Phase Three – Solutions Design Sydney South West Area Health Service CHRONIC AND COMPLEX CARE COLLABORATION AND COORDINATION You have 10 minutes maximum for your presentation including time for questions from the floor. This means that you need to be able to talk to each slide succinctly drawing out the main point(s) or messages. Recommend that you don’t simply read the slides to the audience. Also focus more of your time on the most instructive points. For example, if you are experiencing issues with your project that you believe others would benefit from hearing about, then allocate more time to this part of your presentation.

Scope of the Project Patients with multiple chronic & complex conditions (identified diagnoses) Patients who can be safely managed in the community setting. Patients presenting to Concord and Canterbury hospitals on more than 2 occasions in a calendar year. Patients over the age of 16 years .

Avoidable Admissions (the defined 8 DRGs) Community Acquired Pneumonia (E62C). Chronic Obstructive Pulmonary Disease. (E65B) Bronchitis and Asthma (E69C). Deep Venous Thrombosis (F63B). Acute Non-Surgical Pain (musculotendinous) (I71C). Cellulitis (J64B). Urinary Tract Infections (L63C). Red Blood Cell Disorders and Transfusions (Q61C).

Chronic & complex condition disease groups Respiratory chronic conditions Cardiac chronic conditions Coronary artery disease. Hypertension. Diabetes

Engagement of GPs Survey via GP Division What works well? Gaps? Would you like to be involved? Invitation to participate in Working Parties & interviews Presented the GPC Division Newsletters

Most Prominent Issues Identified by Patients and Staff

Diagnostic themes identified Communication End of Life / Advance Care planning Discharge planning Self Management Duplication & fragmentation of coordination Case management Team work Lack of single point of contact Managing exacerbation in the community – medical governance Information systems & info sharing Referral processes

Patient journey – the current journey Discharge / Transfer of care Health Review Deterioration / Acute Exacerbation Self Management Hospital care Case Management Coordination of Care Hospital presentation Community Care

Patient journey – the desired journey Discharge / Transfer of care Deterioration / Acute Exacerbation Health Review Self Management Coordination of Care Hospital care Case Management Deterioration Hospital presentation Community Care 9

Solutions Expansion of CERNER to include Patient Care Plans Flagging of C&CC patients in the EMR / CERNER GP access to CERNER, sharing medical care & pt action plans Single point of contact Hospital in the Home / Ambulatory Care – rapid assessment/ community treatment Care plans Patient held file Case Management of High Risk Patients Improved discharge processes Increased self management Advance Care Plan Electronic Service Directory Discharge follow-up

What next Finalising Solution Design report Implementation Working Parties Recommendations Cost Benefit Analysis

Project Team & Contact Details For further information or to contribute to the Solutions, please contact the Project Team: Sue Schasser sue.schasser@sswahs.nsw.gov.au Debbie McNamara debbie.mcnamara@sswahs.nsw.gov.au Peter Reisinger peter.reisinger@sswahs.nsw.gov.au