E Care Planning Project

Background In 2010 the Department of Health sought expressions of interest for the “ Electronic care planning project” from PCPs, progressed in service coordination, integrated chronic disease management and e-referral with the goal to: Embed the SCTT 2009 Care Coordination Plan within existing electronic referral systems and develop the necessary electronic functionality and practice standards to support use. Develop governance structures required to support system and practice issues unique to electronic care planning and the full participation of service providers, clients and carers. Share what is learned and leverage on the projects success to support other PCPs to progress their electronic care planning work

Who was involved Consortium Partners GPV Consumer representatives Outer East Health and Community Support Alliance Inner East Primary Care Partnership Central West Gippsland Primary Care Partnership East Gippsland Primary Care Partnership South Coast Primary Care Partnership Wellington Primary Care Partnership North East Primary Care Partnership Inner South East Partnership in Community and Health South East Healthy Community Partnership GPV Consumer representatives Consortium of 9 PCPs OEHCSA held project funding and acted as project sponsor Project Control Group was established to guide the project (included at least one PCP EO representative from each region, GPV representative and two consumer representatives)

The vision To build an electronic care planning module into the ESCS/S2S system to assist “teams” of practitioners from across the health care system: develop integrated care plans for their shared clients. action the care plans in a more dynamic, coordinated and efficient manner. share vital information and updates with each other about the health care requirements of their shared clients. engage consumers/carers in the development and implementation of their care plan. provide a mechanism for the “care team” to conduct timely and coordinated reviews of the care plan with client/carer input.

Taking an action research approach Step 1: Establishing cluster groups of agencies who are already: working together to provide care for a common group of clients. committed to improving their interagency care planning and care coordination practices. had established agreed protocols and procedures for integrating and coordinating inter agency care arrangements. prepared to pilot the E- care planning module .

Process flow for Initiation and Activation of e-care plan Care Planning Process flow for Initiation and Activation of e-care plan Needs Identification and Analysis process to establish agreed Goals Action Plan Conferencing process to discuss and develop care plan Generate invitation via e-system to relevant practitioners to take part in interagency care planning session. In-Person/teleconference process or online process Coordinated Care Plan Specific Services-Referral Process Accept Not Accept Coordinated care planning session in person Coordinated care planning session on line process Coordinated Care Plan case description with goals agreed with client done on S2S-ESCS Service Initiation Process Referral Generation and Send Lodge coordinated care plan on line Agency/Service A Agency/Service B Agency/Service C Feedback Level 1 Information Acknowledgement-Accept/ Not Accept Status Updates Link to coordinated care plan on line Activity Panel care plan information updates Agency/Service specific assessment and plan Link to coordinated care plan on line Activity Panel Status Updates care plan information updates Feedback Level 2 Information Referral outcome information Link to coordinated care plan on line Activity Panel Status Updates care plan information updates Feedback Level x Information Review outcome information Coordinated care plan on line Review

Step 2: Providing practitioners involved in the cluster groups with training and support: All pilots received support and guidance from the project manager and PCP staff to review: key information collection practices information flow and decision making pathways into and through their agency. All cluster groups were provided with training in the use of the E-care planning module. Support through the existing PCP services coordination structures. 2 cluster groups were participating in the DH “Implement Goal-directed Care Planning” workshops.

Step 3: Using the E- Care Planning Module- (commenced September 2011- early successes as at 15th December 2011) 1. Number of care plans: 25 2. Number and type of practitioners enrolled on system: 70 Mental Health Care coordinators Mental Health Clinical/Case Managers, Psychologist and Psychiatric Nurses GPs and Practice Nurses Chronic Disease Care Coordinators HACC Assessors and team leader of service teams Intake/ Service Access Officers District Nurses Allied Health Physiotherapist, Social workers, Occupational Therapists, Dietician, Exercise Physiologist. 3. Type of consumers: Refer to table 4. Care plans at review stage: 4 5. Additional interest in e-care planning: 2 new groups initiated and 3 at planning stage.

What people said about the system? It is evident that the E- care planning system in a short period of time, has enabled shared care planning to occur that otherwise would not have. The technology is easy to use and very capable of achieving communication between different agencies and professionals working jointly with a client to achieve their goals. The system is easy to use... information can be stored in a secure and private manner. It is an excellent communication tool for members of a client’s care plan network.

What people said about participating in the pilots Being involved in joint training and working together made discussing care plans easier. Having access to supportive people like our local project manager who has been good at keeping the process moving and been willing to visit agencies. We are hoping it will improve both our care coordination with district nurses and allied health internally as well as Mecaware, and eventually ACAS. The pilot for E Care coordination has assisted agencies to put the use of the system on their agenda.

What people said would help embed e-care planning into practice What worked for us was the small group training sessions with the agency, followed up by 1:1 coaching to develop live care plans with a champion in each agency or across agencies. Conducting joint training sessions – our agency (Council) conducted a joint session with RDNS and Community health, which demystified the technology and promoted an interest in working together. Increasing the breadth of agencies using the system. Training including: working collaboratively with a client to set goals. identification of need. use of the e-care planning module and E-SCS/S2S.

Presentation of the E-care planning module: Supporting documents handed out for the presentation: Structure of the E-SCS/S2S system and related e-care planning module. Summary of features of the e-care planning module “Information forms” contained in the e-care planning module.

Recommendations Relating to consumers: 1. Development of consumer information documents regarding: what it means to a consumer to participate in the care planning and e-care planning processes and guidelines for discussing the consumer roles and responsibilities in relation to provision of informed consent. 2. That the layout of the compressed view and its printout be reviewed with a view to improving consumer useability and reducing the number of pages in the printout. 3. That the prototype Consumer Access screens for the e-care planning module be constructed in consultation with the Consumer Reference Group and submissions be developed to resource a project to develop and pilot the screen.

Recommendations cont... Supporting practice improvements and reporting requirements: 4. That funding be sought to include within the E-SCS/S2S system: The e-referral feedback functionality described in Report 1 The functionality for the e-referral feedback (level 2) to be provided by each individual service provider when several services are requested in a single e-referral. The Reports functionality

Recommendations cont... Supporting the change process: 5. A proposal be developed and funding sought to trial an experimental approach with the cluster groups, to developing the skills (practitioner and consumer) of “shared deliberation” and to communicate the learnings to the field. 6. That consideration be given to identifying resources to embed inter-agency shared care implementation processes – a structured PDSA approach could be used to further support implementation within each of the cluster group.