Comprehensive Assessment Implementation of the Active Service Model

1. Comprehensive Assessment Implementation of the Active Service Model St. Vincent’s At Home (SVAH) and Domiciliary Therapy Team (Dom) Louise Hogan Acting Manager

2. St. Vincent’s At Home-Fitzroy • District nursing service established in 1959 • LGAs covered include Boroondara, Darebin, Melbourne, Moonee Valley, Morelandand Yarra • Provides nursing services under three programs: • Home and Community care (HACC) • Hospital in the Home (HITH) • Post Acute Care (PAC)

3. Domiciliary Therapy Team-Kew • HACC funded allied health service established in 1992 • Provides low intensity interventions to clients living at home including: • Physiotherapy • Occupational Therapy • Speech Pathology • Podiatry and • Dietetics • LGAs covered include Boroondara, Yarra and the southern part of Darebin.

4. What is the Active Service Model (ASM)? If ageing is to be a positive experience, longer life must be accompanied by continuing opportunities for health, participation and security. Active ageing makes the most of these opportunities in order to enhance quality of life. (Ref: WHO Active Ageing: A Policy Framework)

5. Key Principles of the Active Service Model • Promoting a ‘wellness’ or ‘active ageing’ approach • Acknowledging the importance of social connections to maintain wellness • Holistic and family-centred approach to care • Actively involving clients in setting goals and making decisions about their care • Providing timely, flexible and targeted services

6. Key Principles of the Active Service Model • People want to remain autonomous • People have the potential to improve their capacity • People’s needs should be viewed in an holistic way • Services organised around the person • Collaborative working relationships

7. Where did we start? • HACC funded agencies required to develop an ASM initial implementation plan for 2010-2011 • ASM PREPARE tool used to: • assess strengths and weaknesses • explore opportunities for improvement • develop key priorities and strategies for action

8. Key Areas Identified Strengths: • Both teams have processes and practices that are already closely aligned with the ASM Areas for improvement: • Education and training of staff to ensure a cultural shift towards the ASM model across all staff in both teams • Review assessment framework to improve the focus on client goals rather than nurse/therapist goals

9. What did we do? • Initial education to staff regarding the ASM principles and implementation strategies • Staff workshop to review Client Assessment Tool-revised to include more specific goal setting focusing on client’s strengths and capacities • Revised Assessment Tool implemented for trial February 2011 • ASM is now a standing agenda item on monthly unit meetings • ASM approaches discussed at monthly team/case conferencing meetings

10. Review of Assessment Framework Pre ASM: • Issues/problems identified by Client/carer and ability to manage                                         • Goals to be achieved by Client/Carer ASM Approach: • Client Goals & Aspirations (short/long term)   • Client Identified Issues (Health/ADLs/Social/Cultural) • Carer (Issues/Goals/Support Required) • Achievable steps towards goal  • Strengths/Issues/Actions 

11. Challenges • Continue to develop the capacity of the team to ensure a cultural shift towards the ASM model across all staff • Evaluate the revised HACC Client Assessment Tool-ensure ongoing effectiveness • Improve engagement between staff and client-clients encouraged to suggest personal goals and what would motivate them

12. Successes: Case Studies SVAH • Elderly gentleman referred to SVAH for wound management to leg ulcers. Lives with supportive wife and both client and wife independent with ADLs and home duties. Wife had expressed interest in assisting provide wound care to her husband. • SVAH commenced 2nd daily visits for wound management with the aim of educating wife to perform wound care and reducing visits over a 6 week period.After a 6 week period client’s wife was attending wound care independently and the SVAH nurses reduced their visits to weekly to continue to monitor. • The nurse provided education to client and wife regarding ongoing prevention of leg ulcers. The wife and client both provided positive feedback and were very pleased with the flexible service provided and their increased knowledge about managing and preventing leg ulcers.

13. Successes: Case Studies Dom Team • Socially isolated elderly woman with osteoarthritis of hips, had lost confidence walking in the community. The local council volunteer dog walkers referred to Dom Team Physiotherapy to improve mobility and confidence in walking outdoors with an aid. • Dom Team Physiotherapist commenced weekly visits to implement an exercise program and supervised a progressive outdoor walking program over an 8 week period. • After the 8 week period client was able to accompany the volunteer dog walker for part of the distance as well as regularly walking to the local shops with a mobility aid. • The physiotherapist referred client to a local social support group which she continues to attend weekly. The volunteer coordinator provided positive feedback and stated that the client continues to attend social group and often stays for lunch.

14. Opportunities • Within STV - HIP (Health Independence Program) services have a similar philosophy • Collaboration with City of Yarra • Partner with existing referral agencies and explore new links • Marketing of services to ensure considered for all suitable clients • More proactive discharge planning and referral beyond the standard health care providers • Client Satisfaction Survey

15. Acknowledgments Gen Cooper Manager SVAH & Dom Team Kirsten Rodger Group Manager Integrated Care Staff of SVAH and Dom Teams Emily Hooke and organising committee