrs) Average number of presentations - 4 (Range 3-69) Average Bed days 32 (Range 3-157) 86% of Patients admitted across Multiple Conditions 1 condition 14% 2 condition 19% 3 condition 27% 4 condition 31% 5 condition 10% 50% Patients consented for enrollment and of those 86% patients still current 20% Patients found to be deceased at file review or contact 19% Declined or Did not start 7% Moved out of area or Unable to contact 4% With other Services or not appropriate
7 Patient Profile SCDMP - Overall 1019 Currently enrolled patients up to June Complex Care Coordination - 35% enrolled high risk case mgmt Chronic Disease Program - 65% enrolled lower risk health coaching 5% Cardiac 33% Heart Failure 12% Diabetes 15% Respiratory 1% BHSM 4% enrolled patients identify as Aboriginal/Torres Strait Islander 67% enrolled patients have Care Plans developed
8 COMPLEX CARE COORDINATION TEAM (CCC) COMPLEX CARE ALLIED HEALTH TEAM (CCAHT) Self Management Support Services Diabetes Education Centre Cardiac Rehabilitation Program Heart Failure Service Pulmonary Rehabilitation Program Home Exercise Education Respiratory Support (HEERS) Asthma Management Community Neurological Services including Chronic Pain
9 NUM- Nurse Unit Manager CNC-Clinical Nurse Consultant CNS 2- Clinical Nurse Specialist x2 RN -Registered Nurses x 3 EN -Enrolled Nurses x 4 Admin x 1
10 CCAHT PSYCHOLOGY ICIS OCCUPATIONAL THERAPY CCC DIABETES CARDIAC HEART FAILURE RESPIRATORY REHABILITATION PHYSIO SOCIAL WORK NUTRITION
11 Phase 1 NSW Health generated algorithm targeting Chronic care clients >65yrs with 3+admissions Referral of clients from other Services who are at risk of readmission Phase 2 Building a flag algorithm into EMR Building an ALERT feature in EMR Phase 3 Developing referral pathways for General Practice
12 Health Coaching training rolled out to Practice Nurses Investing in Secure Messaging Development of Central Intake System Link from central intake for SCDMP for enrolled clients into an after-hours diversion to a state-wide call centre
13 Identification Consent GP contacted Holistic assessment Clinical needs addressed Motivational interviewing/explore barriers to behaviour change Patient goals identified Referrals generated Report back to GP Case conferencing Ongoing telephone monitoring/health coaching
14 Referred from Aboriginal Medical Service-AMS 56 yr old Wiradjuri woman, lone liver, housebound Aboriginal, Stolen generation Smoker COPD, Diabetes Type 1 27 yrs Medical issues identified-high blood glucose/copd Previously enjoyed painting Depressed, low self esteem, low motivation
15 The Care Coordinator Attended holistic assessment Motivational interviewing -client identified goals and barriers to achieving her goals Arranged transport/regular GP visits at AMS Assisted with GP management plan/epc Organised Diagnostic tests COPD Action Plan in place Organised Specialist clinic visits Social contact with client
16 HEERS Physiotherapist -active cycle breathing/exercise prescription Diabetes centre Psychologist-depression/anxiety management/motivation Occupational Therapist/energy conservation. Smoking Cessation Clinic Outpatient Pulmonary Rehabilitation Program
17 Client attends monthly Respiratory Support Group, has a smaller group at her house to continue exercise and peer support Client has completed leader training with the Better Health Self Management Program Client reconnected with her Aboriginal family Returned to painting Active in health promotion Non smoker
18 Referral from HEERS 78 yrs, 37 kg female COPD, Macular degeneration Difficult home situation lives with husband, daughter in Queensland Declines home O2 Social isolation/depressed
19 Readmission Transfer to Transitional care unit Liaised with hostel for permanent placement 1 year later CCC was contacted by daughter in Qld Father unwell/declining diagnostic testing CCC spoke to Surgeon re tests CCC/GP organised ambulance to Sydney CCC liaised with GP to refer to Palliative care Father/daughter appreciative care Client RIP 2 months ago
20
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