Release of the SCTT 2009 Information and training session August 2009

1. Service Coordination Release of the SCTT 2009 Information and training session August 2009 Insert the name of your agency here

2. Session structure

3. Learning objectives • By the end of the session you should be able to: • Explain the context of Service Coordination • Describe what is new in SCTT 2009 • Be confident in how you will use SCTT 2009 in your work • Have discussed implementation of SCTT 2009 in your workplace

4. 1. Service Coordination

5. Service Coordination • Service Coordination places consumers at the centre of service delivery to make sure they have access to the services they need, opportunities for early intervention and health promotion, and improved health outcomes • It is a statewide approach to align practices, processes, protocols and systems to enable organisations to work together to provide a seamless and integrated response to consumers

6. Context

7. Four publications • How the publications fit together • Our focus on SCTT 2009 user guide

8. Operational elements of Service Coordination

9. Timeline

10. What are the Service Coordination Tool Templates (SCTT) • A suite of templates designed to: • assist Service Coordination practice and standards • enable organisations to work together to provide a coordinated response • Used for • consistent recording of client information generated by Initial Contact, Initial Needs Identification and Care planning • referral

11. Why have SCTT? • First developed in 2001 in response to practitioners’ requests for a common set of tool templates to standardise and reduce duplication of consumer health and care information collected (SCTT replaces over 350 referral forms) • Revised regularly by DHS and sector to reflect best practice in the identification and service responses to the needs of consumers

12. Improving systems and practice • Revisions accommodate and reflect the broadening range of program areas and agencies implementing service coordination including: • Housing • Disability • Mental health • Child and family services • Palliative care • Problem Gambling, Department of Justice

13. ImplementingSCTT 2009 • Implementing use of SCTT 2009 should be seen in the context of broader service system developments and quality improvement processes • For example: • Reviewing present practice • Client information systems • Communicating with other agencies – referrals, joint assessments, care planning • How to manage the transition from SCTT 2006 to SCTT 2009 • PCPs are available to provide support

14. Assisting service providers to meet quality standards • QICIHS 2.3 Health issues are systematically identified and appropriate early intervention occurs at the most effective stage to maintain or improve health status and quality of life • EQUIP 1.1.2 Care is planned and delivered in partnership with the consumer and where relevant the carer to achieve the best possible outcomes

15. Questions • Any questions about the background and context to Service Coordination?

16. 2. SCTT 2009: What’s new?

17. What’s new? • Various additions and changes to SCTT 2006 • More child and family focused • New profile: Family and Social Network • New look care planning tool • Care Coordination Plan • Palliative Care Supplementary Information template for communicating additional information required for palliative care referrals

18. Completing SCTT - all templates • See the sample template on page 8 • Record code and description • Codes are listed on pp 41-52 and also in drop down lists of electronic versions • At the bottom of each page record name and details of the person who collected the information and the date of collection

19. Core templates

20. Core templates • Consumer Information template • Summary and Referral template • Confidential Referral Cover Sheet • Consumer Consent to Share Information used to record consent but only sent with referral if requested • Core templates are used to send a referral after consumer consents to share information

21. Confidential Referral Cover Sheet • Renewal of ACAS box – see note – if ticked put type of care and date of expiry in the Reason for Referral on the Summary and Referral template • If agency receives a referral remember to send the Acknowledgement of referral back to the referrer!

22. Consumer Consent to Share Information • Complies with State and Commonwealth legislative requirements • Used to record consent to share information for referral, care planning or other purpose as specified

23. Consumer Consent to Share Information • Minor change to the wording in the Verbal Consumer Consent section • ‘I have discussed with the consumer/consumer’s authorised representative how and why certain information may be shared with other service providers. I am satisfied that this has been understood...’ • For further information refer to privacy resources available on the web

24. Consumer Information additions • Postal Address • ‘Little or no literacy’ included in communication method list • Is this the person who makes the consumer’s legal decisions? • Legal orders refers to intervention and Family Court orders

25. Consumer Information • Note the importance of accurate information about who can be contacted • e.g. A young person may not want parents to be contacted • Comments box can be used to record source of referral or other information relevant to consumer information, that is not listed elsewhere

26. Summary and Referral • Provides a summary of issues from the Initial Needs Identification process • Avoid duplicating information on profiles sent with referral • In the Alerts section note cultural issues or safety issues for consumer or visiting service provider such as possible violent behaviour in household

27. Summary and Referral additions • On page 1, in the box titled Description of issues as identified by the Initial Needs Identification, under the heading Significant Histories, the word developmental • Important when making referrals for children or others where developmental history has an impact on health

28. Optional templates

29. Optional templates • Used for recording and communicating screening or Initial Needs Identification • Profile: Need for Assistance • Profile: Living and Caring Arrangements • Profile: Health Behaviours • Profile: Health Conditions • Profile: Psychosocial • Profile: Family and Social Network

30. Need for Assistance • Covers areas of function such as domestic, personal, mobility, transport, cognition, behaviour and communication • May be used by programs such as mental health, housing or community health to identify need for assistance at home or referral to a Home and Community Care (HACC) assessment service

31. Need For Assistance • Similar to 2006 ‘Functional Profile’ with a change of title • Includes section on Communication

32. Health Behaviours • Covers nutritional risk, smoking, oral health, alcohol use, gambling, physical activity and physical fitness and provides prompts for referrals • Consider using this profile if the consumer has, or may have, issues and needs in relation to their health status or specific health conditions

33. Health Behaviours • Oral Health - new question to prompt referral to dental provider ‘Have you had a dental check up in the last three years?’ • Change to section about Alcohol • Gambling new question to prompt referral to Gambler’s Help ‘Have you ever had an issue with your gambling?’

34. Living and Caring Arrangements • Use this to explore and record information about living arrangements, accommodation, employment or school status, financial and legal profile, consumer’s carer information if there are perceived issues or needs in these areas

35. Living and Caring Arrangements • In Accommodation section a prompt to comment on affordability and safety • Referral to Housing services information included in SCTT 2009 User Guide

36. Health Conditions • Covers overall health, pain, chronic conditions, oral health, vision, hearing, falls, health conditions, medications • Note if consumer is pregnant as this may indicate increased risk in situations where family violence occurs

37. Health Conditions • Chronic Conditions - new question ‘Do you have a diagnosed chronic condition?’ • Prompt for completing Health Behaviours profile and referral to chronic disease management and/or lifestyle intervention program

38. Psychosocial • Consider using this if consumer has, or may have issues and needs for personal and social support, family and personal relationships and mental health and wellbeing • A score of 16 or more indicates a need for referral to GP, counsellor or mental health professional

39. Family and Social Network • New profile • Consider using this for vulnerable consumers to record family network including children, young people, adults, parents, guardians, primary carer, grandparents, extended family members, friends and significant others

40. Family and Social Network • With children, include family members • With young people the friendship network would be important • Consider the cultural background consumer’s view of family and social network • Also use to record support networks for elderly • Use this profile if it is useful in supporting the consumer or important for needs identification or referral

41. Supplementary templates

42. Supplementary templates • Functional Assessment Summary used to record and share information following assessment of functional abilities • Palliative Care Supplementary Information used to record and communicate additional information required for a Palliative Care referral

43. Functional Assessment Summary • Not an assessment tool • Maps to HACC MDS version 2 functional status data items • Used by agencies that conduct assessments as a summary to send with referral instead of Need for Assistance Profile

44. Palliative Care Supplementary Information • New tool designed to assist in communicating additional information required for palliative care referrals • Any service provider can use this to make a referral to Palliative Care • Use as well as Summary and Referral Information when sending a referral for Palliative Care (all core templates)

45. Care Coordination Plan

46. Care Coordination Plan • New tool which may be used for all types of care planning but is specifically designed for coordination of care where multiple services are required • Shows who is involved in care, the main issues, agreed goals developed together, planned actions and who is responsible for each action • Includes a page for Review

47. Care Coordination Plan • Developed with the consumer and participants and used for people who have complex needs and who need multiple services • Includes : • Name, role and contact details of participants in care • Consumer goals developed with consumer, family • Name and contact details of the key worker • Date of the planned review and a record of the review (CCP page 3) • GP inclusion in care coordination planning is important

48. Tools for General Practice use only • VSRF for general referral from GPs • VSRF+ for referral to maternity, urology and osteoarthritis hip and knee specialist clinics

49. Use the right tool for the job Consumer Information

50. Using the right tool for the job The right tool for the job