1. I MPLEMENTING INTEGRATED M ULTIDISCIPLINARY M ODELS OF C ARE. D EBRA S TARR I NTEGRATED S ERVICE AND P LANNING M ANAGER

2. I NTEGRATED C OORDINATED C ARE H OW WE ARE CHANGING HOW WE WORK Aims and Objectives Strategy Past Pilots Results Overcoming barriers to implementation Current model of implementation Current Pilots Evaluation 2

3. AIMS Stream-lined, coordinated service for those entering our system with complex and/or chronic diseases. Client-centred approach using self-management models of care. Services focusing on not just presenting issues, but risk prevention and holistic management of health issues. Coordinated Care planning and discharge. REACTIVE PROACTIVE 3

4. O BJECTIVES OF CBCHS I NTEGRATED COORDINATED CARE Multidisciplinary Teams Interdisciplinary Assessment System Redesign Consumers Active Partners Processes/Evaluation/Quality Training and Support 4

5. S TRATEGY Driver Strategic Plan Operational Plan Team Planning Identification of change champions 5 A PRIORITY FOR ORGANISATION

6. C OMMUNICATION S TRATEGY 6 BoardMEC Program Managers Team Leaders Teams Newsletter Client Information Forum Questionnaire Focus Group Client participation Meetings

7. B ACKGROUND PILOTS Pilot – PDSA Approach Interdisciplinary Assessment Learning's from the design and implementation of the tool 7

8. I NTERDISCIPLINARY A SSESSMENT Patient and Carer Issues 8 Physical Psycho-socialCognitive Functional Interdisciplinary Assessment Team Based Assessment Health Needs Identification Planning Goals Actions

9. P ILOT 2 6 month pilot study (2012) Investigated the implementation of how an Integrated chronic disease model of care could be introduced into the Primary Health Service at CBCHS. Involved 22 staff members. Training provided on self-management of chronic disease 3 multidisciplinary pilot groups 9

10. RESULTS Understanding and confidence Job satisfaction Identification of client priorities Collaboration, coordination a resources Multidisciplinary Teams 10

11. O VERCOMING B ARRIERS TO IMPLEMENTATION Discipline Specific Verses Multidisciplinary Change ‘like the way things are’ We already work in an integrated model Previous Pilots and getting staff on board Confidence Time, Wait Lists, Competing Priorities Processes/tools/TRAK 11

12. S YSTEM RE - DESIGN 12

13. N EW PILOT I NTEGRATED H EALTH T EAM (IHT) 13

14. E VALUATION ACIC PACIC Audit Focus Group 14

15. FOCUS GROUP RESULTS One holistic assessment reduced duplication/ better understanding of clients needs Development of Tools: case discussion, care planning, discharge Trust in other Services/ Job satisfaction Collaborative care planning/joint consultations/case conference/home visits Primary Clinician/Learn from others/peer supervision Client outcomes Observed: less hospitalisation, increased confidence, independently attending appointments 15

16. V IGNETTE Frequent non- attender Doctor Shop Not taking Medications Lack of social support Mistrust in health system Reduced ability to manage conditions Attending Appointments Taking Medications Has formulated Goals Walking with an aid Wearing shoes Has council services Has trust in health system Increased Confidence Improvement in health status Before After 16

17. L EARNING ' S Model of implementation takes time Variable evidence suggests that some Health Professionals are on board and some are not. Model and process have been implemented in a pilot with positive results 17

18. F UTURE DEVELOPMENTS The challenge ahead to further implement an Integrated coordinated system across all sites. All Health professionals completing a interdisciplinary assessment on all clients entering our services. 18 Debra Starr dstarr@cbchs.org.au