Embedding a Broader Needs Assessment Changing Practice Embedding a Broader Needs Assessment Framework Acknowledgement to Peninsula Health (demonstrated leadership in taking on this piece of work that has gone on to inform 2 local councils and their assessment frameworks) this was an unfunded piece of work Julie White

Why?-Plan Background Acknowledges an identified need for a more holistic, coordinated and systematic approach to client care and a move away from the current problem-oriented/discipline-specific focus on health. Adopting a holistic and sensitive approach to client needs in context of their physical, social, emotional and cultural environments Supporting the transfer of care between settings to facilitate the provision of integrated care Reducing assessment duplication Integrating self management, health promotion & prevention within the assessment phase of the client journey The Broader Needs Assessment does not replace clinically specific assessments however it aids in identifying the interrelated factors(social determinants) identified by the World Health Organisation that impact a client’s capacity to self-manage their chronic condition Acknowledgement to Peninsula Health demonstrated leadership by taking on the area of assessment a piece of work that was unfunded There are a number of good reasons for exploring the possibility of a standard comprehensive assessment approach for clients with complex and chronic conditions. These client groups are frequent users of health and aged services across the service spectrum and a standardised approach to comprehensive assessment would potentially be an important step towards the following:’ Achieving person and family centred care Adopting a holistic and sensitive approach to client needs in context of their physical, social, emotional and cultural environments Optimising self-management Supporting the transfer of care between settings to facilitate the provision of integrated care Ensuring that broader client needs are identified regardless of their entry point into the health system Reducing assessment duplication The potential to benchmark client groups and outcomes Integrating health promotion & prevention within the assessment phase of the client journey The Review and Identification of an existing validated comprehensive assessment tool. Final Report Oct 2004 A project undertaken by the Lincoln Centre for ageing and Community Care Research, Australian Institute of Primary Care and La Trobe University for the Department of Human Services Ibid

Do-Getting the evidence to drive change Benchmarked 11 assessment templates in community health against an existing validated assessment template A medical record audit of 120 files was also undertaken with a focus on best practice chronic care e.g. does evidence based decision support drive the care pathway Findings analyzed and benchmarked against Wagner Chronic Care /and Victorian Service Coordination Practice Manual.

Study 0% of assessment templates captured depression and anxiety, oral health, transport issues, financial concerns, formal supports and carer involvement 27.3% of assessments captured smoking and client identified needs 18.2% of assessments captured pain, nutrition and weight 9.1 % of assessments captured cognition and memory, falls, living arrangements and informal supports

Study- Governance- Formation of working group-Key stakeholders from multiple settings and sectors were engaged. Department of Health Industry advisor/DHSV/ Acute Mental Health -key members of working group Developed -Overarching principles aligned with National and State Policy directions All domains sought clinical expertise aligned with evidence based practice and identified locally relevant pathways Obtained consensus and agreement around question set to be trialed Consumer input- we trialed question set with focus group and also utilized a mental health community advisory committee Implement-ACT Three month pilot across multiple services and settings e.g. Koori / PenDAP / Mi Health / Early Intervention /HARP/ Domiciliary Care /Counselling

Study-Outcomes/ Evaluation File Audit Applicability and Practicality of the template questionnaire Post pilot Focus Group Consumer feedback MENTAL HEALTH &WELLBEING %that asked about domain prior %asked about domain after BNA Living Arrangements 52% 94.2% Relationships 88.8% Depression, Anxiety and Stress 50% 86.1% Social Activities (isolation flag) 39 .5% 80.50% Culture, Values and Religion 0%

Study- Domain %that asked about domain prior %asked about domain after BNA Medical Conditions 96.3% 75% 96.3% Client stated issue (client centred care) 47.9% 86% Monitoring Signs and Symptoms 29.1% 63.6% Ability to get to appointments (transport) 6.25% 77.7% Confidence at appointments 2.08% 77% Medication management 27% 88.23% Pain 48% 91.6% Caring for others (carer strain) 8.3% 82% Cognition and Memory 25% 82.35% Falls 31.25% 88.57% Self efficacy 16.6 % 91.4 Eyesight 27.03% 94.2% Hearing 27.03% 93.75% Sleep 16.6 % 87.8%

Integrating Self management into assessment HEALTH RELATED BEHAVIOUR Domain % of files that asked about the domain PRIOR to the BNA template WITH the BNA pilot Oral Health 17.0% 87.87% Smoking 31% 88.57% Client importance and confidence Of the clients who answered yes to smoking 7.1% asked about client importance and readiness to change smoking 53% asked about client importance and readiness to change

Collaboration-Shared Learning's & expertise The Frankston Mornington Peninsula Primary Care Partnership-had identified through a large catchment wide scoping activity that Assessment was an area its partnership would like to focus on A proposal was put fourth that the work undertaken by Peninsula Health could be shared and further roll out could occur across the catchment for a more consistent approach to assessment could be