1. Inter-Agency Care Planning The EICD / Darebin Community Health perspective Carolyn Hines Manager – Chronic and Complex Care Program

2. Today’s presentation The Early Intervention in Chronic Disease (EICD) program model (Health Wise) Health Wise and inter-agency care planning Issues and challenges The way forward

3. Background Care planning at DCH -Some discipline-specific care planning for internal use only -Inter-agency care planning is limited -Specific to certain programs eg HARP HARP -Austin Health, St Vincent’s, Northern Health -Inter-agency care planning occurs to varying degrees Early Intervention in Chronic Disease (EICD) -Health Wise -Care planning is in development stage

4. LEVEL 4 LEVEL 3 LEVEL 2 LEVEL 1 Levels of Chronic and Complex Care Primary Prevention for whole population eg Go For Your Life HARP People with chronic conditions / complex needs who use, or are at risk of using, hospitals frequently EICiD People with chronic conditions / complex needs who do not use, or are at low risk of using, hospitals frequently Intensity

5. Health Wise Program Model

6. Key Worker role Comprehensive assessment - general chronic disease screening, self management assessment (Flinders), Client Survey (DHS) Preparation of a Healthy Living Care Plan based on self management needs / goals (Flinders) Further appointments with KW for 1:1 self management; referral to other services (internal or external) as required The main point of contact for client and GP Extent of involvement with each client will vary according to needs

7. Healthy Living Care Plan Flinders Care Plan V9 April 06 Client Problem Statement:This Problem interferes with my daily activities 0 1 2 3 4 5 6 7 8 does not slightly definitely often severely Client Goal/s:My progress towards achieving this goal 0 1 2 3 4 5 6 7 8 100% 75% 50% 25% no success IDENTIFIED ISSUES [INCLUDING SELF MANAGEMENT] MANAGEMENT AIMS INTERVENTION WHO IS RESPONSIBLE DATE REVIEWED PROGRESS (eg no progress, some progress, completed) Sign Off - Patient I ……………………………………(patient name) agree that the information contained within this care plan is true and correct and currently reflects my needs for the forthcoming year. Additionally, I consent to this information relevant to my care will be released to my health providers. Signature: ………………………………….. Date: ………/………/……… Sign Off - Doctor I ……………………………………(GP name) agree that the services prescribed within this care plan are true and correct at the time of development but are subject to review based on the patient's needs and / or my professional opinion as the responsible Medical Practitioner. Provider No:[ ] [ ] [ ] [ ] [ ] [ ] [ ] Date: ………/………/……… Care Plan Review Date: ………/………/……… Signature: ………………………..… MBS ITEM: GP Management Plan - 721  Team Care Arrangements - 723 

8. The HARP / EICD interface The GP / EICD Interface

9. Health Wise and inter-agency care planning Focus will be: General practitioners HARP programs and other external organisations / programs Internal service providers -Maintain communication -Streamline client care

10. Health Wise and inter-agency care planning (cont) Progress to date: Working group has been established with staff from EICD project the DCH Medical Practice (GP, Practice Nurse, Chronic Condition Practice Coordinator) Started investigating care planning options -Service Coordination Plan -HARP

11. Community Care Plan Coordinator:GP:Other care provider: Phone: 9290 6615Phone: Fax: 9290 6650Fax: Client’s address and phone number (if different to usual): Participants and Service Provider Details NamePositionContact DetailsDate Helen GlouftsisCardiac Nurse9290 6615 Community Care Plan UR NO: Surname: Given Names: DOB: Sex: Authority to proceed with care plan  The purpose of this care plan has been explained. I/my carer, give permission for its preparation and for the discussion of my medical history and diagnosis, with the providers listed above.  All participants are to retain confidentiality.  I/my carer have been asked if any medical/personal information should be withheld from other participants  I am aware that my GP will bill me in their usual way for their participation and that a Medicare rebate is available for this service Signature: Helen Glouftsis Date: Client / Carer / Verbal (please circle)

12. Community Care Plan UR NO: Surname: Given Names: DOB: Sex: Client Summary Principal diagnosis and other significant health issues: Medications: Aims and outcomes: GoalTask/recommendationReview date & person responsible 1. 2. 3. 4. 5.

13. Issues / challenges Multiple options available Multiple views about the ideal care plan Terminology - medical care plans, service coordination plans, community care plans…………. Commitment to self-management - need to incorporate client-centred goals Don’t want to reinvent the wheel!

14. What do we need? We can’t do it alone! Small EICD project managers network but cuts across different regions Regional approach (state-wide) -Support and leadership from DHS -Bring service providers / Divisions of General Practice together to establish definitions, common needs, standard care plan format/s -Strategy to promote the “why” and “how” to agencies / staff