1. Cardinia-Casey Community Health Service (CCCHS) Partnership Development with Casey Hospital Michael Jaurigue Senior Clinician Physiotherapist Belinda Ogden Senior Clinician Occupational Therapist

2. Why? What? Who? How? When? Cardinia-Casey Community Health Service (CCCHS) Partnership Development with Casey Hospital

3. We Got Thinking What would a ‘good’ client journey through our health service look like? Let’s look at someone discharged from Emergency or an Acute Medical Ward Clinician (usually PT or OT) refers client for follow-up in CHS Access and Intake process referral and arrange an appointment in a timely manner Client and clinician discuss and establish a Care Plan Client and clinician act on Care Plan

4. What does it actually look like? Clinician (usually PT or OT) refers client for follow-up in CHS Access and Intake process referral and arrange an appointment in a timely manner Client and clinician discuss and establish a Care Plan Client and clinician act on Care Plan Acute clinicians may not be fully aware of what services we offer Often a delay in processing referrals at Access and Intake P1 appointments may not be available for 4- 6 weeks Waitlist for routine referrals may be up to 3 months Something we could do more consistently across clinicians and services We are mandated to complete Care Plans for each client Something we do quite well We have programmes in place to support a journey towards ‘Self- Management’

5. What do we do? Employ more clinicians? Expand Access and Intake? What if we targeted this specific population? What if we re-think our current processes? – WHY? Southern Health Key Priorities The Low Back Pain Project Opportunity to raise the profile off CCCHS Opportunity to review our clinical staff profile

6. Southern Health Key Priorities National Emergency Access Target (NEAT) Introduced by the Federal Government in 2012 By December 2012, within 4 hours of someone arrive arriving at our Emergency Departments 72 per cent of people will be admitted, treated, referred elsewhere for treatment, or discharged to recover at home By the end of 2015 this target increases to 90 per cent This is not only a mandatory target it is also the right thing to do for our patients We will improve the patient experience and outcomes by providing timely access to care. As an organisation, we have to work in a sustainable way to ensure we use our resources wisely and effectively The key priority of Living Within Our Means ensures we asses our resource use and actively look for ways to reduce unnecessary spending According to the Institute for Healthcare Improvement, the overall vision for all healthcare services is to have: No needless deaths No needless pain or suffering No helplessness in those served or serving No unwanted waiting No waste No one left out Patient Centred Care means that we put the patient at the centre of absolutely everything that we do By ensuring our systems and process and our general way of working is focused on our patients we will directly improve healthcare outcomes.

7. The Low Back Pain Project Conducted in 2009 To determine the effectiveness of a CCCHS physiotherapist working with allied health at Casey Hospital ED 3 month duration Findings: – Average 6.4 day gap from referral to initial assessment – 95% attendance rate at LBP clinic – 7% re-presented to ED

8. An Opportunity for Community Health To raise our profile in a large organisation To review the clinical profile in community health To improve relationship between Community Health and Acute sector To improve communication flow between sectors

9. Project Brief CCCHS Partnership Development with Casey Hospital Key points: Refer to success of LBP Project Emphasise potential for an improved client journey Highlight need for experienced clinicians in the roles Acknowledge need to involve key stakeholders in development Outline potential of maximising resources – Reduce likelihood of re-admissions – Reduce reliance on brokered services

10. Objectives To develop a care pathway from the Emergency Department and General Medicine Wards at Casey Hospital to Community Health Services which facilitates the uptake of early intervention strategies and service provision To reduce the number of times a client has to go through screening and assessment processes Project Brief

11. The role of the Senior Clinicians would include: Establishing a partnership between Casey Hospital Allied Health and CCCHS Allied Health Providing a seamless transition of clients from Casey Hospital to CCCHS Providing a new service that provides clients/patients with ongoing management in the community that ensures their needs are being met through an integrated care plan Identifying client goals and facilitating interventions in order to achieve these goals Project Brief

12. The Building Blocks What have we done so far? Appoint Senior Clinicians Meet with stakeholders Come up with a name! Establish eligibility criteria Establish referral process Promote the service Assessment tools Data collection and methodology

13. Senior Clinicians Belinda Ogden -OT 8 years experience 3 years in Community Health Michael Jaurigue - PT 11 years experience 8 years in Community Health Intimate knowledge of Community Health Advocates of Social Model of Health Experience in implementing Active Service Model Experience in partnership development and inter- agency care coordination

14. Stakeholders Casey Hospital Allied Health Met with AH Manager and Senior Clinicians Presented at Allied Health meeting Mobile Access Services Team Post Acute Care Care in Context Clients

15. What do we call ourselves? Community Health Emergency Response Service Acute Community Health Acute Response Community Health Community Health Acute Response Team

16. Getting clients Eligibility criteria Referral process Promote the service

17. Assessment Tools The EQ-5D for all clients SCTT templates – Including Single page screener of health and social needs Plus more specific measures as determined by the treating clinician

18. Data Collection Key points: Time from referral to initial contact EQ-5D results at initial Ax, d/c from CHART, at 6 months Number of CHART sessions Whether they were added to the PT/OT wait-list Re-admitted to Casey Hospital? Client satisfaction survey

19. To infinity and beyond Review at 3/6/12 months Troubleshoot as we go along Maintain relationship with Casey Hospital

20. Questions?