1. The Health Roundtable MELBOURNE HEALTH | Community Pathways Model of Care Presenter: Sandra Savy Hospital Code Name: Innovation Poster Session HRT1215 – Innovation Awards Sydney 11 th and 12 th Oct 2012

2. The Health Roundtable KEY PROBLEMS & RECOMMENDATIONS | Direct Access Unit – Activity & Referrals Referral forms redeveloped Ongoing education sessions for key Referrers / Ward Staff DAU Coordinators share responsibility as key Contacts Ongoing education sessions for key Referrers / Ward Staff Non-clinical tasks removed and portfolios established Staff retention low Limited education to Referrers around referral destinations Post Acute Care (PAC) activity below target No key Staff links between Referrers and referral destinations Referral Process too fragmented

3. The Health Roundtable OUTCOME

4. The Health Roundtable Further Review & Innovation | Melbourne Health Home Based Review The internal governance within Medicine & Community Care for home-based services be streamlined to improve coordination of services, optimise efficiencies in staffing and purchasing of brokered services. Expand the role of the Direct Access Unit to provide a single point of access for referrals, including out-of-catchment referrals (Community Access Doorway). That RMH consider implementing a ‘mobile’ team model, working in collaboration with the Direct Access Unit, that supports ward staff with the referral process and facilitates the identification of patients for subacute and community services. That the Direct Access Unit take an organisational lead in educating staff in discharge planning and referral options and processes. Medicine and Community Care conduct a cost/benefit analysis for developing a Post Acute Care (PAC) Nursing workforce to reduce brokerage costs. This includes considering how a PAC Nursing workforce could be incorporated with other appropriate home-based nursing programs to achieve optimal flexibility and efficiency.

5. The Health Roundtable MELBOURNE HEALTH Community Services | Community Pathways Model of Care

6. The Health Roundtable Benefits of the Model Ensures continuum of care – the right care at the right place at the right time Reduces hospital length-of-stay Addresses preventable readmission through various links across Program Areas Supports clear communication across the entire Patient healthcare pathway Considers healthcare as a process and not a solution Reduces operational costs without compromising Patient care

7. The Health Roundtable LESSONS LEARNED  Resourcefulness leads to sustainability  Sustainability is about having the capacity to do what needs to be done: the right care, right place, right time