Presentation on theme: "The Practice Standards for the Implementation of Care Planning in Victoria. Presented by: Kate Boucher, Integrated Chronic Disease Management Team &"— Presentation transcript:
1 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 activityCare Planning ProjectWhat we hope to achieve today is to articulate Victoria’s Service Coordination vision and practice standards for Care PlanningProvide some clear expectations for service providersProvide information about state-wide tools, resources and support available to implementing care planningGuide the implementation of care planning practice at a service provider level
3 Service Coordination Tower of Babel according to the Book of Genesis, was an enormous tower built at the city of Babylon.Some believe that a vengeful God, seeing what the people were doing, came down and confused their languages and scattered the people throughout the earth.The purpose of the Service coordination Practice Manual is to assist service providers to implement SC in a consistent manner. The manual has been designed as a reference guide for leading and implementing the practices and standards that underpin SC
4 Better Access to Services BATS (2001)framework Service coordination is underpinned by consumer focus, social model of health, partnership & collaboration, competent staffSignificant change required to embed all elements of service coordination–Systems & processes, cultural-organizational & individualSince Service Coordination was introduced in 2001, government funded health and community services have been progressively implementing service coordination to achieve better outcomes for clients.Consumer focus- driven by the needs of consumers and the community rather than the needs of the system or those who practice in it.Social model of health- this framework is concerned with addressing the social & environmental determinants of health & wellbeing, as well as biological and medical factors ( bio/psycho/social)Partnership & Collaboration- service providers work together ad take responsibility for the interests of consumers, not only in their own service but across the service system as a whole.Competent staff- service coordination ( care planning) is undertaken by staff who are appropriately skilled, qualified, experienced, supervised and supportedRecognition that significant work would be required across a diverse sector to embed the principles of service coordination
5 What does Service Coordination mean to our consumers? Easy, visible ‘entry’ into the systemTheir full range of needs are identified as early as possibleThey are treated as a whole personInformation about all services are up to date and readily availableThey don’t have to retell their story every-time they see a new serviceThey control who and what information is shared
7 Service Coordination Progress Acknowledgement of urgent referrals within 2 working daysInitial Needs Identification is conducted within 7 working days of initial contactKey message: results of the 2008 service coordination survey indicate mature levels of service coordination implementation in most of the areas covered by the survey.commencing in the depth and breadth of service coordination implementation has been measured.a web based tool is completed by PCP member agencies203 agencies responded to the 2008 service coordination survey this included a total of 636 programs.The chart on the slide shows that more than 90% of agencies who completed the survey responded to urgent referrals within 2 days.Similar results were found for:- obtaining client consent for disclosure of client informationmonitoring clients between referralsproving referral feedback andresponding to routine referralsService Coordination Survey 2008
8 Care Planning ResultsService 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).Although care planning is an integral element of service coordination it has been one of the least progressedParticularly a coordinated approach where there are multiple issues and multiple providers involvedToday’s PresentationWhat we hope to achieve today is to articulate Victoria’s Service Coordination vision and practice standards for Care PlanningProvide some clear expectations for service providersProvide information about state-wide tools, resources and support available to implementing care planningGuide the implementation of care planning practice at a service provider levelFinally to achieve an outcome of improving the consumer journey and experience by implementing care planning as part of SC in a consistent, high quality manner.This presentation should also generate some thought and discussion into monitoring, benchmarking and continuous improvement activities to help develop care planning processes within your organisation.Service Coordination Survey 2008
9 Service Coordination Progress Care planning is an integral element of service coordinationBUT …..still a complex area which generates many questions……Although care planning is an integral element of service coordination it has been one of the least progressedParticularly a coordinated approach where there are multiple issues and multiple providers involvedToday’s PresentationWhat we hope to achieve today is to articulate Victoria’s Service Coordination vision and practice standards for Care PlanningProvide some clear expectations for service providersProvide information about state-wide tools, resources and support available to implementing care planningGuide the implementation of care planning practice at a service provider levelFinally to achieve an outcome of improving the consumer journey and experience by implementing care planning as part of SC in a consistent, high quality manner.This presentation should also generate some thought and discussion into monitoring, benchmarking and continuous improvement activities to help develop care planning processes within your organisation.
10 What is Care Planning?Care planning required whenever assessment occursDynamic process that incorporates care coordination, case management, referral, feedback, review, re-assessment, monitoring and exitingCare 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)-creates structure in the client pathway and links the client journey for chronic disease management-ensures consistent and planned care across the continuumSingle service – straightforwardWhere more than one service and more than one practitioners can require a coordinated approach particularly for people with chronic & complex conditions who are moving in and out of the system
11 Where does Care Planning fit? Service specificIntra-agency care planInter-agency care planSingle service – straightforward one practitioner involved e.g. Individual Treatment Plan, Self Management plan, Individual support Plan ( Disability)An Intra- agency care plan is used for clients who require multiple services from within a single organisation, in order to coordinate service delivery. Clients have service specific care plans and an overarching intra-agency care plan. An intra-agency care plan can be documented using the SCTT Care Coordination Plan toArticulate shaerd goalsOutline roles and responsibilities of each practitionerCoordinate internal service provision to support and achieve their goalsFacilitate communication of agreed strategies and interventions, to ensure all involved in the consumer’s plan are well-informed and working towards rthe same goals.Identify the person responsible for care coordination, key worker, care coordinator or case manger as appropriateMonitor and review service provision (including recall) and plan for d/c, transition or exit from serviceE.g a care plan involving a range of workers ( such as counsellor, support worker, GP) who work in the same organsiationInter-agency care planAn inter-agency care plan is used with clients who have complex or multiple needs and require services from more than one organisation ( for example a client with a chronic disease). An inter-agency care plan can be developed using the SCTT Care Coordination Plan for clients whoAre involved with more than one organisationHave multiple issues or problems that need to be addressed concurrently, such as chronic or terminal conditionsAre likely to experience better outcomes if the care and services they receive are coordinated between organisation over time.
12 What are the Benefits of Care Planning? Assists consumers in achieving goalsEncourages active participationManages long term care/continuityProvides documentationEncourages a team approachProactive rather than reactiveIncreases consumer awareness of servicesEffective monitoringGoals are identified by the client- goal directed care planning- encourages the client to be involved in their care and incorporates self management support, where possible.Provides an essential checklist to ensure continuity of careProvides a way of documenting essential information to be shared by others, including life saving actions for emergencies.Encourages a team based approach, with the client at the centreIncreases consumer and carer awareness of support services available, and how and when to access themEnsures effective monitoring of the clients health & wellbeing.
13 Key Features of Care Planning in Vic. Nominate single key worker who has a specific role and responsibilitiesIncorporation of care planning activitiesProvision of effective monitoringCoordination of referrals & feedbackMaximise collaboration with GPUse of SCTT TemplatesNomination of a single key worker to promote effective communication between the client & service providers. The key worker may have a specific role, such as a coordinator. They are responsible, within the scope of their role, for ensuring the care plan is delivered and monitored, review dates are set, re-assessment are initiated, and feedback is given to referring service providersIncorporation of care planning activities (from a simple booking of services through to comprehensive case management) for clients, where a client requires multiple services, or has complex multiple needsAcknowledgment of the potential contribution of education and self-management to effective careProvision of effective monitoring (both formal/informal) of a consumers health and wellbeing, and the effectiveness of services being delivered, for example through regular reviewsReferral and other information is coordinated, planned and efficient, and specific feedback loops are in place for other service providers and the clientMaximising the opportunities inherent in the federal governments MBS items, to facilitate and support collaborative Care Planning with GPsUsing the care Coordination Template for clients with complex or multiple needs, who require more than one service provider
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-agencyMust have a coordinated response across services and communication between service providersEffective inter-agency care planning enables proactive rather than reactive approach to care for people with multiple support needs.It is the most complex form of care planning, requiring a person in a specific role to coordinate information and assist the consumer to access appropriate care.An interagency care plan provides a document for the coordination and client centred approach to addressing client needs.The SCTT Care Coordination Plan is useful for documenting essential information, including life-saving actions for emergencies. It has been designed to encourage a team approach with the client at the centre.The development of a care coordination plan can increase client and carer awareness of the support services available to them.Service providers can use secure electronic forms of the Care Coordination Plan for efficient information sharing and on-line case conferencingExamples of inter-agency Care Plan ( between organisations)A care plan for an older person with a chronic condition, who receives services from a GP, uses a range of HACC services and allied health services from a Community Health Centre
15 Person Centred Practice Partnership approach to careHolistic approach to practiceValue of the role of family/carersSupport consumer to identify own needs/goalsEncourage consumer decision makingSupport autonomy and choiceA partnership approach to care where consumers and service providers share knowledge, values, experience and information, and collaborate to develop goals and plan actionsHolistic approach to practiceOpen clear communication, which respects a consumers values, culture and beliefs, based on practice that sensitive to cultural, communication and cognitive needs of the consumer ( for example, use of interpreters, translated material)Respect for privacyConsider the role of family and carersSupport clients to identify their own needs and develop their own goalsEncourage consumers to choose outcomes they define as meaningfulEncourage clients to participate in decision making partnerships in treatment, program planning and policy formationBase practice on client values, backgound and choice as much as possibleSupport consumers to examine risks and consequencesEncourage clients to use their own strengths and natural supportsProvide information to involve clients in decision making choices and streamline access to servicesRespect the clients own style of coping and bringing about changeSupport autonomy and choiceEncourage clients and participants to take responsibility for their part in the planBe flexible and responsive in planning car5e within the parameters of safety and service guidelines
16 What is in a Care Plan? Date care plan developed Participants Consumer stated agreed issues/problemsConsumer stated agreed goalsAgreed actions/responsibilities/timeframesPlanned review dateConsumer acknowledgement of care planActual review dateA Care plan is the documentation of items agreed to in the care planning process. All care plans should include these items:
17 Key Worker Role is likely to involve: Engaging and empowering the consumer and acting as an advocate as requiredConsolidating assessment or care plansGood knowledge of existing servicesDeveloping/documenting agreed goals/actions in collaboration (SMART)Facilitate the creation, documentation and communication of initial care planMonitoring and reviewThe key worker role in Care Planning should be fulfilled by a trained service provider with the skills and competence to undertake care coordination. Each program area and local service system will have different guidelines, which determine availability of staff to perform the key worker role. Service providers may elect to elect to create a specific key worker role to support the implementation of Service Coordination.A range of staff may participate in Care Planning by communicating communicating outcomes and progress to the key worker. People who may perform key worker functions, within the scope of their role, include: family support case managers, aged care case managers, disability support workers, integrated cancer services professionals, mental health case managers, housing support workers, nurses, d/c planners, social workers, care coordinators, GPs, HACC, Aboriginal liaison staff, or assessment staff.When determining the key worker, consider client preference, relationship to client, level of engagement, frequency of contact, skills and capacity of the worker. The key worker may change over time.
18 Key Worker contin………… Liaising and communicating with participants Organising & facilitating the case conferenceWorking in virtual/multi/inter discipline teamDiscussing exit options and proceduresFeedback to referrers, GP & support workersEnsuring documentation meets requirements of privacy legislationDiscuss with participants what key worker models are currently being utilised- share examples regarding above elemenets
19 MonitoringCare 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 essentialCommunicate with GP’s to determine if there is an existing care planA copy of any developed care plan should be provided to the GPCDM items available to General Practice- Team Care ArrangementThe involvement of GPs in Care Planning for people with complex or multiple needs or chronic diseases is essential.Importantly, GPs can be involved in care planning led by other service providers, or they can lead Care Planning, which involves other service providers.When a multi-service care plan is needed, service providers should consider communicating with the consumers GP to establish if there is already an existing care plan and determine the roles and responsibilities of the participants in the care planning process.When a care plan is developed a copy of the care plan should be sent to the GP, with the consumers consent.The ways that GPs can be involved in Care Planning are guided by the MBS Guidelines and general practice tools, which have been developed to meet MBS rules.As part of the Chronic Disease Management (CDM) items available to general practice is a service for GP-only care planning, which is the General Practice Management Plan (GPMP). This is for clients who have a chronic or terminal medical condition without multi-disciplinary care needs.The Team Care arrangement (TCA) is for consumers who have complex care needs and require other service providers in their care. If eligible, the consumer can access multi-disciplinary services, such as subsidised access to allied health, through a TCA. GP’s can be assisted by practice nurses, Aboriginal health workers and other health professionals in providing these items.Further information about how GP’s can be involved in Care Planning can be obtained from your local PCP, local division of general practice.
21 How Can Agencies Support the Process of Care Planning? Documented protocolsDocumented care pathwaysUp-to-date resources for staffRelevant staff trainingDefined practices/processes/protocols/systemAgreements between services (+GP’s)Defined processes for monitoring, review, recallThis section sets out the Victorian Practice Standards for Care Planning:Service providers implementing service coordination are expected to have these systems and processes in placeDocumented protocols to guide a person-centred approach, including multi and inter-disciplinary practicesDocumented care pathways that include early identification for consumers with complex and multiple issuesUp to date evidence and resources for staff, including service directoriesRelevant staff training, for example in goal setting nad case conferencingDocumentation for staff that defines practices, processes, protocols and systems for intra-agency and inter-agency care planningDocumentation for staff such as position descriptions and service delivery models that defines the role, functions and responsibilities of the key workerAgreements between services, including GPs, for communication, sharing information, referral, feedback, and exciting processes with other services including GP’sClearly defined processes for monitoring, review and recallProcess Objectives – Care PlanningTo ensure that consumers are offered and have access to care planning and service coordination that :Takes into account social, emotional, and health needs ( not just the presenting issues)Is based on documented needs, consumer-centred goals and actionsIs person centredProvides health education and empowers consumers to self manage, where appropriateIncludes an agreed monitoring process and review datesIs underpinned by communication between the consumers and service providers
22 Good Practice Indicators VHA IndicatorsService Coordination ManualConsumer Outcomes
23 Care Plan Elements Date care plan developed Client stated/agreed issues/problemsClient stated/agreed objectives/goals,Client stated/agreed strategies/actionTimeframe for attainment of objectives/goalsResponsibilities for implementing strategies/actionParticipants in development of care planConsumer Acknowledgement (signed or verbal acknowledgement recorded)Review date of care plan (planned and actual)Goal attainmentIn the absence of clear guidelines for care planning we came up with a definition based on a review of literature and current practice which includes the components to be included in a care plan irrespective of the type of care planTo be complete it requires all the elements to be presentThese elements are consistent with the care plan as outlined in the new service coordination practice manual with the exception that we have the additional elements of goal attained which is a measure of outcome
24 ActivityThe answers you seek…………are in this room
25 Steps to Develop A Care Plan Activity Does this person need a Care Plan?What other care plans could this person already have?How would you explain to this person what a care plan is and why you think they will benefit?How do you obtain consumer consent to the care planning process?Who are the people that need to be involved?How would you obtain and record consent to share information?How would you organise a case conference and who would be involved?How would you agree on who the key worker would be?Record all participants in care, their role and contact details.Identify key issues, agreed goals (SMART), actions, responsibilities/target dates for each goal.How do you decide on the review date?How would you be confident that the consumer understands and agrees on the plan?
26 Care Planning Project 2007-2009 Initially developed to progress inter-agency care planning through PCPsCare planning seen as a complex area requiring experienced practitioners able to coordinate care using a comprehensive person centred approachBasic elements & principles of person- centred coordinated care planning not well knownThis was intended to build on SC work & ICDM work of the PCPsConsiderable progress in areas of intake and referral and developing systems to support communicationService coordination work at systems level- cross agency communication, intake & referral protocols, shared consumer pathways,
27 Care Planning Project found: Care planning practice inconsistentat inter-agency and intra-agency levelCare planning seen as a complex area requiring experienced practitioners able to coordinate care using a comprehensive person centred approachBasic elements & principles of person- centred coordinated care planning not well knownThat is care planning both within and across agencies
28 Why has it been difficult? Increasing complexity & diversity within the service system itselfDiverse 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, toolsGaps in knowledge and skills in care planningDefinitions, guidelines not consistentLack 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 levelsProvide resources to support systems developmentOpportunity to start process of integration of consistent principles and guidelines across programs where possibleImprove care planning practice – particularly a coordinated approach across & within agenciesAssist change management and systems approachDiscuss ways of integrating consistent guidelines & approach
31 Tools and ResourcesService provider or program Care Planning Guidelines and toolsService Coordination Tool Templates (SCTT) Care Coordination PlanSCTT 2009 User GuideService Provider policies: Eligibility, criteria, priority, accessThe human Services DirectoryMBS care planning itemsIntegrated Health Promotion Tool KitTraining resources
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