Inter-Agency Care Planning The EICD / Darebin Community Health perspective

1. Inter-Agency Care Planning The EICD / Darebin Community Health perspective Carolyn Hines Manager – Chronic and Complex Care Program

2. Today’s presentation • The Early Intervention in Chronic Disease (EICD) program model (Health Wise) • Health Wise and inter-agency care planning • Issues and challenges • The way forward

3. Background • Care planning at DCH • Some discipline-specific care planning for internal use only • Inter-agency care planning is limited • Specific to certain programs eg HARP • HARP • Austin Health, St Vincent’s, Northern Health • Inter-agency care planning occurs to varying degrees • Early Intervention in Chronic Disease (EICD) • Health Wise • Care planning is in development stage

4. Levels of Chronic and Complex Care HARP People with chronic conditions / complex needs who use, or are at risk of using, hospitals frequently EICiD People with chronic conditions / complex needs who do not use, or are at low risk of using, hospitals frequently LEVEL 1 Intensity LEVEL 2 Primary Prevention for whole population eg Go For Your Life LEVEL 3 LEVEL 4

5. Health Wise Program Model

6. Key Worker role • Comprehensive assessment - general chronic disease screening, self management assessment (Flinders), Client Survey (DHS) • Preparation of a Healthy Living Care Plan based on self management needs / goals (Flinders) • Further appointments with KW for 1:1 self management; referral to other services (internal or external) as required • The main point of contact for client and GP • Extent of involvement with each client will vary according to needs

7. Healthy Living Care Plan Flinders Care Plan V9 April 06 Sign Off - Patient I ……………………………………(patient name) agree that the information contained within this care plan is true and correct and currently reflects my needs for the forthcoming year. Additionally, I consent to this information relevant to my care will be released to my health providers. Signature: ………………………………….. Date: ………/………/……… Sign Off - Doctor I ……………………………………(GP name) agree that the services prescribed within this care plan are true and correct at the time of development but are subject to review based on the patient's needs and / or my professional opinion as the responsible Medical Practitioner. Provider No:[ ] [ ] [ ] [ ] [ ] [ ] [ ] Date: ………/………/……… Care Plan Review Date: ………/………/……… Signature: ………………………..…MBS ITEM: GP Management Plan - 721 Team Care Arrangements - 723 

8. The GP / EICD Interface The HARP / EICD interface

9. Health Wise and inter-agency care planning Focus will be: • General practitioners • HARP programs and other external organisations / programs • Internal service providers • Maintain communication • Streamline client care

10. Health Wise and inter-agency care planning (cont) Progress to date: • Working group has been established with staff from EICD project the DCH Medical Practice (GP, Practice Nurse, Chronic Condition Practice Coordinator) • Started investigating care planning options • Service Coordination Plan • HARP

13. Issues / challenges • Multiple options available • Multiple views about the ideal care plan • Terminology - medical care plans, service coordination plans, community care plans…………. • Commitment to self-management - need to incorporate client-centred goals • Don’t want to reinvent the wheel!

14. What do we need? • We can’t do it alone! • Small EICD project managers network but cuts across different regions • Regional approach (state-wide) • Support and leadership from DHS • Bring service providers / Divisions of General Practice together to establish definitions, common needs, standard care plan format/s • Strategy to promote the “why” and “how” to agencies / staff