Macedon Ranges Service Coordination Meeting

1. Macedon Ranges Service Coordination Meeting Better Connections Better Care Forum Loddon Mallee DHS Bendigo 21st November 2007 Macedon Ranges Care Coordination Meeting 2007

2. In this presentation we will attempt to give you: • A History of the Macedon Ranges Service Coordination Meeting • A brief overview of the Processes we have developed • Identified Problems and Improvements Macedon Ranges Care Coordination Meeting 2007

3. Who attends? • Macedon Ranges Shire Council Aged & Disability Unit • Kyneton District Health Outreach Service • Aged Care Assessment Service • Cobaw Community Health • Macedon Ranges Health Service • Carer Support Services • Clients & Carers • Other invited relevant services and/or Case Managers * Central Victorian Health Alliance (Primary Care Partnership) attend the process development part of this meeting, but do not attended when clients being discussed. Macedon Ranges Care Coordination Meeting 2007

4. Pre-2001 • Originally this meeting was known as the HACC providers meeting • HACC providers and Case Managers met once a month to discuss clients that had been referred to them. • Often there was no consent from clients, and the number of clients discussed was huge. • The impending Privacy Act and the introduction of the SCTT gave us pause, and we had to make a decision as to whether to continue this forum or not. • In its current form it clearly did not comply with privacy, and we needed to look at ways to link the SCTT with this meeting. Macedon Ranges Care Coordination Meeting 2007

5. We had a complete revamp of our network practices and processes, and developed TOR for the now ‘Aged Care and Disability Planning & Advisory Network’ The latter part of this meeting was the now named the ‘Care Coordination Meeting’, which had a usable process with referral pathways and client consent written in to the TOR, and it was a ‘closed’ meeting. Only clients with 3 or more needs / complex needs would be discussed in this meeting, and consent was to be obtained before discussing. From 2001 to now Macedon Ranges Care Coordination Meeting 2007

6. It still gave us the opportunity to discuss clients anonymously if we felt we needed peer support and advice. • We were able to invite clients and carers to this meeting, and many less clients were discussed. • Often this forum was seen as a major referral pathway for CACP’s, EACH and Linkages, but this discontinued with ACAS centralised register. • Often the clients discussed would be an appropriate referral to case management, but as there are not enough packages we often ‘hold the fort’. Macedon Ranges Care Coordination Meeting 2007

7. In 2007 we reviewed our referral pathway, and have just introduced electronic referral though connectingcare. Previously this was manual system – email, fax, phone. MRSC is accepting referrals to this meeting, which consist of: Consumer Information Summary & Referral – consent  but referring agency holds consent Blank Service Coordination Plan Referral Macedon Ranges Care Coordination Meeting 2007

8. Macedon Ranges Care Coordination Meeting 2007

9. Benefits • Services now able to be alerted when a client in their service is being discussed, so they may not have to attend every meeting. • Clear referral and consent pathway • Often the only time we can all get together • Better communication – ‘putting a face to a name’ • Does not exclude organising meetings outside of this forum, but may avoid extra meetings • Peer Support and Problem Solving • Sharing Information • Advocacy Macedon Ranges Care Coordination Meeting 2007

10. Problems • Who is the Key Worker (the ongoing question) – often we are reluctant to ask peers or put up our own hands to take on more work, as we are all flat out. If there is no Key Worker it is difficult as SCTT relies on it to work. • Not enough Case Management packages, and CACP’s particularly difficult to work with - Full Cost Recovery required for services – many people excluded so they bounce back to SC and Key worker model – more work for us … we would like to see Case Management not linked to service $$$. Macedon Ranges Care Coordination Meeting 2007

11. Areas to improve • We would like to see an automatic trigger when a complex client is identified through ACAS back to this meeting while they are waiting for Case management, and work more proactively to avoid crisis response. • Agency Encryption NEARLY THERE – so we can refer in and get responses to this meeting safely and efficiently. Macedon Ranges Care Coordination Meeting 2007

12. Does It Work? Yes. Much easier to adapt this type of forum to be person centred. Case 1 • Elderly frail man. Past history of refusing care and deteriorating health. Neighbour (Carer) on the verge of collapse. Multiple Hospital admissions. Assisted to move from primitive to better housing, services implemented and coordinated so not invasive. No refusal of service. Case 2 • A couple won a trip to go to Europe. Problem – 25 year old son with a disability. Mother able to sit down with all services and develop a plan that would work for the family. All services aware of responsibilities. Very few hiccoughs – had a great time. Is it hard work? – Yes again. Macedon Ranges Care Coordination Meeting 2007

13. Questions? Macedon Ranges Care Coordination Meeting 2007

14. Macedon Ranges Shire Council Aged & Disability Unit Kyneton District Health Outreach Service Aged Care Assessment Service Cobaw Community Health Macedon Ranges Health Service Carer Support Services Central Victorian Health Alliance Participating Agencies Macedon Ranges Care Coordination Meeting 2007