Care Planning/Care Coordination Initiative (CPCCI)

1. Care Planning/Care Coordination Initiative (CPCCI) Second Steering Committee meeting Wednesday 28 November 2007

2. Service Directories e-referral Care Coordination (as required) Service delivery • Assessment • Comprehensive • Service specific • Specialist Care Plan Service plan Initial Needs Identif-ication (INI) Initial Contact (IC) Individual treatment plan Clinical plan Service Coordination Tool Templates (SCTT) Agency assessment tools Service Coordination Plan (as required) Privacy requirements e.g. Health Records Act and privacy principles

4. CARE PLANNING/CARE COORDINATION INITIATIVE – WORKING GROUP TASKS CARE COORDINATION PPPS DEVELOPING AND IMPLEMENTING CARE COORDINATION PRACTICES, PROCESSES PROTOCOLS AND SYSTEMS GPs AND CARE COORDINATION HOW CARE COORDINATION MIGHT WORK BETWEEN GENERAL PRACTITIONERS AND THE BROADER HEALTH CARE SECTOR HOW TO ENCOURAGE MAP, EXPERIMENT, PILOT AND APPLY PPPS Greater involvement of the broader health sector in GPMPs and TCAs Involvement of GPs in Service Coordination Plans/care coordination activities WORKING GROUP ‘X’ WORKING GROUP ‘Y’ WORKING GROUP ‘Z’ CONSUMER INFORMATION ELECTRONIC CARE COORDINATION DEVELOP AND IMPLEMENT E-CARE COORDINATION (ECC) ON-LINE CARE COORDINATION - SERVICE COORDINATION PLANS AND CASE CONFERENCING GP INTERFACE TRANSPARENT LINK BETWEEN GP SOFTWARE AND E-SCS (E-REFERRAL SYSTEM) TO ALLOW REFERRALS AND CARE COORDINATION

5. WHO ARE CARE COORDINATION CLIENTS? Clients who: • are being seen by more than one agency and/or more than one discipline • have multiple issues/problems that need to be addressed concurrently, and • whose outcomes are likely to be better if the care and services they receive are coordinated across agencies and over time.

6. LEVELS OF COMPLEXITY 1 COMPLEX Page 1 & 2 of SCP? 2 Page 1 of SCP only? MEDIUM Typically EIiCD plan or CACPs/EACH package or TCA/GPMP? 3 LOW MEDIUM 4 Individual care plan or no care plan? LOW

8. Click for Service Coordination Plan hyperlink in slideshow mode

9. ELEMENTS OF FULL, FORMAL CARE COORDINATION • The appointment or nomination of a Key Worker or Facilitator; • A central role for the client; • A common document to which all participants have access; • Formal procedures for obtaining and coordinating input; • Case conference procedures; • Feedback on or access to information; • The tracking of client progress.

10. NEXT STEPS (#1) • Call for participants: Tuesday, 4 December 9.30-1.00pm – Box Hill • Intensive working party • Involve discharge planners from Private hospitals • Develop PPPS for SC plan • Redesign SC Plan: • Distribute to consultative group • Feed back to DHS (regional feedback)

11. Issues for consideration • Consumer – How is SC Plan addressing consumer needs? Consumer doesn’t have control. • SC designed for agencies – not for consumers. • Take into account multiple perspectives – State / C’Wealth / various agencies/services’ perspective • Dealing with electronic platform – numerous perspectives: Technical ability / privacy / client concern of information transmission • DHS establish Statewide guide (VB Recommend) • 2009 Release of electronic SC Plan post review • Develop electronic system • Run pilots with re-designed SC Plan • Lessons from and inform HACC Access Points project

12. Develop electronic system • Run pilots with re-designed SC Plan

13. Next steps (continued #2)

14. Next steps (continued #)