Service Coordination projects Rochester & Elmore District Health Service
REDHS received funding for service coordination project in both 2012 & 2013 Both projects undertaken by Leanne Rankin Diabetes Educator and community health nurse at REDHS Previous experience as ICDM worker for Campaspe PCP.
Issues addressed Central intake All primary care referrals to central intake Including using Connecting care for all internal and external referrals. Referral acknowledgement processes GP Communication Processes when clinicians should communicate to GP Following initial assessment Any time during episode of care as required On discharge Templates for all letters
Central intake Referral acknowledgement practices both CCC and Fax Use of CCC for all internal referrals within REDHS Use of CCC by REDHS for referrals out Local agreements with GP Development of local agreements around referrals, communication and acceptance of Team Care Arrangements
Connecting care usage
Staff change over within Primary Care Ongoing education for all staff re Connecting care usage Policies development & implementation
Issues addressed Review of last years project areas Care planning As extension of HACC ASM work to all primary care services Assessments Review by clinicians and format for client records Central client record Primary care client record amalgamated into hospital client record and stored in medical records department.
Medical records standardised UR All records common file and stored in medical records Service coordination online education package part of PC staff orientation. Care planning service specific REDHS shared support plan Assessments.
Issues with HSD and connecting care change over Ongoing staff changes Ongoing staff education
Fortnightly staff meetings Small team New younger clinicians
Thanks to PCP for the funding for the project. Advantages to having a worker at a local level to initiate activities specific to the needs of our own organisation Networks within service coordination steering committee.
Leanne Rankin Rochester &Elmore District Health Service