Presentation is loading. Please wait.

Presentation is loading. Please wait.

Department of Human Services The Practice Standards for the Implementation of Care Planning in Victoria. Presented by: Kate Boucher, Integrated Chronic.

Similar presentations


Presentation on theme: "Department of Human Services The Practice Standards for the Implementation of Care Planning in Victoria. Presented by: Kate Boucher, Integrated Chronic."— Presentation transcript:

1 Department of Human Services The Practice Standards for the Implementation of Care Planning in Victoria. Presented by: Kate Boucher, Integrated Chronic Disease Management Team & Shelly Lavery, Partnerships Team. Primary Health Branch

2 Care Planning in Victoria What is Service Coordination? Where does care planning fit into service coordination? What is a care plan? What is the role of the Key Worker? Practical activity Care Planning Project

3 Service Coordination

4 Better Access to Services BATS (2001)framework Service coordination is underpinned by consumer focus, social model of health, partnership & collaboration, competent staff Significant change required to embed all elements of service coordination –Systems & processes, cultural- organizational & individual

5 What does Service Coordination mean to our consumers? Easy, visible ‘entry’ into the system Their full range of needs are identified as early as possible They are treated as a whole person Information about all services are up to date and readily available They don’t have to retell their story every-time they see a new service They control who and what information is shared

6 Elements of Service Coordination

7 Service Coordination Progress Acknowledgement of urgent referrals within 2 working days Initial Needs Identification is conducted within 7 working days of initial contact Service Coordination Survey 2008

8 Care Planning Results Service Coordination Survey 2008 Service Coordination Plans have been documented for consumers with complex or multiple needs who are receiving services from more than one agency. When there is a Service Coordination Plan, the consumer's GP has a copy of the agreed Service Coordination Plan (if appropriate).

9 Service Coordination Progress Care planning is an integral element of service coordination BUT …..still a complex area which generates many questions……

10 What is Care Planning? Care planning required whenever assessment occurs Dynamic process that incorporates care coordination, case management, referral, feedback, review, re-assessment, monitoring and exiting Care planning involves discussion, negotiation and decision making between service provider and consumer to define goals and strategies, then identify actions and service to meet those goals. Can be at a number of levels- single service, or a number of services both within (intra-agency) & across agencies (inter-agency)

11 Where does Care Planning fit? Service specific Intra-agency care plan Inter-agency care plan

12 What are the Benefits of Care Planning? Assists consumers in achieving goals Encourages active participation Manages long term care/continuity Provides documentation Encourages a team approach Proactive rather than reactive Increases consumer awareness of services Effective monitoring

13 Key Features of Care Planning in Vic. Nominate single key worker who has a specific role and responsibilities Incorporation of care planning activities Provision of effective monitoring Coordination of referrals & feedback Maximise collaboration with GP Use of SCTT Templates

14 Care Planning in Context of Chronic Disease Management Particularly important in facilitating appropriate care for consumers with chronic and complex needs who require multiple services. Consumers with chronic conditions may require care planning at all levels – single service plan, intra-agency and inter-agency Must have a coordinated response across services and communication between service providers

15 Person Centred Practice Partnership approach to care Holistic approach to practice Value of the role of family/carers Support consumer to identify own needs/goals Encourage consumer decision making Support autonomy and choice

16 What is in a Care Plan? Date care plan developed Participants Consumer stated agreed issues/problems Consumer stated agreed goals Agreed actions/responsibilities/timeframes Planned review date Consumer acknowledgement of care plan Actual review date

17 Key Worker Role is likely to involve: Engaging and empowering the consumer and acting as an advocate as required Consolidating assessment or care plans Good knowledge of existing services Developing/documenting agreed goals/actions in collaboration (SMART) Facilitate the creation, documentation and communication of initial care plan Monitoring and review

18 Key Worker contin………… Liaising and communicating with participants Organising & facilitating the case conference Working in virtual/multi/inter discipline team Discussing exit options and procedures Feedback to referrers, GP & support workers Ensuring documentation meets requirements of privacy legislation

19 Monitoring Care Planning includes monitoring to ensure service is delivered as intended and is fulfilling the agreed goals. The role of the key worker and monitoring processes will be developed in the future.

20 GP Involvement in Care Planning Involvement by GPs is the care planning for people with chronic/complex needs is essential Communicate with GP’s to determine if there is an existing care plan A copy of any developed care plan should be provided to the GP CDM items available to General Practice- Team Care Arrangement

21 How Can Agencies Support the Process of Care Planning? Documented protocols Documented care pathways Up-to-date resources for staff Relevant staff training Defined practices/processes/protocols/system Agreements between services (+GP’s) Defined processes for monitoring, review, recall

22 Good Practice Indicators VHA Indicators Service Coordination Manual Consumer Outcomes

23 Care Plan Elements 1.Date care plan developed 2.Client stated/agreed issues/problems 3.Client stated/agreed objectives/goals, 4.Client stated/agreed strategies/action 5.Timeframe for attainment of objectives/goals 6.Responsibilities for implementing strategies/action 7.Participants in development of care plan 8.Consumer Acknowledgement (signed or verbal acknowledgement recorded) 9.Review date of care plan (planned and actual) 10.Goal attainment

24 Activity The answers you seek…… ……are in this room

25 Steps to Develop A Care Plan Activity 1.Does this person need a Care Plan? 2.What other care plans could this person already have? 3.How would you explain to this person what a care plan is and why you think they will benefit? 4.How do you obtain consumer consent to the care planning process? 5.Who are the people that need to be involved? 6.How would you obtain and record consent to share information? 7.How would you organise a case conference and who would be involved? 8.How would you agree on who the key worker would be? 9.Record all participants in care, their role and contact details. 10.Identify key issues, agreed goals (SMART), actions, responsibilities/target dates for each goal. 11.How do you decide on the review date? 12.How would you be confident that the consumer understands and agrees on the plan?

26 Care Planning Project Initially developed to progress inter- agency care planning through PCPs Care planning seen as a complex area requiring experienced practitioners able to coordinate care using a comprehensive person centred approach Basic elements & principles of person- centred coordinated care planning not well known

27 Care Planning Project found: Care planning practice inconsistent at inter-agency and intra-agency level Care planning seen as a complex area requiring experienced practitioners able to coordinate care using a comprehensive person centred approach Basic elements & principles of person- centred coordinated care planning not well known

28 Why has it been difficult? Increasing complexity & diversity within the service system itself Diverse range of workers with different skills, qualifications and value bases. Varied & inconsistent practice & approaches resulting in different outcomes for consumers

29 Key Issues Identified Through Care Planning Project CP project identified skills & knowledge gaps, need for change management, definitions, guidelines, tools Gaps in knowledge and skills in care planning Definitions, guidelines not consistent Lack of a consistent approach at DHS program level- policy & operational guidelines

30 Need for DHS Response to the Sector To improve care planning practice at all levels Provide resources to support systems development Opportunity to start process of integration of consistent principles and guidelines across programs where possible

31 Tools and Resources Service provider or program Care Planning Guidelines and tools Service Coordination Tool Templates (SCTT) Care Coordination Plan SCTT 2009 User Guide Service Provider policies: Eligibility, criteria, priority, access The human Services Directory MBS care planning items Integrated Health Promotion Tool Kit Training resources


Download ppt "Department of Human Services The Practice Standards for the Implementation of Care Planning in Victoria. Presented by: Kate Boucher, Integrated Chronic."

Similar presentations


Ads by Google