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Published byBreana Thomas Modified over 8 years ago
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
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 activity Care Planning Project What we hope to achieve today is to articulate Victoria’s Service Coordination vision and practice standards for Care Planning Provide some clear expectations for service providers Provide information about state-wide tools, resources and support available to implementing care planning Guide the implementation of care planning practice at a service provider level
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
Better Access to Services BATS (2001)framework
Service coordination is underpinned by consumer focus, social model of health, partnership & collaboration, competent staff Significant change required to embed all elements of service coordination –Systems & processes, cultural-organizational & individual Since 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 supported Recognition that significant work would be required across a diverse sector to embed the principles of service coordination
What does Service Coordination mean to our consumers?
Easy, visible ‘entry’ into the system Their full range of needs are identified as early as possible They are treated as a whole person Information about all services are up to date and readily available They don’t have to retell their story every-time they see a new service They control who and what information is shared
Elements of Service Coordination
Service Coordination Progress
Acknowledgement of urgent referrals within 2 working days Initial Needs Identification is conducted within 7 working days of initial contact Key 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 agencies 203 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 information monitoring clients between referrals proving referral feedback and responding to routine referrals Service Coordination Survey 2008
Care Planning Results Service 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 progressed Particularly a coordinated approach where there are multiple issues and multiple providers involved Today’s Presentation What we hope to achieve today is to articulate Victoria’s Service Coordination vision and practice standards for Care Planning Provide some clear expectations for service providers Provide information about state-wide tools, resources and support available to implementing care planning Guide the implementation of care planning practice at a service provider level Finally 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
Service Coordination Progress
Care planning is an integral element of service coordination BUT …..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 progressed Particularly a coordinated approach where there are multiple issues and multiple providers involved Today’s Presentation What we hope to achieve today is to articulate Victoria’s Service Coordination vision and practice standards for Care Planning Provide some clear expectations for service providers Provide information about state-wide tools, resources and support available to implementing care planning Guide the implementation of care planning practice at a service provider level Finally 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.
What is Care Planning? Care planning required whenever assessment occurs Dynamic process that incorporates care coordination, case management, referral, feedback, review, re-assessment, monitoring and exiting Care 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 continuum Single service – straightforward Where 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
Where does Care Planning fit?
Service specific Intra-agency care plan Inter-agency care plan Single 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 to Articulate shaerd goals Outline roles and responsibilities of each practitioner Coordinate internal service provision to support and achieve their goals Facilitate 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 appropriate Monitor and review service provision (including recall) and plan for d/c, transition or exit from service E.g a care plan involving a range of workers ( such as counsellor, support worker, GP) who work in the same organsiation Inter-agency care plan An 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 who Are involved with more than one organisation Have multiple issues or problems that need to be addressed concurrently, such as chronic or terminal conditions Are likely to experience better outcomes if the care and services they receive are coordinated between organisation over time.
What are the Benefits of Care Planning?
Assists consumers in achieving goals Encourages active participation Manages long term care/continuity Provides documentation Encourages a team approach Proactive rather than reactive Increases consumer awareness of services Effective monitoring Goals 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 care Provides 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 centre Increases consumer and carer awareness of support services available, and how and when to access them Ensures effective monitoring of the clients health & wellbeing.
Key Features of Care Planning in Vic.
Nominate single key worker who has a specific role and responsibilities Incorporation of care planning activities Provision of effective monitoring Coordination of referrals & feedback Maximise collaboration with GP Use of SCTT Templates Nomination 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 providers Incorporation 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 needs Acknowledgment of the potential contribution of education and self-management to effective care Provision of effective monitoring (both formal/informal) of a consumers health and wellbeing, and the effectiveness of services being delivered, for example through regular reviews Referral and other information is coordinated, planned and efficient, and specific feedback loops are in place for other service providers and the client Maximising the opportunities inherent in the federal governments MBS items, to facilitate and support collaborative Care Planning with GPs Using the care Coordination Template for clients with complex or multiple needs, who require more than one service provider
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-agency Must have a coordinated response across services and communication between service providers Effective 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 conferencing Examples 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
Person Centred Practice
Partnership approach to care Holistic approach to practice Value of the role of family/carers Support consumer to identify own needs/goals Encourage consumer decision making Support autonomy and choice A partnership approach to care where consumers and service providers share knowledge, values, experience and information, and collaborate to develop goals and plan actions Holistic approach to practice Open 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 privacy Consider the role of family and carers Support clients to identify their own needs and develop their own goals Encourage consumers to choose outcomes they define as meaningful Encourage clients to participate in decision making partnerships in treatment, program planning and policy formation Base practice on client values, backgound and choice as much as possible Support consumers to examine risks and consequences Encourage clients to use their own strengths and natural supports Provide information to involve clients in decision making choices and streamline access to services Respect the clients own style of coping and bringing about change Support autonomy and choice Encourage clients and participants to take responsibility for their part in the plan Be flexible and responsive in planning car5e within the parameters of safety and service guidelines
What is in a Care Plan? Date care plan developed Participants
Consumer stated agreed issues/problems Consumer stated agreed goals Agreed actions/responsibilities/timeframes Planned review date Consumer acknowledgement of care plan Actual review date A Care plan is the documentation of items agreed to in the care planning process. All care plans should include these items:
Key Worker Role is likely to involve:
Engaging and empowering the consumer and acting as an advocate as required Consolidating assessment or care plans Good knowledge of existing services Developing/documenting agreed goals/actions in collaboration (SMART) Facilitate the creation, documentation and communication of initial care plan Monitoring and review The 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.
Key Worker contin………… Liaising and communicating with participants
Organising & facilitating the case conference Working in virtual/multi/inter discipline team Discussing exit options and procedures Feedback to referrers, GP & support workers Ensuring documentation meets requirements of privacy legislation Discuss with participants what key worker models are currently being utilised- share examples regarding above elemenets
Monitoring Care 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.
GP Involvement in Care Planning
Involvement by GPs is the care planning for people with chronic/complex needs is essential Communicate with GP’s to determine if there is an existing care plan A copy of any developed care plan should be provided to the GP CDM items available to General Practice- Team Care Arrangement The 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.
How Can Agencies Support the Process of Care Planning?
Documented protocols Documented care pathways Up-to-date resources for staff Relevant staff training Defined practices/processes/protocols/system Agreements between services (+GP’s) Defined processes for monitoring, review, recall This section sets out the Victorian Practice Standards for Care Planning: Service providers implementing service coordination are expected to have these systems and processes in place Documented protocols to guide a person-centred approach, including multi and inter-disciplinary practices Documented care pathways that include early identification for consumers with complex and multiple issues Up to date evidence and resources for staff, including service directories Relevant staff training, for example in goal setting nad case conferencing Documentation for staff that defines practices, processes, protocols and systems for intra-agency and inter-agency care planning Documentation for staff such as position descriptions and service delivery models that defines the role, functions and responsibilities of the key worker Agreements between services, including GPs, for communication, sharing information, referral, feedback, and exciting processes with other services including GP’s Clearly defined processes for monitoring, review and recall Process Objectives – Care Planning To 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 actions Is person centred Provides health education and empowers consumers to self manage, where appropriate Includes an agreed monitoring process and review dates Is underpinned by communication between the consumers and service providers
Good Practice Indicators
VHA Indicators Service Coordination Manual Consumer Outcomes
Care Plan Elements Date care plan developed
Client stated/agreed issues/problems Client stated/agreed objectives/goals, Client stated/agreed strategies/action Timeframe for attainment of objectives/goals Responsibilities for implementing strategies/action Participants in development of care plan Consumer Acknowledgement (signed or verbal acknowledgement recorded) Review date of care plan (planned and actual) Goal attainment In 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 plan To be complete it requires all the elements to be present These 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
Activity The answers you seek…… ……are in this room
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?
Care Planning Project 2007-2009
Initially developed to progress inter-agency care planning through PCPs Care planning seen as a complex area requiring experienced practitioners able to coordinate care using a comprehensive person centred approach Basic elements & principles of person- centred coordinated care planning not well known This was intended to build on SC work & ICDM work of the PCPs Considerable progress in areas of intake and referral and developing systems to support communication Service coordination work at systems level- cross agency communication, intake & referral protocols, shared consumer pathways,
Care Planning Project found:
Care planning practice inconsistent at inter-agency and intra-agency level Care planning seen as a complex area requiring experienced practitioners able to coordinate care using a comprehensive person centred approach Basic elements & principles of person- centred coordinated care planning not well known That is care planning both within and across agencies
Why has it been difficult?
Increasing complexity & diversity within the service system itself Diverse range of workers with different skills, qualifications and value bases. Varied & inconsistent practice & approaches resulting in different outcomes for consumers
Key Issues Identified Through Care Planning Project
CP project identified skills & knowledge gaps, need for change management, definitions, guidelines, tools Gaps in knowledge and skills in care planning Definitions, guidelines not consistent Lack of a consistent approach at DHS program level- policy & operational guidelines
Need for DHS Response to the Sector
To improve care planning practice at all levels Provide resources to support systems development Opportunity to start process of integration of consistent principles and guidelines across programs where possible Improve care planning practice – particularly a coordinated approach across & within agencies Assist change management and systems approach Discuss ways of integrating consistent guidelines & approach
Tools and Resources Service provider or program Care Planning Guidelines and tools Service Coordination Tool Templates (SCTT) Care Coordination Plan SCTT 2009 User Guide Service Provider policies: Eligibility, criteria, priority, access The human Services Directory MBS care planning items Integrated Health Promotion Tool Kit Training resources
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