1. Service Redesign On The Run Katrina Scott-Charlton, Care Coordinator, Chronic Care Program, ACT Health

2. Improving the management and quality of life for ACT residents with:  Chronic Obstructive Pulmonary Disease  Chronic Heart Failure  Parkinson’s disease

3.  Client Nurse Care Coordinator

4. Respiratory specialist podiatrist Community nursing Endocrine ACAT oxygen cylinder hire Medication management Mobility aids Social worker GP OT Hospital Admissions Cardiology Community services Physio Geriatrician

5.  Provide holistic assessment, care planning, education and support  Assist clients to access health and community services  Attend appointments with clients  Provide psychosocial support and advocacy  Facilitate Advance Care Planning  Support for carers/family

6. ProblemPlanActObserveReflect

8. 1)Create a safe, systematic approach for moving clients toward self-management and discharge 2)More time efficient Literature review

9. Category 1: high needs (usual input) Category 2: Low needs (monthly phone call only) Graduation discharge to CCP nurse support

10. 9 month trial  Quantitative ◦ Monitoring of:  Staff to client ratios  Numbers of Category 1 and Category 2 clients  Activity through Occasions Of Service  Qualitative ◦ Client feedback via survey ◦ Staff feedback via regular team meetings ◦ Staff focus group

11.  46.6% increase in staff to client ratio  58.4% increase in clients receiving care coordination  79% increase in Occasions of Service

13. Staff Feedback: ◦ Occasional home visits were needed for some Category 2 clients Client Survey: ◦ 52% response rate! ◦ 90% felt they had enough support and information through a monthly phone call ◦ 45% felt that it would be beneficial to have an occasional home visit

14. Staff Focus Group Feedback: ◦ Trial streamlined service, increased efficiencies but remained flexible and client focussed ◦ Occasional home visits in addition to phone contact was important to ensure client safety and compliance ◦ Part of the success of the monthly phone call was due to relationship built during face to face contact during home visits

15. 1)Create a safe, systematic approach for moving clients toward self-management and discharge? 2)More time efficient? What Next?

16.  Service redesign and research is possible - even on the run  Start planning early  Stay client/patient focussed  Mix methods

17.  The Care Coordination Clients  Wendy Appleton and Toni Heazlewood, Care Coordinators, Chronic Care Program  Chronic Care Program team  Jan Ironside, Manager, Chronic Care Program  Associate Professor Paul Dugdale, Director, Chronic Disease Management  Dr Geetha Isaac-Toua, Deputy Director, Chronic Disease Management  Claire Pearce, Senior Project Officer, Chronic Disease Management