1. SWAHS Clinical Redesign Aged & Chronic Complex Peter Stralow Responding to the Challenge Forum 12 September 2007

2. Background Improve interfaces between: Aged Care Chronic care Cardiac & Respiratory Community Health PACC/NOS GPs NGOs Specifically to improve: patient intake, triage, assessment, and cross referral between service providers.

3. Summary of patient interviews

4. Patient interviews The staff sometimes don’t give us information as they think we know it all. I’ve been doing this for 40 years. (carer) They need co-ordinating in one hit. I had visits by Nepean outreach and the community nurses. There was a bit of a mix up between NOS and the community nurses-one did not know the other was coming”. Number of patient interviews attended: 21 The tool used was the NSW Health Patient and Carer Experience Discussion Record.

5. In summary… what did we learn? There is nothing systemically wrong with current practices, however there is; Little to no coordination & standardisation across services & clusters SWAHS hospital, outreach and community services operate on a ‘hub and spoke’ model to external services such as GPs, RACFs and NGOs Knowledge of services and access to information is disjointed with reliance placed on informal ‘experts’ for advice (rightly or wrongly) Intake criteria are inconsistent – but should they be standardised?

6. In summary… what did we learn? High commitment among staff and evidence of numerous innovations (e.g. OPERA, HOPE Project, HOME First) in models of care. There was a clear commitment to move forward to a successful program of cohesive, integrated and aligned solutions. To facilitate this desired outcome the project team identified the need to develop a framework that would provide coherence and rigour in the solution design process.

7. Chronic care model – best practice Best practice elements to be included in the design of Aged and Chronic models

8. The ‘Total Care Navigation’ framework

9. Reflects the focus on enabling patients to access the right services from the right providers at the right time matched to their level of need. It provided a way of cohesively considering solutions, their design, their priority and their interconnections, as part of the larger picture. In essence, this served as a guide for solution design with a focus on delivering improved patient journeys A key focus of the project has been to ensure that strategies are in place to respond to the challenges of winter 2008.

10. Solutions Implementation of a system for care coordination Care coordination including a strategy that places a person in appropriate programs Systems that flags clients and provides an understanding of the level of engagement e.g. at risk patients First point of contact early identification

11. Solutions Implementation of a Navigation Hub Single point of access within SWAHS Access to information and advice for patients Service directory that facilitates the identification of pathways for patient care Utilise existing systems to provide access to patient information A system that provides required levels of patient information to relevant service providers across the continuum of care

12. Solutions Development and implementation of a self management program Self management programs (stratify low, medium and high) including opportunities for consumers to self manage using communication tools, e.g. electronic home based care Enhanced participation of GPs in the core management of these patients Develop and implement a suite of solutions that enhance GP participation in the core process as well as investigate the functions of GP liaison nurses across SWAHS

13. Solutions Service enhancements Rapid access/response Enhance hospital in home programs including opening up access points Advance care planning in SWAHS by utilising a model of expansion of Geriatric Medicine into RACFs (GRACE) Alignment of aged and chronic care services Carers program of coordinated Transport services / car parking Tele-based medicine