Connecting Care Making connections: people, disease and care Prepared by Paul van den Dolder Director Ambulatory and Primary Health Care Illawarra Shoalhaven Local Health District August 2011
Acknowledgements SESIAHS Michelle Noort Tish Bruce Jane Graham Linda Soars Franca Facci Simone Jones Virginia McMahon Samara Lewis NSW Health Chronic Disease Management Office NSW Health External Partners Divisions of GP HCA staff Healthways Australia
Current Chronic Disease Programs Cardiac/Heart failure Pulmonary Rehabilitation Diabetes General Chronic disease Self Management programs Aboriginal health programs
Background Program office commenced in May 2010 Starting from minimal base of care coordination Multiple CDM services Poor coordination and communication between teams No common emr system Minimal health coaching Some work with Divisions of GP
Aims of the NSW Connecting Care program To improve the quality of life for people living with severe chronic disease To create a seamless and integrated health care journey for patients with chronic disease To assist in the reduction of debilitating physical and social effects of chronic disease To reduce unplanned hospital presentations To reduce the burden of chronic diseases on the client, their carers and the health system
Intensity Target population Care Coordination People with multimorbid chronic disease +/- geriatric syndromes with complex needs who are at very high risk of hospitalisation Health Coaching People with established chronic disease with complex needs who are at high risk of hospitalisation People with established chronic disease who are at low risk of hospitalisation People at risk of chronic disease Well population 8
So what have we achieved? Regional CDM Committees Agreements with Divisions of GP Care Coordinators based in Divisions Standardised reports developed to ID patients CHIME developed as emr for service. Most CDM teams now using CHIME. Over 1800 patients currently enrolled
More achievements.. Health coaching through External provider - Healthways Health coaching skill development workshops - HCA Development of emr alerts Alignment of 48 hour follow-up for Chronic Care for Aboriginal People program RN positions developed for Access and Referral Centres Provision of an on-line resource kit for carers Re-develop the DocMail system Implementing Argus Word
Impediments Development of the model in partnership model with Divisions of GP took time resulting in a slow start-up Development of new positions, new processes and new systems for the program Re-alignment of health system to ensure that both specialist focussed and generalist models of care could comfortably coexist Transition from AHS to LHD via Cluster! Changing goal posts
Challenges Moving from program implementation to whole of system change Working with the social support sector Continuing to manage the ongoing relationship with the Divisions of GP with move to Medicare Locals Demonstrating change with this new approach Working with Aboriginal and CALD populations Kiama NBN telehealth trial
Moving towards integrated patient care Connecting Care holistic review Pre Hospital Emergency Department Inpatient Care Transfer of Care Person in the Community GP case management Intervene Early Minimise ED LOS Alternative paths Minimise inpatient LOS Linking services Prevent readmission/ optimise care