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SW HARP Care Planning

SW HARP Care Planning. Janine Dureau-Finn. SW HARP. Established Jan 06 To reduce avoidable Emergency Department presentations, hospital admissions & length of stays of the target groups through the use of best practice principals , resulting in client centred care & support. SW HARP.

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SW HARP Care Planning

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  1. SW HARPCare Planning Janine Dureau-Finn

  2. SW HARP • Established Jan 06 • To reduce avoidable Emergency Department presentations, hospital admissions & length of stays of the target groups through the use of best practice principals, resulting in client centred care & support

  3. SW HARP • Based in Community Health – will work across all service sectors • Acute hospitals • Nursing Homes • GP practices • Specialist rooms • Clients homes ***no limitation on where they provide service delivery

  4. SW HARP Indigenous Chronic Illness HARP Indigenous Health Promotion

  5. SW HARP

  6. SW HARP - Tools • Assessment – interRAI (pilot) • Disease specific QOL • Flinders • Partners in Health • Cue & Response • SCTT • Referral – out • Service Coordination • Consent • Care Plan • Goal setting

  7. SW HARP - SCTT • SCTT Service Coordination Plan – all SW HARP clients have a Service Coordination Plan (page 1) completed. • Referrals – all referrals from SW HARP are made on the SCTT referral tool (not always electronic!). This includes internal referrals. If appropriate a copy of the Service Coordination Plan is sent with the referral.

  8. Care Plan/Goal Setting • Individual agency • SCTT • Flinders • interRAI • Health Coaching / BHSM • All have either care plans or goal setting tools. Which do you use?

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