1. Review of the Peninsula Health Hospital Admission Risk Program (HARP) Presenter: Belinda Berry PENINSULA HEALTH COMMUNITY HEALTH

2. HARP Redesigning Care Before redesign HARP services had evolved to: Community Based  Residential Outreach Support Service ROSS Team  Peninsula Complex Care Team  MI Health  SHARPS  Hospital Based  Response Assessment & Discharge RAD Team  Drug & Alcohol Liaison

3. HARP Redesigning Care Concerned over time there had been a:  Shift in focus away from Frequent Presenters  Limited Pathways to Community HARP  HARP Services spread over 5 program areas  Need for review of our HARP Governance in light of revised HIP Guidelines  Evidence to support intensive care coordination model for this target group  Need to clarify outcomes for HARP Service

4. HARP Redesigning Care

5.  Issue 1 – Focus on Ambulatory Sensitive Conditions

6. HARP Redesigning Care  Issue 2 – Focus on Care Coordination

7. HARP Redesigning Care  Issue 3 – Focus on Frequent Presenters

8. HARP Redesigning Care  Issue 3 – Focus on Frequent Presenters

9. HARP Redesigning Care  Issue 4 - Where do our Frequent Presenters go?

10. HARP Redesigning Care  Issue 5 – Outcomes & Deliverables HARP criteria not consistent within HARP programs Lack of unified focus on frequent presenters & ACSC Core HIP Guidelines not met; –Lack of Care Coordination –Multiple access points for HARP contact –Medical support lacking from interdisciplinary approach –Marginalised groups who meet HARP criteria not well engaged –Self Management Support not implemented across HARP –Lack of focus on Advanced Care Planning

11. Decision Support -Evidenced based practice - Risk calculating tools - Self Management - Consistent with ACCESS Clinical Information Systems - Utilise blackberry for frequent presenters -IPM alert system to Support frequent presenters & ED management plans -PJB data management system -VINAH reports generated Delivery System Design -Regular, proactive visits - Multidisciplinary - Targeted recruitment - Responsive to patient needs - Integrated throughout settings Community Resources -Engaged & utilised to support clients -Involved & active in the community -Develop partnerships for service delivery -Right place -Right time Self Management Support -Support clients to Educate & self manage themselves -Tailor strategies - Educate carers & family - Symptom diaries - Action plans -Document & Record - Measure improvement HARP Redesigning Care Framework for future HARP Service Delivery

13. HARP Redesigning Care HARP Clinical Response Service HARP HELD Outreach & Care Coordination HARP Care Coordination & Coaching Program SAACS GP care Self Management Programs Community Health Health Promotion & Prevention Go for Your Life Programs Obesity Reduction Smoking cessation Health promotion Planned Managed Proactive Care -Access to mainstream community services High Need Frequent Hospital Visits - 6+ Presentations - Diabetes, COPD, CHF - Homelessness, D&A, Mental Health Immediate Risk of Hospitalisation - Ambulance - RCF’s - GP’s Whole Population Health Promotion Services ACUTE SERVICES COMMUNITY SERVICES

14. CLINICAL RESPONSE SERVICE ____________ Functions: Community based outreach to RCFs and Patient’s homes. Focus on preventing Presentation to ED Facilitating direct Transfers to sub-acute Partnership with Ambulance Victoria HOSPITAL EARLY LINKAGES & DISCHARGE STREAM _____________ Functions: Targeted risk screening of frequent presenters Diabetes, COPD & CHD AOD, mental health & Homelessness ED Management Plans ED, Wards & Subacute Outreach from ED COMMUNITY CARE COORDINATION ____________ Functions: Provision of Evidenced Based self management Interventions Care Coordination Community Linkages HARP SUPPORT _______________ Functions: Admin Dietetics Pharmacy CNC’s Physio Data Specialists Adavanced Care Planning Medical Support Accessible across streams HARP Redesigning Care

15. Before

16. HARP Redesigning Care After

17. - Population Health - Targeted Recruitment - Medical Support - Timely notification of presentation to ED - Self Management - Evidenced Based Standards Of Care - HIP Guidelines HARP Redesigning Care  Revised Model Based on