Service Coordination projects 2012- 2013 Rochester & Elmore District Health Service

1. Service Coordination projects 2012- 2013 Rochester & Elmore District Health Service

2. REDHS received funding for service coordination project in both 2012 & 2013 • Both projects undertaken by Leanne Rankin • Diabetes Educator and community health nurse at REDHS • Previous experience as ICDM worker for Campaspe PCP.

3. 2012 project Issues addressed • Central intake • All primary care referrals to central intake • Including using Connecting care for all internal and external referrals. • Referral acknowledgement processes • GP Communication • Processes when clinicians should communicate to GP • Following initial assessment • Any time during episode of care as required • On discharge • Templates for all letters

4. Outcomes 2012 project • Central intake • Referral acknowledgement practices both CCC and Fax • Use of CCC for all internal referrals within REDHS • Use of CCC by REDHS for referrals out • Local agreements with GP • Development of local agreements around referrals, communication and acceptance of Team Care Arrangements

5. Outcomes 2012 project • Connecting care usage

6. Barriers • Staff change over within Primary Care • Ongoing education for all staff re Connecting care usage • Policies development & implementation

7. 2013 project. Issues addressed • Review of last years project areas • Care planning • As extension of HACC ASM work to all primary care services • Assessments • Review by clinicians and format for client records • Central client record • Primary care client record amalgamated into hospital client record and stored in medical records department.

8. Outcomes • Medical records • standardised UR • All records common file and stored in medical records • Service coordination online education package part of PC staff orientation. • Care planning • service specific • REDHS shared support plan • Assessments.

9. Barriers • Issues with HSD and connecting care change over • Ongoing staff changes • Ongoing staff education

10. Enablers • Fortnightly staff meetings • Small team • New younger clinicians

11. Thanks to PCP for the funding for the project. • Advantages to having a worker at a local level to initiate activities specific to the needs of our own organisation • Networks within service coordination steering committee.

12. Leanne Rankin Rochester &Elmore District Health Service 5484 4481 lrankin@redhs.com.au