Review of the Peninsula Health Hospital Admission Risk Program (HARP) Presenter: Belinda Berry

1. PENINSULA HEALTH COMMUNITY HEALTH Review of the Peninsula Health Hospital Admission Risk Program (HARP) Presenter: Belinda Berry

2. HARP Redesigning Care Before redesign HARP services had evolved to: Community Based • Residential Outreach Support Service ROSS Team • Peninsula Complex Care Team • MI Health • SHARPS • Hospital Based • Response Assessment & Discharge RAD Team • Drug & Alcohol Liaison

3. HARP Redesigning Care Concerned over time there had been a: Shift in focus away from Frequent Presenters Limited Pathways to Community HARP HARP Services spread over 5 program areas Need for review of our HARP Governance in light of revised HIP Guidelines Evidence to support intensive care coordination model for this target group Need to clarify outcomes for HARP Service

4. HARP Redesigning Care

5. HARP Redesigning Care • Issue 1 – Focus on Ambulatory Sensitive Conditions

6. HARP Redesigning Care • Issue 2 – Focus on Care Coordination

7. HARP Redesigning Care • Issue 3 – Focus on Frequent Presenters

8. HARP Redesigning Care • Issue 3 – Focus on Frequent Presenters

9. HARP Redesigning Care • Issue 4 - Where do our Frequent Presenters go?

10. HARP Redesigning Care • Issue 5 – Outcomes & Deliverables • HARP criteria not consistent within HARP programs • Lack of unified focus on frequent presenters & ACSC • Core HIP Guidelines not met; • Lack of Care Coordination • Multiple access points for HARP contact • Medical support lacking from interdisciplinary approach • Marginalised groups who meet HARP criteria not well engaged • Self Management Support not implemented across HARP • Lack of focus on Advanced Care Planning

11. HARP Redesigning Care Framework for future HARP Service Delivery Where We came From • Delivery System • Design • Regular, proactive • visits • - Multidisciplinary • Targeted recruitment • Responsive to patient • needs • Integrated throughout • settings • Decision • Support • Evidenced based • practice • Risk calculating tools • Self Management • Consistent with • ACCESS • Clinical • Information • Systems • - Utilise blackberry for • frequent presenters • IPM alert system to • Support frequent • presenters & ED • management plans • PJB data management • system • VINAH reports • generated • Community • Resources • Engaged & utilised to • support clients • Involved & active in • the community • Develop partnerships • for service delivery • Right place • Right time • Self • Management • Support • Support clients to • Educate & self manage • themselves • Tailor strategies • Educate carers & family • Symptom diaries • Action plans • Document & Record • Measure • improvement

12. Self Management Support HITH, PenPAC, Mental Health, EiCD, Community Health, Children's Services, Counselling, Dental, Diabetes Education, Drug & Alcohol Services, Family Violence Programs, ACAS, GP, HACC, SACS Improved Outcomes

13. HARP Clinical Response Service HARP HELD Outreach & Care Coordination HARP Care Coordination & Coaching Program SAACS GP care Self Management Programs Community Health • Health Promotion & Prevention • Go for Your Life Programs • Obesity Reduction • Smoking cessation • Health promotion HARP Redesigning Care Immediate Risk of Hospitalisation - Ambulance - RCF’s - GP’s ACUTE SERVICES High Need Frequent Hospital Visits - 6+ Presentations - Diabetes, COPD, CHF - Homelessness, D&A, Mental Health • Planned Managed Proactive Care • Access to mainstream • community services COMMUNITY SERVICES Whole Population Health Promotion Services

14. HARP Redesigning Care • CLINICAL RESPONSE • SERVICE • ____________ • Functions: • Community based • outreach to RCFs and • Patient’s homes. • Focus on preventing • Presentation to ED • Facilitating direct • Transfers to sub-acute • Partnership with • Ambulance Victoria • HOSPITAL EARLY • LINKAGES & • DISCHARGE • STREAM • _____________ • Functions: • Targeted risk • screening • of frequent presenters • Diabetes, COPD • & CHD • AOD, mental health & • Homelessness • ED Management • Plans • ED, Wards & Subacute • Outreach from ED • COMMUNITY CARE • COORDINATION • ____________ • Functions: • Provision of • Evidenced Based • self management • Interventions • Care Coordination • Community Linkages • HARP SUPPORT • _______________ • Functions: • Admin • Dietetics • Pharmacy • CNC’s • Physio • Data Specialists • Adavanced Care • Planning • Medical Support • Accessible across • streams

15. HARP Redesigning Care Before

16. HARP Redesigning Care After

17. HARP Redesigning Care - Population Health- Targeted Recruitment- Medical Support- Timely notification of presentation to ED- Self Management- Evidenced Based Standards Of Care- HIP Guidelines • Revised Model Based on