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1 On-line Service Coordination Learning Module Presenter’s name or details (Arial 22 pt) white

2 Service Coordination “If we do our job well the changes will be hard to notice, things will just work better and people will experience smooth stress free journeys through the care system.” Sophy Athan, Chair, Outer East Primary Care Partnership Consumer Reference Group (2010)

3 About this Resource Service Coordination: Why? What? How? Learning Module What is this Resource? This learning module is an e-learning tool developed by the Victorian Department of Health (DH) to support the practice of Service Coordination in Victoria. This learning module has been developed as an ‘open-book’ learning experience: consequently a hard-copy or electronic copy of the Victorian Service Coordination Practice Manual is a requirement. It is estimated that each participant, depending on knowledge and experience will take between 30 minutes to one hour to complete this learning module. A progress bar is available for participants to view how far they have progressed through this resource.Victorian Service Coordination Practice Manual Who should use this resource? Staff new to Service Coordination may either complete part or all of this learning module It is envisaged that staff who are new to Service Coordination use this learning module in conjunction with their manager to identify areas of focus/priority for their role and responsibility and facilitate a clear understanding of effective Service Coordination practice within their organisation. Other staff who are experienced in Service Coordination may wish to utilise this learning module as a refresher, or as a mechanism to keep updated of the changes to the agreed Service Coordination practice as stated in the Victorian Service Coordination Manual.Victorian Service Coordination Manual Additional Resources Included in this learning module are three additional resources: A template has been developed for participants to record relevant information as they move through the resource. There is a ‘way-out’ option to allow marking of progress in the resource to allow for return and completion at a later date. And a ‘pre-test’ is provided for participants experienced in Service Coordination which provides them with the opportunity to pass over areas in which they can demonstrate competence. Further Information Further information about the template, the way out option and the pre-test can be found in the Overview Section below.

4 Contents OverviewService Coordination Learning UnitsSupporting Sections Introduction to learning moduleUnit 1: Why do we need Service Coordination?Why do we need Service Coordination Where to learn about Service Coordination Structure of learning moduleUnit 2: What is Service Coordination?What is Service CoordinationReference Section Acronyms Common terms How to use learning moduleUnit 3: How is Service Coordination implemented?How is Service Coordination implemented Development of Why? What? How? Contact details

5 Service Coordination Learning Units Unit 1: The Why? Of Service Coordination Unit 2: The What? Of Service Coordination Unit 3: The How? Of Service Coordination 1. Why do we need Service Coordination?Why do we need Service Coordination? 2. What is the policy and why is it important?What is the policy and why is it important? 3. What are the benefits for: 3.1 ConsumersConsumers 3.2 Service ProvidersService Providers 1. What is Service Coordination?What is Service Coordination? 2. What principles underpin Service Coordination?What principles underpin Service Coordination? 3. What are the objectives of Service Coordination?What are the objectives of Service Coordination? 4. Operational elements of Service CoordinationOperational elements of Service Coordination 4.1 Initial ContactInitial Contact 4.2 Initial Needs IdentificationInitial Needs Identification 4.3 AssessmentAssessment 4.4 Care planningCare planning 5. Additional Processes of Service Coordination 5.1 Information provisionInformation provision 5.2 Consent to share informationConsent to share information 5.3 ReferralReferral 5.4 Information exchangeInformation exchange 5.5 Service deliveryService delivery 5.6 ExitingExiting 1.Partnerships/networksPartnerships/networks 2.The Victorian Service Coordination Practice StandardsThe Victorian Service Coordination Practice Standards 3.Service Coordination Tool TemplatesService Coordination Tool Templates 4.Privacy and Consent ResourcePrivacy and Consent Resource 5.Human Service DirectoryHuman Service Directory 6.Your Agency Resources and SupportYour Agency Resources and Support

6 Overview This learning module has been developed as an introduction to Service Coordination and to complement service provider and agency orientation and induction programs. It is a self paced learning package for staff involved in Service Coordination activities. Staff who undertake this learning module will be prompted to discuss various aspects of this learning package with their manager or team leader as they move through the resource. They will need access to the Victorian Department of Health (DH) on-line resources: www.health.vic.gov.au/pcps/coordination and agency specific documents. www.health.vic.gov.au/pcps/coordination Learning Objectives: On successful completion of this learning module the participant will have an understanding of:  the Service Coordination practice in Victoria and its benefits  how Service Coordination enables service providers and agencies to efficiently and effectively meet the needs of consumers and their carers  the operational elements of Service Coordination  the resources available to support Service Coordination 1. Introduction

7 Overview This module is comprised of learning units, a supporting section and appendix. Learning units The learning units are presented in the same format, and include information, learning activity and assessment tasks. The three learning units are:  Why do we need service coordination?  What is service coordination?  How is service coordination implemented? Supporting sections  Where to learn about Service Coordination  Reference  Department of Health Contact details  Development of Why? What? How? Learning Module  Acronyms Appendix The Appendix contains two resources:  A template for recording general and local information as the participant moves through Why? What? How? This template can be printed or saved for future reference.  A pre-test has been developed for staff with an in-depth knowledge of Service Coordination as practiced in Victoria. This test provides participants with the option of reviewing and demonstrating their level of knowledge of Service Coordination. On completion the sections are nominated where participants need to review and refresh their knowledge of Service Coordination. Structure of Learning Module

8 Overview Learners’ Instructions This e-learning tool has been developed to be used in conjunction with The Victorian Service Coordination Practice Manual, therefore a hard-copy or electronic copy must be available for use. Participants are expected to familiarise themselves with the information and case studies provided in each Learning Unit, and to complete all Learning Activities. Information Please read the summarised information provided within this module. This information is indicated by this icon: Learning Activities The Learning Activities are interspersed throughout each unit, and the Learning Activities are indicated by this icon: Assessment Tasks When participants are familiar with the learning materials and information, they can complete the self-assessment tasks to monitor their understanding of the content. Assessment Tasks are indicated by this icon: Links to Internet Resources All links to online resources located elsewhere on the internet will open in a new browser window. Close that window when you are ready to return to the unit. Internet resources are indicated by this icon: 3. How to Use the Learning Module

9 1.1 Why do we need Service Coordination?  A lack of information about what services are available and how the service system works.  Inconsistent practice in identifying needs, assessment and privacy.  A lack of coordination between agencies.  A lack of clear and transparent referral pathways.  Inconsistent quality in information provision, screening, assessment, care/case planning and referral.  Poor information sharing and feedback when referrals are made. Unit 1: The Why? Of Service Coordination What is the aim of Service Coordination? Read through Section 2.3 of The Victorian Service Coordination ManualThe Victorian Service Coordination Manual The concept of Service Coordination was introduced in response to problems experienced by consumers, including:

10 1.2. What is the supporting policy and why is it important? The foundation of Service Coordination is the Better Access to Services: A Policy and Operational Framework (usually referred to as the BATS Strategy). This policy describes why there was a need for Service Coordination to be implemented across primary health, disability and welfare services. The BATS strategy sets out the principles that guide, improve and support consistent practice of Service Coordination. In addition, the framework supports agencies to work together so that, from the consumer’s perspective, services operate in an integrated way and are easier to access and navigate. Better Access to Services: A Policy and Operational Framework Unit 1: The Why? Of Service Coordination Read through the Better Access to Services: A Policy and Operational Framework Executive Summary.Better Access to Services: A Policy and Operational Framework

11 Unit 1: The Why? Of Service Coordination 1.3.1. The Benefits for Consumers Service Coordination enables service providers to work together to ensure a coordinated and integrated response to consumer needs. Some of the benefits for consumers are they:  receive up-to-date information about services in their local area and their options when they first contact a service  experience a faster response time for requests  can expect the same standards of service and approach from each agency  are supported to contact the most appropriate service  experience clear entry points, referral pathways and Service Coordination processes that are easy to navigate, transparent and consistently applied  experience improved access to assessment and care planning services  are supported to be actively engaged in the planning and delivery of services and receive support appropriate to their needs, wishes, circumstances, abilities, safety and cultural background  have information confidentially transferred for the purposes of a referral in a way that does not require them to repeat the information  experience a more coordinated response to their needs from a range of service providers. 1.3 What are the benefits of Service Coordination?

12 1.3.2. The Benefits for Service Providers By aligning systems, process and practice, Services can better communicate and work with each other to share information that will improve consumer outcomes. The partnership approach has provided service providers with an appreciation of their role within the wider service system and their place within it. Some of the benefits for service providers include:  improved working relationships and networks to identify local issues and problem solving opportunities  common practice standards which set out clear guidelines and expectations around key areas of practice between agencies  defined roles and responsibilities  access to resources which support service coordination practice, such as common referral tools (eg SCTT) and Human Services Directory. Stronger inter-agency relationships built around agreed and documented practice standards.  increased awareness of the need for a continuing focus on consumer engagement and consumer- driven decision making.  improved efficiencies with reduced duplication of assessments, services and Streamlined referral processes  improved waiting list management.  service Coordination aligns with accreditation standards of providing quality services and programs and sustaining quality external relationships. Unit 1: The Why? Of Service Coordination 1.3 What are the benefits of Service Coordination?

13 2.1 What is Service Coordination? Service Coordination places consumers at the centre of service delivery to ensure that they have access to the services they need, opportunities for early intervention and improved outcomes. Service Coordination enables services (e.g. aged care, disability, mental health, justice, housing, general practice and alcohol and other drug) to function independently while working in a cohesive and coordinated way to provide shared consumers with a seamless and integrated response. Consider these questions and discuss with a colleague or your manager if you need help:  How is your agency coordinating services for your consumers?  Does your agency’s consumer satisfaction survey reflect that your consumers are experiencing coordinated care? Unit 1: The What? Of Service Coordination

14 Service Coordination is built upon the following principles: A central focus on consumers. This means that service delivery needs to be driven by the needs of consumers and the community rather than the needs of the system, or those who practice in it. Partnerships and collaboration. This refers to agencies working together and taking responsibility for the interests of consumers not only within their own agency, but across the service system as a whole. The social model of health. This framework is concerned with addressing the social and environmental determinants of health and wellbeing such as education and housing as well as the biological and medical factors. Competent staff. This means that the operational elements and processes of Service Coordination must be undertaken by staff members that are appropriately skilled, qualified, experienced, supervised and supported. A duty of care. A duty to take reasonable care of a person. The duty of care extends to Service Coordination where staff have a duty of care to provide accurate and timely information and assist consumers with referrals. Protection of consumer information. The protection of clients’ information is one of the most important principles of Service Coordination. This includes maintaining client confidentiality, protecting the privacy of clients’ personal information and obtaining clients’ consent to their information being collected and used for specified purposes, including being shared with another provider. Engagement of other sectors. Service Coordination embraces the broadest range of partnerships across agency types (small – large, non- government – government etc) and across disciplines. A key role for program/service networks e.g. Primary Care Partnerships includes aligning systems and processes between services within a geographical location. Consistency in practice standards. Service Coordination enables agencies to remain independent of each other as entities but work in a cohesive and coordinated way to ensure that consumers experience a seamless and integrated response. 2.2 What principles underpin Service Coordination? Unit 2: The What? Of Service Coordination

15 The objectives of Service Coordination are: consumers and carers can access accurate and relevant information. consumers can make choices and informed decisions about their care. consumers and carers are able to access appropriate services in a timely and convenient manner. increased the engagement of consumers and carers in the services and programs they need. improved access to services and service outcomes by providing a seamless and coordinated system. consumers participate in the management of their care and care information. 2.3 What are the objectives of Service Coordination? Read pages 11 and 12 of the Victorian Service Coordination Practice Manual.Victorian Service Coordination Practice Manual. Unit 2: The What? Of Service Coordination

16 1.Service Coordination enables services to ………. Answer: function independently while working in a cohesive and coordinated way to provide consumers with a seamless and integrated response. 2. List four of the eight principles of Service Coordination Answer: A central focus on consumers; partnerships and collaboration; the social model of health; competent staff; a duty of care; protection of consumer information; engagement of other sectors; consistency in practice standards. 3. What provides for state-wide consistency in Service Coordination practice? Answer:Practice standards for how agencies should work together, developed by a broad range of programs/services across Victoria, are documented in the Victorian Service Coordination Practice Manual.Victorian Service Coordination Practice Manual Unit 2: The What? Of Service Coordination

17 2.4 Service Coordination operational elements Several operational elements and process have been identified to implement Service Coordination providing a common language and understanding for services to work together and ensure that consumers have a seamless and coordinated care. Service Coordination operational elements Description Initial ContactFirst contact with the service system e.g. via outreach, drop in centre, phone call, presentation at reception etc Initial Needs IdentificationIdentification of the full range of social and health needs, including eligibility, priority and risk. AssessmentAn investigative process using professional and interpersonal skills to uncover relevant issues to develop a care/case plan. Care/case PlanningCare/Case Planning involves discussion, negotiation and decision-making between service provider/s and consumer to define their goals and strategies, resulting in identifying actions and services to meet those goals Unit 2: The What? Of Service Coordination Service Coordination Operational Elements

18 2.5 Service Coordination additional processes. Service Coordination additional processes Description Information ProvisionThe provision of required, relevant and appropriate information to consumers Consent to share InformationThe flow of information between consumers and service providers is vital for effective Service Coordination, and in most circumstances obtaining consent from the consumer is obligatory ReferralReferral is the transmission of personal and/or health information relating to a consumer from one service provider to another service provider/s with the consumer’s consent and for the purpose of further assessment, care or treatment Information ExchangeInformation provision and exchange within and between service providers is a requirement when referring the consumer and/or when constructing and managing a consumer care plan. Service DeliveryThe overall aim of Service Coordination is to “place consumers at the centre of service delivery – ensuring that they have access to the services they need, [and] opportunities for early intervention…” ( www.health.vic.gov.au/pcps/coordination/overview).www.health.vic.gov.au/pcps/coordination/overview ExitingThe consumer can choose to exit at any time from the Service Coordination framework Unit 2: The What? Of Service Coordination

19 The following section that expands on the Service Coordination Operational Elements and Processes Each module has been designed as a separate learning module, and so it is not necessary for all learners to complete all modules of this section. Learners should only complete those modules which are relevant to their job role. If you are uncertain about which parts to complete consult your manager or team leader. Operational elements of Service Coordination 4.1 Initial ContactInitial Contact 4.2 Initial Needs IdentificationInitial Needs Identification 4.3 AssessmentAssessment 4.4 Shared Care PlanningShared Care Planning Additional Processes 5.1 Information provisionInformation provision 5.2 Consent to share informationConsent to share information 5.3 ReferralReferral 5.4 Information exchangeInformation exchange 5.5 Service deliveryService delivery 5.6 ExitingExiting Unit 2: The What? Of Service Coordination

20 Initial Contact is the point a person makes his or her first contact with the service system and will most commonly include:  the provision of accurate service information,  the provision of other information such as health promotion literature  support access to Initial Needs Identification  support consumer to access an external service. Consumers initiate Initial Contact most commonly by telephone or in person but possibly through a friend, relative or other service provider, such as financial counsellors, police or hospital staff. Initial contact may also be part of an outreach program. All agencies provide some Initial Contact. Importantly, formalising the role of Initial Contact has meant a change to the responsibilities and practice of many front of house staff and health/welfare professionals. Which staff members are involved in Initial Contact? Initial Contact happens differently in every agency: in some agencies Initial Contact will be carried out by reception or front of house staff, in other agencies it may be done by a duty worker or information officer. Elsewhere it may be the responsibility of the Service Coordinator (or intake worker). Outreach workers also provide an important point of Initial Contact. Initial Contact and Initial Needs Identification may be carried out by a single staff member at the one time such as the Service Coordinator (or duty worker). In other agencies Initial Contact may be the responsibility of a range of different staff, and Initial Contact and Initial Needs Identification may be completed over a number of days. 2.4.1 Initial Contact Unit 2: The What? Of Service Coordination

21 Consider these questions and discuss with a colleague or your manager if you need help: a.Has initial contact occurred when the consumer has not directly made contact? b.What information may be given and/or collected at Initial Contact? c.Who routinely conducts Initial Contact in your agency? 2.4.1: Initial Contact Unit 2: The What? Of Service Coordination Gary’s story Gary is in his mid 30s, lives on his own following a marriage breakdown and is unemployed. Gary’s sister-in-law rang a counseling service at a local community health centre and made an appointment for him to see some-one as she is concerned that he seems down and the only outings Gary has during the week are to the local pub to play the pokies.

22 1. Who can conduct an Initial Contact with a consumer? Answer - Usually front of house/receptionist, but it may be conducted by any staff member 2. Which of the following best describes Initial Contact? a.When a consumer rings to make an appointment b.When a consumer first contacts the service provider for information c.When the Consumer Information Tool template is documented 3. Consumers should be provided with information about services available in response to their inquiry or as part of an outreach approach (such as: when & where the service is provided, eligibility or access criteria & how to get an appointment) within how many working days of making contact (according to the Victorian Service coordination Manual)? a.1 working day b.2 working days c.7 working days 2.4.1 Initial Contact Unit 2: The What? Of Service Coordination

23 Resources to support Initial Contact  Good practice indicators for initial contact are listed in the VSCPM http://www.health.vic.gov.au/pcps/downloads/sc_pracmanual2.pdf http://www.health.vic.gov.au/pcps/downloads/sc_pracmanual2.pdf  Human Services Directory (http://www.humanservicesdirectory.vic.gov.au) to identify local serviceshttp://www.humanservicesdirectory.vic.gov.au  Service Coordination Tool Templates (SCTT): Consumer Information http://www.health.vic.gov.au/pcps/coordination/sctt2009.htm. In some agencies staff begin to collect and document Consumer Information at Initial Contact. http://www.health.vic.gov.au/pcps/coordination/sctt2009.htm For more information on resources go to Unit 3 2.4.1 Initial Contact Unit 2: The What? Of Service Coordination

24 Initial Needs Identification is an initial screening for risk and service requirements. The practitioner undertaking Initial Needs Identification looks beyond the presenting issues to what underlying issues may exist. Initial Needs Identification is not a diagnostic process but is a determination of the consumer’s risk, eligibility and priority for services. Initial Needs Identification allows for the consumer’s needs to be broadly identified, early in their contact with the service system, not just those needs that can be met by the agency. Consumers can be subsequently informed about the range of service options available to meet their needs and consideration can be given to the wider range of service supports and resources. Which staff members are involved in Initial Needs Identification? Initial Needs Identification needs to be done by staff who possess a broad understanding of the service system, advanced interviewing skills and high-level interpersonal skills, including the ability to develop a rapport with consumers. Initial Needs Identification happens differently in every agency and across funding programs. Initial Needs Identification may be done by dedicated Service Coordination workers (or intake and duty workers) in one agency and by individual practitioners in another agency. Initial Contact and Initial Needs Identification may be done by one staff member all at the same time, or by different staff and over a period of days. 2.4.2: Initial Needs Identification Unit 2: The What? Of Service Coordination

25 Play video to view a role play of Gary’s INI 1. Consider these questions and discuss with a colleague or your manager if you need help: Can you identify any risk and/or service requirements for Gary, beyond the presenting issue? What communication skills did the worker use in the video? Which staff member in your agency would conduct an Initial Needs Identification? What resources could be used? Which SCTT INI templates would be relevant? 2. Search the Human Services Directory (HSD) for the services that Gary requires in your area. http://www.humanservicesdirectory.vic.gov.auhttp://www.humanservicesdirectory.vic.gov.au. 3. Go to http://supportivecancercarevictoria.org/Resources/ResourcesCSVTR.html and play the communication skills video training resources: Responding to anger and responding to emotional skills.http://supportivecancercarevictoria.org/Resources/ResourcesCSVTR.html 2.4.2: Initial Needs Identification Gary is in his mid 30s, lives on his own following a marriage breakdown and is unemployed. Gary’s sister-in-law rang a counseling service at a local community health centre and made an appointment for Gary to see some-one as she is concerned that Gary seems down and the only outings Gary has during the week are to the local pub to play the pokies. Karen is identifying Gary’s issues as part of an INI, in a private room at the community health service. Karen explained the reason for collecting information and how it would be used to assess his needs and support him to access the services he requires. Gary’s story Unit 2: The What? Of Service Coordination

26 1. Which of the following best describes Initial Needs Identification? a.A consumer’s first contact with the service system for information, services, or referral b.When the SCTT are filled in c.An initial screening for risk and service requirements carried out by a professional d.When a comprehensive assessment and analysis of need is conducted 2. Which of the following resources have been developed to support Initial Needs Identification? a.State-wide Human Services Directory b.Your Information – it’s Private brochure c.SCTT INI Templates d.All of the above 3. Who can conduct an Initial Needs Identification? answer: Qualified staff who possess a broad understanding of the service system, advanced interviewing skills and high-level interpersonal skills, including the ability to develop a rapport with consumers. 4 What is the number of working days from the Initial Contact to an Initial Needs Identification, as stated by the Victorian Service Coordination Practice Manual? a.2 working day b.7 working days c.14 working days 2.4.2: Initial Needs Identification Unit 2: The What? Of Service Coordination

27 Resources to support Initial Needs Identification  Good practice indicators for initial needs identification are listed in the VSCPM http://www.health.vic.gov.au/pcps/downloads/sc_pracmanual2.pdf http://www.health.vic.gov.au/pcps/downloads/sc_pracmanual2.pdf  Human Services Directory http://www.humanservicesdirectory.vic.gov.au to identify local serviceshttp://www.humanservicesdirectory.vic.gov.au  Service Coordination Tool Templates (SCTT) have been developed to support Service Coordination: INI templates http://www.health.vic.gov.au/pcps/coordination/sctt2009.htm.http://www.health.vic.gov.au/pcps/coordination/sctt2009.htm For more information on resources go to Learning Unit 3 2.4.2 Initial Needs Identification Unit 2: The What? Of Service Coordination

28 Assessment builds on information collected at Initial Contact and Initial Needs Identification. Assessment requires a more in-depth collection, weighting and interpretation of relevant information. Assessment may involve collecting information on the consumer’s medical, physical, social (such as housing), functional, emotional, lifestyle, cultural, religious, spiritual and psychosocial needs. Many government-funded programs have assessment frameworks, guidelines, templates and tools to guide this process. Assessment is completed by a qualified service provider to:  identify consumer needs, capacity and goals  discuss consumer and relevant others’ goals  determine services required  inform the development of a Care/Case Plan  determine appropriate referrals required and share information with the consumer’s consent. 2.4.3 Assessment Unit 2: The What? Of Service Coordination

29 1. Go to Section 6 of the Victorian Service Coordination Manual, 2009, and read page 50 in relation to Assessment. 2. Read the following excerpt from a case study: Gary is in his mid 30s, lives on his own following a marriage breakdown and is unemployed. Gary’s sister-in-law rang a counseling service at a local community health centre and made an appointment for him to see some-one as she is concerned that he seems down and the only outings Gary has during the week are to the local pub to play the pokies (Initial Contact). At the community health service, Karen has identified Gary’s issues (INI). Karen identified that Gary had a number of issues including:  depression  excessive drinking  a problem with gambling  social isolation  poor nutrition  stomach pains Karen discussed options for support and services available. Initially Gary only agreed to see his GP about his stomach pains. With Gary’s consent, Karen sent the GP all the issues that had been identified in the INI. The GP is able to build on this information and makes an assessment of the presenting issues with consideration of medical, social, functional, lifestyle, cultural, religious and emotional needs. The GP uses appropriate assessment tools to determine the consumer’s needs, existing supports, ability, level of risk and priority for access to other services or further referrals. With Gary’s consent the GP makes a referral to a counsellor to help Gary with his depression and shares the information collected in the INI and his assessment summary with the counsellor. 2.4.3 Assessment Unit 2: The What? Of Service Coordination

30 3. Consider these questions and discuss with a colleague or your manager if you need help:  What SCTT would Karen send for the referral to the GP?  What information sources are available for the GP to use in the assessment?  What is the consent process needed for the GP to share the assessment summary with the counsellor?  What assessment tools does your service use and does it take into consideration medical, social (such as accommodation), functional, lifestyle, cultural, religious and emotional needs? Cont…2.4.3 Assessment Unit 2: The What? Of Service Coordination

31 1. Who can conduct and Assessment? Answer: Trained staff in particular area of service delivery 2. How does Assessment differ from Initial Needs Identification? Answer: Assessment builds on information collected at Initial Contact and Initial Needs Identification, and Assessment requires a more in-depth collection, weighting and interpretation of relevant information. Initial Needs Identification is a broad screening process to identify consumer needs. 2.4.3 Assessment Unit 2: The What? Of Service Coordination

32 Resources to support Assessment  Good practice indicators for assessment are listed in the VSCPM http://www.health.vic.gov.au/pcps/downloads/sc_pracmanual2.pdf http://www.health.vic.gov.au/pcps/downloads/sc_pracmanual2.pdf For more information on resources go to Learning Unit 3 2.4.3 Assessment Unit 2: The What? Of Service Coordination

33 Shared Care/Case Planning is required when the consumer has numerous issues that require the coordinated support of multiple program areas/services from within or between organisations. Information gathered from Initial Contact, Initial Needs Identification, Assessment and service specific Care/Case Plans will inform the shared Care/Case Planning process. Shared Care/Case Planning involves discussion, negotiation and decision-making between service provider/s and consumer to define their goals and strategies, resulting in identifying actions and services to meet those goals. Care/Case Coordinator The Care/Case Coordinator acts as a single point of contact for the consumer and can engage them in making choices, navigating their way through the system and effecting change. The term Care/Case Coordinator may be also be referred to as key worker, lead professional, case worker or case manager. The nomination of a single Care/Case Coordinator promotes effective communication between the consumer and service providers to reduce duplication and inconsistency. The Care/Case Coordinator is responsible for ensuring the Shared Care/Case Plan is developed and monitored, review dates are set, re-assessments are initiated and relevant information is shared with participating service providers. Which staff members are involved in Case/Care Coordination? The Care/Case Coordinator role in Shared Care/Case Planning will be fulfilled by a trained service provider with the skills and competence to undertake Service Coordination. Each program area and local service system will have different guidelines to determine availability of staff to perform the Care/Case Coordinator role. When choosing the Care/Case Coordinator, consider consumer preference, relationship to consumer, level of engagement, frequency of contact, skill and capacity of the worker. The Care/Case Coordinator may change over time. 2.4.4 Shared Care/Case Planning Unit 2: The What? Of Service Coordination

34 1. Read the following excerpt from a case study: Gary is in his mid 30s, lives on his own following a marriage breakdown and is unemployed. Gary’s sister-in- aw rang a counseling service at a local community health centre and made an appointment for him to see some-one as she is concerned that Gary seems down and the only outings Gary has during the week are to the local pub to play the pokies (Initial Contact). At the community health service, Karen has identified Gary’s issues (INI). Karen identified that Gary had a number of issues including:  depression  excessive drinking  a problem with gambling  social isolation  poor nutrition  stomach pains Through the INI and assessment processes Gary was referred to his GP, AOD service, counselor for depression, dietitian, problem gambling and has applied for the Australian Apprenticeships Access Program through centre-link. Each service provider undertook an assessment, drawing on Karen’s initial needs identification and specialist assessments performed prior to their appointment. The assessment included a picture of Gary’s ongoing social, functional, emotional, lifestyle and health needs. Each discipline developed their service specific care/case plans relevant to their areas. The Mental Health counselor, Jenny, identified Gary as having chronic and complex needs, and assumed the role of his care/case coordinator. As Gary’s care/case coordinator, Jenny was the main point of contact for Gary. Jenny developed a shared care/case plan, using the SCTT Shared Support Plan Template. This plan was underpinned by a person-centred, coordinated approach. Gary was actively involved in the development of the plan, and Jenny documented his needs, goals and individual circumstances, as well as opportunities for early intervention. Jenny communicated with other participants in his care when developing the plan, providing opportunity for assessments and service specific care/case plans to inform this process. The Shared Care/Case plan also included actions that ensured continuity of care, such as regular review processes, and indicators for further collaboration. A copy of the Shared Care/Case plan was sent to all the participants in Gary’s care 2.4.4 Shared Care/Case Planning Unit 2: The What? Of Service Coordination

35 2.1 Access online and read through the SCTT - Shared Support Plan Template and the relevant associated guidelines which can be found at: http://www.health.vic.gov.au/pcps/downloads/coordination/sctt2009/care_coordination_plan_lo_3c.pdf, andhttp://www.health.vic.gov.au/pcps/downloads/coordination/sctt2009/care_coordination_plan_lo_3c.pdf 2.2 View the Multidisciplinary Team Communication video at: www.supportivecancercarevictoria.org/Resources/Video/MDT.phpwww.supportivecancercarevictoria.org/Resources/Video/MDT.php 3. Read the Steps to develop a care plan in the Victorian Service Coordination Practice Manual 2009, page 35. 4. Consider these questions and discuss with a colleague or your manager if you need help:  Does your agency’s protocols, guidelines or job description identify or define the care/case coordination (or equivalent) role/responsibilities? Does the shared care/case plan template that your service use comply with the items listed on page 27 of the Victorian Service Coordination Practice Manual?  date care plan developed  participants in development of care plan  consumer-stated and agreed issues or problems  consumer-stated and agreed goals  agreed actions and the name of person or service responsible for each action  timeframe for attaining goals and actions  planned review date  consumer acknowledgement of the care plan (signed or verbal)  actual review date.  What are the benefits of developing a Shared Care/Case plan for Gary and the service providers involved in his care  How would Gary’s needs/goals be prioritised? 2.4.4 Shared Care/Case Planning Unit 2: The What? Of Service Coordination

36 1. The information for a Shared Care/Case Plan is gathered at: a.Initial Contact and Initial Needs Identification b.Initial Needs Identification only c.Initial Contact, Initial Needs Identification and Assessment d.A meeting of practitioners who know what the consumer needs 2. A Shared Care/Case Plan is suitable for consumers who: a.Are being seen by more than one agency and more than one discipline b.Have multiple issues/problems that need to be addressed concurrently c.Are likely to benefit if the care and services they receive are coordinated across agencies over time d.All of the above 3. what should be considered when determining who the case/care coordinator will be? a.Consumer’s preference b.Relationship to consumer c.Level of engagement d.Frequency of contact e.Skill and capacity of the worker f.All of the above 4. Planned reviews for care planning should occur within what timeframe of the date listed for review a.Within one month of the date listed for review b.Within a time frame stipulated in your service provider procedures c.Either A or B 2.4.4 Shared Care/Case Planning Unit 2: The What? Of Service Coordination

37 Resources to support Shared Care/Case Planning  Good practice indicators for Shared Care/Case Planning are listed in the VSCPM http://www.health.vic.gov.au/pcps/downloads/sc_pracmanual2.pdf http://www.health.vic.gov.au/pcps/downloads/sc_pracmanual2.pdf  How to develop a Shared Care/Case Plan is documented in the VSCPM  Service Coordination Tool Templates (SCTT) have been developed to support Service Coordination: Shared Support Plan http://www.health.vic.gov.au/pcps/coordination/sctt2009.htm. http://www.health.vic.gov.au/pcps/coordination/sctt2009.htm For more information on resources go to Learning Unit 3 2.4.4 Shared Care/Case Planning Unit 2: The What? Of Service Coordination

38 2.5. Service Coordination Operational Elements & Processes. Additional Service Coordination processes Description 5.1 Information ProvisionThe provision of required, relevant and appropriate information to consumers 5.2 Consent to share Information The flow of information between consumers and service providers is vital for effective Service Coordination, and in most circumstances obtaining consent from the consumer is obligatory 5.3 ReferralReferral is the transmission of personal and/or health information relating to a consumer from one service provider to another service provider/s with the consumer’s consent and for the purpose of further assessment, care or treatment 5.4 Information ExchangeInformation provision and exchange within and between service providers is a requirement when referring the consumer and/or when constructing and managing a consumer care plan. 5.5 Service DeliveryThe overall aim of Service Coordination is to “place consumers at the centre of service delivery – ensuring that they have access to the services they need, [and] opportunities for early intervention…” ( www.health.vic.gov.au/pcps/coordination/overview).www.health.vic.gov.au/pcps/coordination/overview 5.6 ExitingThe consumer can choose to exit at any time from the Service Coordination framework Unit 2: The What? Of Service Coordination

39 Information literacy Whilst the term health literacy has been defined by the World Health Organisation with specific application to health, the concept of ‘information literacy’ extends beyond health and is equally applicable to other elements of information provision and understanding that underpins Service Coordination. It is generally accepted that ‘information literacy’ is the degree to which individuals have the capacity to obtain, understand and use information. Cultural and linguistic competency Culture affects how people communicate, understand and respond to information. Cultural competence is the ability of organisations and practitioners to recognise the cultural beliefs, values, attitudes, traditions, language preferences and practices of diverse populations and to apply that knowledge to produce a positive outcome. Service providers have their own culture and language. Many adopt the language of their specialty as a result of their training and work environment. This can affect how service providers communicate with consumers. 2.5.1 Information Provision Unit 2: The What? Of Service Coordination Providing information that is relevant to the consumer’s needs may be undertaken at any and all stages of the Service Coordination process. When choosing the type and complexity of information to provide, service providers will be receptive to and guided by the consumer’s needs, learning styles and their capacity to understand information (taking into account issues such as preferred language, visual or cognitive requirements). An understanding of the concept of health literacy may assist service providers to check that consumers have understood and importantly are able to use the information that is being provided. Health literacy Health literacy has been defined as “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health” (World Health Organisation 1998). Health Literacy means more than being able to read pamphlets and successfully make appointments. Consumers are empowered when access to health information is improved and their capacity to use it is effective (World Health Organisation. 7th Global Conference on Health Promotion, 2009).7th Global Conference on Health Promotion

40 Strategies that can enhance the consumer’s understanding of the information that has been provided include:  the ‘teach back’ method confirms service providers have explained what consumers need to know in a manner that they understand  asking consumers what strategies may help them to understand and act on the information acknowledging that many people have difficulty understanding this type of information  creating an atmosphere of respect and comfort with the consumer  limiting information given to consumers during each visit  providing information with visual prompts, simple information and colourful cues. 2.5.1 Information Provision Unit 2: The What? Of Service Coordination

41 Consider these questions and discuss with a colleague or your manager if you need help: 1.What consumer information resources are used at your agency? 2.How is consumer literacy assessed in regard to service requirement and provision at your agency? 3.How can information provision to consumers be improved in your agency? Go to www.nchealthliteracy.org/teachingaids.html and watch the video on the “teach back” methodwww.nchealthliteracy.org/teachingaids.html Optional: Go to http://www.youtube.com/watch?v=4Y0R6s7Y54w for Professor Richard Osborne’s (Deakin University) presentation on Health Literacy, and view the on-line Cultural Awareness video at: www.supportivecancercarevictoria.org/Resopurces/Video/Cultural.php.http://www.youtube.com/watch?v=4Y0R6s7Y54w www.supportivecancercarevictoria.org/Resopurces/Video/Cultural.php. Unit 2: The What? Of Service Coordination 2.5.1 Information Provision

42 1.How is information literacy defined? Answer: The degree to which individuals have the capacity to obtain, understand and use information. 2. List four ways service providers can enhance the consumer’s understanding of the information that has been provided. 1.the ‘teach back’ method 2.asking consumers what strategies may help them to understand 3.creating an atmosphere of respect and comfort with the consumer 4.limiting information given to consumers during each visit 5.providing information with visual prompts, simple information and colourful cues. Unit 2: The What? Of Service Coordination 2.5.1 Information Provision

43 Resources to support information Provision  Information about health literacy can be found at www.nchealthliteracy.org/teachingaids.html www.nchealthliteracy.org/teachingaids.html  Consumer Consent to Share Information form and Consumer Privacy Information brochure are available in a range of languages, including Easy English. Consumer Consent to Share Information form and Consumer Privacy Information brochure Unit 2: The What? Of Service Coordination 2.5.1 Information Provision

44 2.5.2 Consent to Share Information Workers in health and community services have a legal and ethical obligation to support and maintain the rights and safety of the people they support. One of these obligations is to maintain consumers’ privacy and confidentiality, which relates to respecting information about the consumer and its source. Such information should only be disclosed to those who require it and only after agreement with the person concerned; this is referred to as ‘consent’ There are two Acts relevant to Service Coordination, these are the:  Health Records Act, 2001, which regulates the collection and handling of consumer information by health service providers in the State public sector and also seeks to govern acts or practices in the Victorian private health sector; and the  Information Privacy Act, 2000, which regulates the collection and handling of all personal information except health information in the public sector in Victoria. The protection of consumers’ information is one of the most important principles of Service Coordination. Service Coordination models and strategies should incorporate clear arrangements for maintaining consumer confidentiality, protecting the privacy of consumers’ personal information and obtaining consumers’ consent to their information being collected and used for specified purposes, including being shared with another provider as part of a referral (refer to the Health Records Act 2001). A broad screening of a person’s needs may identify multiple, interrelated issues. This information gives service providers a more comprehensive picture of the consumer’s circumstances and wellbeing. However, some of the information may not be directly related to the primary reason for a referral, so consent must be obtained to share this additional information. Unit 2: The What? Of Service Coordination

45 2.5.2 Consent to Share Information 1. Read the following excerpt from a case study: Gary is in his mid 30s, lives on his own following a marriage breakdown and is unemployed. Gary’s sister- in-law rang a counseling service at a local community health centre and made an appointment for him to see some-one as she is concerned that he seems down and the only outings Gary has during the week are to the local pub to play the pokies (Initial Contact). At the community health service, Karen has identified Gary’s issues (INI). Karen identified that Gary had a number of issues including:  depression  excessive drinking  a problem with gambling  social isolation  poor nutrition  stomach pains Through the INI and assessment processes Gary was referred to his GP, AOD service, counselor for depression, dietitian, problem gambling and has applied for the Australian Apprenticeships Access Program through centre-link. Prior to referral, information from INI and assessment were collected using a common referral tool (SCTT), which included what services Gary was currently using, and the services where he had been referred to reduce duplication. Karen explained to Gary his rights to privacy and that consent was needed to share information with other service providers. Gary was given a copy of the brochure Your Information—It’s private. He agreed that Karen could share his information with the other services and practitioners and signed the Consumer Consent to Share Information form. Karen then sent an electronic referral. Unit 2: The What? Of Service Coordination

46 1.read pages 10-11 of the SCTT User Guide at http://www.health.vic.gov.au/pcps/downloads/sctt_user_guide09_intro.pdf and. http://www.health.vic.gov.au/pcps/downloads/sctt_user_guide09_intro.pdf 2.Gary was given a copy of the Consumer Privacy Information Brochure. Locate the Consumer Privacy Information Brochure at http://www.health.vic.gov.au/pcps/publications/languages_privacy.htm http://www.health.vic.gov.au/pcps/publications/languages_privacy.htm 3.Consider these questions and discuss with a colleague or your manager if you need help:  What privacy information is routinely provided, at your service, to your consumers?  What Consent to Share Information form is used at your service? Unit 2: The What? Of Service Coordination 2.5.2 Consent to Share Information

47 Read the following case study and answer the accompanying questions: Ruth, aged 46, has a history of high blood pressure and obesity. She was newly diagnosed with diabetes by her GP and referred to a diabetic educator to support her diabetes management. While discussing eating habits, Ruth became emotional and revealed that she overeats when she feels stressed. She confided in the diabetic educator that she had a problem with drinking alcohol, which she feels stems from sexual abuse that she suffered several years ago. The diabetic educator offered to refer Ruth to services to help manage her diabetes (such as a dietician, podiatrist and ophthalmologist). The diabetic educator also discussed with Ruth if she would like to be referred to a service to support her with her drinking problem, and to a sexual assault service (such as The Centre Against Sexual Assault). Prior to the referral, the diabetic educator explains what happens to Ruth’s private information and how it is protected. Ruth was given a copy of the brochure Your information—It's private. The SCTT consent form was completed, including what information will be shared with which service provider. Ruth consented for all of her information to be shared with the sexual assault service, but indicated that she did not want her sexual abuse experience shared with the other service providers. 1. Which act regulates the collection and handling of consumer information by the diabetic educator? Answer: Health Records Act, 2001 2. Ruth did not want some of her history shared with all of her service providers. How can this be guaranteed for Ruth? Answer: Document Ruth’s request on the consent form. Consent form not to be sent with referral to service providers. Unit 2: The What? Of Service Coordination

48 2.5.2 Consent to Share Information Resources to Support Consent to Share Information  SCTT Consumer Consent to Share Information form and Consumer Privacy Information brochure are available in 53 languages and Easy English.Consumer Consent to Share Information form and Consumer Privacy Information brochure  SCTT User Guide http://www.health.vic.gov.au/pcps/coordination/sctt2009.htmhttp://www.health.vic.gov.au/pcps/coordination/sctt2009.htm  Privacy Resource Packs for PCPs http://www.health.vic.gov.au/pcps/coordination/privacy.htm  Privacy and Consent Training  Office of the Health Services Commissioner: http://www.health.vic.gov.au/hsc/training.htm http://www.health.vic.gov.au/hsc/training.htm  Office of the Victorian Privacy Commissioner: http://www.privacy.vic.gov.au/privacy/web2.nsf/pages/training http://www.privacy.vic.gov.au/privacy/web2.nsf/pages/training For more information on resources go to Learning Unit 3 Unit 2: The What? Of Service Coordination

49 Referral is the transmission, with consent, of a consumer's information from one service provider to another for the purpose of further assessment, or service provision. The objectives of the referral process are to:  assist consumers in a seamless and timely manner, by streamlining access to appropriate services through self-referral or assisted referral  empower consumers to participate in decisions about their care  respect a consumer’s rights and privacy  facilitate choice and understanding  enable referrals to be conducted efficiently and effectively  minimise risk and meeting duty-of-care requirements. Good practice indicators set out the expected response times for acknowledgement of referrals e.g. the service provider receiving a referral is expected to: –acknowledge urgent referrals within no-more-than 2 working days of receipt –acknowledge non-urgent referrals within no more than 7 working days of receipt 2.5.3 Referral Unit 2: The What? Of Service Coordination

50 1.Read page 40 of the Victorian Service Coordination Practice Manual  What are the 3 types of referral? 2.Consider these questions and discuss with a colleague or your manager if you need help:  When would you need to do an active referral?  Discuss when consent must be obtained for a referral, situations when consent is not required and what the process is when a consumer refuses consent.  How are non-urgent referrals sent from your agency?  How does your agency ensure that this information remains secure and confidential until it is delivered to the right person? 3.In Gary’s Story case study,  How many, and to whom were the referrals made? 2.5.3 Referral

51 1. Which of the following templates must be completed prior to sending a referral? a.Palliative Care Supplementary Information b.Need for Assistance c.Consumer Consent to Share Information d.Referral Cover Sheet 2. Which referrals do not require consumer consent? a.All assisted referrals b.Some assisted referrals where referrals are made to other services c.All active referrals d.Some active referrals where referrals are made to statutory services 3. Within how many days should an urgent referral be acknowledged upon receipt according to Victorian Service Coordination Practice Manual?Victorian Service Coordination Practice Manual a.2 working days b.7 working days c.14 working days 4. Within how many days should a non-urgent referral be acknowledged upon receipt according to Victorian Service Coordination Practice Manual?Victorian Service Coordination Practice Manual a.2 working days b.7 working days c.14 working days Unit 2: The What? Of Service Coordination 2.5.3 Referral

52 Unit 2: The What? Of Service Coordination Resources to Support Referral  Good practice indicators for referral are listed in the VSCPM http://www.health.vic.gov.au/pcps/downloads/sc_pracmanual2.pdf http://www.health.vic.gov.au/pcps/downloads/sc_pracmanual2.pdf  The state-wide Human Services Directory/ Better Health Channel has been designed to support Referral. http://www.humanservicesdirectory.vic.gov.au/.http://www.humanservicesdirectory.vic.gov.au/  Service Coordination Tool Templates (SCTT) have been developed to support referral http://www.health.vic.gov.au/pcps/coordination/sctt2009.htm. http://www.health.vic.gov.au/pcps/coordination/sctt2009.htm  Consumer Consent to Share Information form and Consumer Privacy Information brochure are available in 53 languages and Easy English. Consumer Consent to Share Information form and Consumer Privacy Information brochure For more information on resources go to Learning Unit 3 2.5.3 Referral

53 2.5.4 Information Exchange Information exchange is the transmission, with consent, of a consumer’s information from one service to another for the purpose of informing decision-making and coordinating service provision. Exchange of information between services reduces duplication of assessment/services and identifies service gaps. Information exchange between services and service providers may occur throughout the consumers care pathway including:  acknowledgement of referral  following assessment or intervention  care/case planning, review or change in service delivery  handover or transition  exiting service. Unit 2: The What? Of Service Coordination

54 2.5.4 Information Exchange 1.Log on to: www.health.vic.gov.au/pcps/coordination/sctt2009.htm and locate the SCTT Summary Information Exchange.www.health.vic.gov.au/pcps/coordination/sctt2009.htm 2.Consider these questions and discuss with a colleague or your manager if you need help:  Along which points of a consumers care may information exchange between services occur?  What is your service’s protocol on providing feedback on your assessment to the referral agency?  Does your agency have local agreements with referral partners regarding expectation for communicating about common/shared consumers?  Discuss what the benefits are to sharing consumer information between services participating in the consumer’s care. Unit 2: The What? Of Service Coordination

55 2.5.4 Information Exchange Which SCTT is used to exchange information between service providers after referral? Answer: SCTT: Information Exchange Unit 2: The What? Of Service Coordination

56 2.5.4 Information Exchange Resources to Information Exchange  SCTT: Summary Information Exchange  SCTT: Consumer Consent to Share Information form and Consumer Privacy Information brochure are available in 53 languages and Easy English.Consumer Consent to Share Information form and Consumer Privacy Information brochure  Privacy and Consent Training  Office of the Health Services Commissioner: http://www.health.vic.gov.au/hsc/training.htm http://www.health.vic.gov.au/hsc/training.htm  Office of the Victorian Privacy Commissioner: http://www.privacy.vic.gov.au/privacy/web2.nsf/pages/training http://www.privacy.vic.gov.au/privacy/web2.nsf/pages/training For more information on resources go to Learning Unit 3 Unit 2: The What? Of Service Coordination

57 2.5.5 Service Delivery Service delivery is generally undertaken in accordance with local protocols, the needs of the consumer and the level of skill of the person providing the service. Effective service delivery is achieved when the consumer is linked to service providers which provide access and coordinated care that meets the consumer’s full range of needs in a timely manner and without duplication of services. The service provider’s work is supported by the Victorian Service Coordination Practice Standards. These Standards set out agreed process objectives, consumer outcomes, good practice indicators, statewide tools, and resources required for effective Service Coordination. use of Service Coordination Tool Templates (SCTT) enhances effective communication and reduces duplication of services. Use of these templates ensures standardised collection, recording and management of consumer information. Unit 2: The What? Of Service Coordination

58 2.5.5 Service Delivery Consider the question and discuss with a colleague or your manager if you need help:  Do your program protocols or guidelines reflect good service coordination practice? Go to http://www.health.vic.gov.au/pcps/coordination/programs.htm and from the Government Program Policy and Guidelines table, identify if your program is represented. Unit 2: The What? Of Service Coordination

59 2.5.5 Service Delivery 1. When is effective service delivery achieved? Answer: When the consumer is linked to service providers which provide access and coordinated care that meets the consumer’s full range of needs in a timely manner, and without duplication of services. 2. Which resource supports service providers by making available agreed process objectives, consumer outcomes, good practice indicators, state-wide tools, and resources? Answer:The Victorian Service Coordination Practice Standards.The Victorian Service Coordination Practice Standards. Unit 2: The What? Of Service Coordination

60 2.5.6 Exiting Exiting can occur at any stage of the Service Coordination process and is generally managed in accordance with local protocols. Unit 2: The What? Of Service Coordination How can consumers exit from the Service Coordination process at your agency? Discuss with your Manager. A consumer can exit from the Service Coordination process: a.Any time b.Only once a consent form has been signed

61 Unit 3: The How? Of Service Coordination How is Service Coordination delivered? There are a number of resources that support and facilitate the delivery of Service Coordination in Victoria, these are: 1.Partnerships/networksPartnerships/networks 2.The Victorian Service Coordination Practice StandardsThe Victorian Service Coordination Practice Standards 3.Service Coordination Tool TemplatesService Coordination Tool Templates 4.Privacy and Consent ResourcePrivacy and Consent Resource 5.Human Service DirectoryHuman Service Directory 6.Your Agency Resources and SupportYour Agency Resources and Support Unit 3: The How? Of Service Coordination

62 3.1 Partnerships/Networks 1. Partnerships/Networks Effective implementation of Service Coordination principles is achieved through committed and collaborative partnerships. Local partnerships support agencies to work together and take responsibility for the interests of consumers—not only within their own agency, but across the service system as a whole. This starts with fostering relationships and building trust. Achieving shared commitment, mutual respect and trust is no small accomplishment, and requires organisations to reach consensus on the nature of the problems and the outcomes sought. The Victorian Government currently funds local partnership networks (for example, Primary Care Partnerships) to provide administration support and facilitate organisations within a geographic area to come together to agree on how they will coordinate their services and put Service Coordination principles into practice so that consumers experience services that work together. Other networks include:  General Practice Divisions/Medicare Locals  Local Area Service Networks  Local Government Service Provider networks  Mental Health Alliances  Aboriginal Community-Controlled Health Organisations (ACCHOs)  Aged Care Networks  Culturally and Linguistically Diverse service networks  Palliative Care Consortia  Integrated Cancer Services Unit 3: The How? Of Service Coordination

63 3.1 Partnerships/Networks 1.Consider these questions and discuss with a colleague or your manager if you need help:  Is there is any regular interaction between your agency and other local service providers?  If there is interaction, what form does it take, for example, is it on a needs basis, does a MOU exist, do some practitioners have exclusive partnerships, or are all partnerships at your agency shared? 2.Search on-line for your local Primary Care Partnership (PCP) web-site http://www.health.vic.gov.au/pcps/locate.htm http://www.health.vic.gov.au/pcps/locate.htm 3.Search the Human Service Directory for your agency. Which PCP is listed?Human Service Directory Unit 3: The How? Of Service Coordination

64 3.2 The Victorian Service Coordination Practice Standards Programs/services have their own individual program guidelines and protocols to guide practice within their service. A broad range of programs/services across Victoria (e.g. disability, homelessness services, mental health, community health, problem gambling services) have developed practice standards for how they should work together. This is documented in the Victorian Service Coordination Practice Manual.Victorian Service Coordination Practice Manual Operational elements and process have been identified to implement Service Coordination. Defining these elements and processes provides a common language and understanding for services to work together and ensure that consumers have a seamless and coordinated care. Unit 3: The How? Of Service Coordination Go to Section 3 of the Victorian Service Coordination Practice Manual, and read pages 11 and 12.Victorian Service Coordination Practice Manual,

65 3.3 Service Coordination Tool Templates (SCTT) The Service Coordination Tool Templates (SCTT) is a suite of templates developed to facilitate and support Service Coordination. The SCTT support the collection and recording of initial contact, initial needs identification, referral and coordinated care planning information in a standardised way. Using the SCTT can improve communication between service providers, the recording of information generated by screening and assessment processes, information sharing, and the quality of referrals and feedback between service providers. This can assist service providers to share relevant information to support better outcomes for consumers. The templates replace over 300 different tools, are used by more than 600 services across the state and are currently integrated into over 30 different consumer information management systems. Over 500 services make referrals using the SCTT through secure electronic systems. SCTT can be accessed on http://www.health.vic.gov.au/pcps/coordination/sctt2009.htm http://www.health.vic.gov.au/pcps/coordination/sctt2009.htm Unit 3: The How? Of Service Coordination

66 3.3 Service Coordination Tool Templates (SCTT)

67 Consider these questions and discuss with a colleague or your manager if you need help:  Is the SCTT within your Client Information Management System?  Go to http://www.health.vic.gov.au/pcps/downloads/coordination/sctt2009/imple mentation_surveyresults.pdf and check if your client information management system is listed and what is the status of SCTT 2009 implementation. http://www.health.vic.gov.au/pcps/downloads/coordination/sctt2009/imple mentation_surveyresults.pdf  Go to http://www.health.vic.gov.au/pcps/coordination/sctt2009.htmhttp://www.health.vic.gov.au/pcps/coordination/sctt2009.htm  locate the SCTT Core Referral Templates and identify the items that supports reduced duplication.  Locate the guidelines that support completing the SCTT Core Referral Templates Unit 3: The How? Of Service Coordination 3.4 Service Coordination Tool Templates (SCTT)

68 3.5 Privacy and Consent to Share Information The Privacy and Consent resource facilitates discussions between the practitioner and consumer regarding how the information provided by the consumer will be managed. This resource includes two parts: the first part consists of the Consumer Privacy Information Brochure and the SCTT Consumer Consent Form. These resources are available in a range of languages, including Easy English and informs how the consumer’s information will be managed in regard to commonwealth and state privacy legislation. Acts of Law The Health Records Act 2001 (the Act) creates a framework to protect the privacy of individuals' health information. It regulates the collection and handling of health information… The Act applies to the health, disability and aged care information handled by a wide range of public and private sector organisations. This includes health service providers, and also other organisations that handle such information (www.health.vic.gov.au/healthrecords, 2011).www.health.vic.gov.au/healthrecords Unit 3: The How? Of Service Coordination Information Privacy Act (IPA), 2000: The objects of the IPA are to balance the public interest in the free flow of information with the public interest in respecting privacy and protecting personal information in the public sector; and promote the responsible and transparent handling of personal information in the public sector and promote awareness of these practices. Under the IPA, State government organisations, local councils and private sector organisations acting as contracted service providers to the Victorian government are all bound to protect the privacy of people’s personal information. “Personal information” means recorded information which can identify someone… examples of personal information might be someone’s name, address, sex, age, financial details, marital status, education or employment history. Some personal information is called “sensitive information” and is given special treatment under the Act. This includes information about an individual’s ethnic origin, religious beliefs, sexual preferences and criminal record. (www.privacy.vic.gov.au, 2011)www.privacy.vic.gov.au

69 3.5 Privacy and Consent to Share Information Privacy and Consent Training Office of the Health Services Commissioner: Provides two free introductory seminars per year for staff working at agencies and health services that collect, disclose or hold health information in Victoria. Information about the seminars can be found at: http://www.health.vic.gov.au/hsc/training.htmhttp://www.health.vic.gov.au/hsc/training.htm Office of the Victorian Privacy Commissioner: Provides training through Privacy Victoria to assist Victorian public sector organisations inform staff of the requirements of the Information Privacy Act 2000 and to comply with the Information Privacy Act, 2000. Information about the training can be found at: http://www.privacy.vic.gov.au/privacy/web2.nsf/pages/training. http://www.privacy.vic.gov.au/privacy/web2.nsf/pages/training Unit 3: The How? Of Service Coordination

70 Download a copy in English:  the Consumer Privacy Information brochure  the Consumer Consent form. Down-load a copy in Japanese (or a language commonly spoken in your area) of  the Consumer Privacy Information brochure,  the Consumer Consent form. Consider these questions and discuss with a colleague or your manager if you need help:  Which act is relevant for your organisation’s privacy guidelines?  Health Records Act  Information Privacy Act (IPA), 2000  Does your agency provide privacy and consent training opportunities for staff? Unit 3: The How? Of Service Coordination 3.5 Privacy and Consent to Share Information

71 3.6 Human Services Directory The Statewide Human Services Directory (HSD) is a comprehensive repository of health and human services to assist referral and access to services. Consumers, carers and workers may search on the HSD for over 15,000 service sites and 24,000 practitioners (including the States 5,900 GP's). Agencies and practitioners can register their details on the HSD at: http://www.humanservicesdirectory.vic.gov.au. To ensure that the information is kept up to date the agencies/practitioners will be sent a reminder every 6 months and if there is no response after repeated attempts, the information is hidden from public view. http://www.humanservicesdirectory.vic.gov.au Some examples which use the data from the HSD are the Better Health Channel which you have mentioned and also the "Arthritis Map" (www.arthritismap.com.au) which has a consumer/GP focus on one website and a Health Planning component for research/health planning activities. Unit 3: The How? Of Service Coordination

72 Go to the Human Service Directory web-site and search for your agency.Human Service Directory  What Drug and Alcohol Services are available in  your area,  the Alpine Shire.  Find out what counselling and referral services are available for Aborigines in the Lake Tyers area.  Search for any translating and/or interpreting service. Unit 3: The How? Of Service Coordination 3.6 Human Services Directory (HSD)

73 3.7 Your Agency Resources and Support Service Coordination is supported at an agency level by electronic and hard-copy of:  agency specific policies, procedures  resources such as forms, and checklists  consumer data bases and related information management systems  referral pathways  service directories  information packages, pamphlets and fliers. Unit 3: The How? Of Service Coordination Find out what are your agency specific policies, procedures and work instructions that support Service Coordination. Locate the forms, resource folders and checklists that support the implementation of Service Coordination in your agency.

74 Supporting Section Where to learn about Service Coordination What do you want for this section? DH sites and publications plus other sites, eg education sites for SC certificates and diplomas etc?

75 Supporting Section Reference The Reference section contains the following pages: see comment Acronyms Common Terms: A-B Common Terms: C-D Common Terms: E-K Common Terms: L-R Common Terms: S Common Terms: T-Z

76 Supporting Section Development of Why? What? How? The Victorian Department of Health's Self Paced Training Module (SPTM) entitled “Service Coordination: What? Why? How?” was developed in July 2005 to support the process of orientating service provider staff to the fundamentals of Service Coordination by using a web- based and self-paced delivery method. In 2009 the SPTM was found to contain out-dated material and was withdrawn from the web-site. Consequently a review of the SPTM was initiated through the Primary Care Partnership network via the State-wide Service Coordination Network Group to undertake the process of revising the content. South Coast Primary Care Partnership (SCPCP) elected to lead the review as it aligned closely with a key activity of SCPCP’s 2009-2012 Strategic Plan: “Key strategy: Access existing training resources – modify to local needs where necessary including self-directed learning packages (paper and web-based).” The review of the SPTM was undertaken to primarily update the content to ensure its consistency with current best practice and evidence, but also aiming to provide a resource that engages and supports the learner effectively to promote best practice in Service Coordination across a broad range of services. Authors of the review advised a modification of the SPTM’s title to: Why? What? How?

77 Supporting Section Contact details For further information on Why? What? How? please contact: Shelly Lavery Project Manager: Service Coordination & Integrated Chronic Disease Management The Victorian Department of Health Integrated Care Branch, Ph: (03) 9096 1322 Email: Shelly.Lavery@health.vic.gov.auShelly.Lavery@health.vic.gov.au

78 Appendix Appendix one: Service Coordination Information Template Added in comment section as too much information for slides –perhaps best for delivery to clinicians to have hard copy to refer to Appendix two: Pre-test Added in comment section as too much information for slides –perhaps best for delivery to clinicians to have hard copy to refer to


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