1. The Health Roundtable Connecting Care in the Community Presenter: Nicole McDonald, Manager Ongoing and Complex Care, CCLHD Central Coast LHD - NSW Innovation Poster Session HRT1215 – Innovation Awards Sydney 11 th and 12 th Oct 2012 1

2. The Health Roundtable KEY PROBLEM  Increasing prevalence of chronic disease  Increasing hospital utilisation associated with complications of chronic disease and access to primary care.  Recommendation of Garling Inquiry - in response to hospital utilisation by chronic, complex and elderly patients – people with multiple health and social issues  Key strategy driving NSW Health Efficiency Plan - hospital avoidance program.  Implementation of the NSW Chronic Disease Management Program (Connecting Care in the Community) 2

3. The Health Roundtable AIM OF THIS INNOVATION  Improve the health system’s capacity to respond to the needs of people with chronic diseases with proactive identification, assessment, enrolment and monitoring.  Provide integrated, patient focused care - addressing clinical and non clinical functional deficits.  Increase service continuity and build strong support for multidisciplinary care, care planning and care coordination.  Increase client capacity for self management and improve the quality of life of people with chronic diseases with support to their carers and families  Reduce the progression and complications of chronic disease  Reduce unplanned and avoidable admissions to hospitals 3

4. The Health Roundtable BASELINE DATA  The Central Coast area has an aging population, lower socio- economics, low education attainment and high reliance on public health care.  A low ratio of GP FTEs per population, which are lower than the recommended national levels.  Only half of chronic condition patients are referred to community services.  Chronic condition patients have low rates of referral to, and completion of rehabilitation. 4

5. The Health Roundtable KEY CHANGES IMPLEMENTED Central Coast Ongoing & Complex Care  Model of Care 5

6. The Health Roundtable KEY CHANGES IMPLEMENTED Established a Care Coordination Team to provide case management and coaching for complex high risk clients. Established an Complex Care Allied Health team to provide and support client interventions. Integrated Connecting Care with capacity to enroll patients across all of the Chronic Disease Management Programs. Trained all Chronic Disease staff in the Health Coaching through HCA. Developed an algorithm into EMR for identification of eligible patients on their 3rd admission. Developed referral pathways for General Practice and 48hr Follow-up. 6

7. The Health Roundtable OUTCOMES SO FAR Patient Profile Connecting Care ICIS Snapshot June 2012 from Complex Care, Respiratory and Diabetes 1640 patients identified as suitable for enrollment  1207 (74%) patients consented and enrolled Ever  433 (26%) Suitable but not consented 86% Declined (Self Managing, RACF, Other appropriate Services) 6% Deceased on follow-up 7% Moved out of area / Unable to contact 1207 patients consented and enrolled Ever  Male 52%Female 48%  Average Age - 70yrs (Range 16yrs – 98yrs) 42% of Patients have Multiple Conditions 1 condition 58% 2 condition 14% 3 condition 12% 4 condition 8% 5 condition 2% Not recorded 6% 770 (64%) Patients Still Current 58% Coaching 38% Case management 4% Tele-monitoring  40% of current patients have care plans shared with GP  Average Length of Enrolment for current patients - 361days  Average Length of Enrolment for discharged patients - 213days 437 (36%) from Ever enrolled but no longer current 24% Deceased 69% Discharged but not deceased 7% Consent to enrol but did not start  Aboriginal Clients slightly younger 60yrs compared to overall 70year and more females enrolled 62% compared to 48% overall.  Clients enrolled with Complex Care slightly older 74yrs compared to 70years overall and more likely to have multiple conditions 62% compared to 42% overall. 7

8. The Health Roundtable LESSONS LEARNT  Need capacity to provide a range of service interventions from intense case management - to health coaching - to follow-up and monitoring.  Need access to the range of services that clients need to be connected to including Allied, Rehab, Community or Medical.  Need to train staff in chronic disease case management, provide tools, scripts and protocols to support client management, and ensure appropriate case load mix.  Need to support capacity for enrolment and management of clients through out the range of chronic disease programs. 8