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

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

 Client Nurse Care Coordinator

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

 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

ProblemPlanActObserveReflect

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

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

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

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

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

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

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

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

 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