1. Care Planning at ISIS Primary Care successes, challenges, conflicts Anne Cox ISIS Primary Care

2. Care planning Treatment plan Care plan Coordinated care plan (within agency-multi service providers within program area) Coordinated care plan (Within agency – other program areas or external agencies)

3. Questions???  How well are we really care planning? QUALITY  If we are not care planning well at an individual level, how can we plan well at a coordinated level?

4. Challenges  Providing service providers with skills to think beyond their discipline  Creating a change environment where holistic documented care planning is an expectation  Providing SPs with adequate support to work in their discomfort zone  Increased wait lists –this takes time  Embedding self management practice into CH caseloads

5. A clash of care planning models? Client Self managementMedical model With the clientFor the client Client as expertService provider expert Client owns the plan SP writes the plan Best practice guidelines for chronic conditions

6. Questions??  Who is benefiting from the care plan?  How can the plan be client driven but still meet best practice guidelines for care?

7. Challenges  COACHING clients so that a care plan is theirs-a fine line  Adopting client /family centred practice into CH –philosophy is easy but practice is difficult

8. ISIS Primary Care Seven sites across three local government areas CH Directorate -140 staff - CH Allied Health, Nursing and Counselling, HACC Allied Health, Refugee Health Team, 3 Child Health teams, EICD, AHPCC, HARP and HP.

9. Care planning at ISIS PC  Management commitment to quality in care planning  All Clients have their own care plan which they develop themselves with staff member-very simple based on self management principles with SMART goals  Some clients have Flinders care plans-as appropriate

10.  Team of trainers in Flinders Chronic Disease Self management  100 + staff and managers trained in Flinders  Ongoing motivational interviewing and coaching training for staff  Ongoing vision, support and performance management  Change champion role-trainers-peer support  Living Well team work with more complex clients to complete Flinders Chronic Condition Self Management and also have organisational change champion role  Diabetes HARP program-complements our work and has provided training and support and inspiration  An action and evaluation plan How did we do it?

11. Successes  Introduced January 2006- Last audit November 2006 -70% of clients had a care plan compared with 35% in June 2006  MA (moderate achievement) care planning accreditation EQUIP November 2006  Staff are using ISIS PC care plans with clients, carers and other organisations to develop coordinated care plans  Client Satisfaction survey 2006- 95% of clients reported they were involved in developing their own care plan

12. Things we are working on  Child health teams modifying Flinders CCSM tools for working with children and families-pilot with Flinders Uni, adopting family centred approach  LW teams considering how to integrate self management and coordinated care planning

13. Still on the burner  Poor use of SCTT care planning mechanism- the tool is poor  GP care plans-just where do these fit in and how?  How do we do coordinated care planning well?