1. Phase Three – Solutions Design
Sydney South West Area Health Service
CHRONIC AND COMPLEX CARE COLLABORATION
AND COORDINATION
You have 10 minutes maximum for your presentation including time for questions from the floor. This means that you need to be able to talk to each slide succinctly drawing out the main point(s) or messages. Recommend that you don’t simply read the slides to the audience. Also focus more of your time on the most instructive points. For example, if you are experiencing issues with your project that you believe others would benefit from hearing about, then allocate more time to this part of your presentation.

2. Scope of the Project
Patients with multiple chronic & complex conditions (identified diagnoses)
Patients who can be safely managed in the community setting.
Patients presenting to Concord and Canterbury hospitals on more than 2 occasions in a calendar year.
Patients over the age of 16 years .

3. Avoidable Admissions (the defined 8 DRGs)
Community Acquired Pneumonia (E62C).
Chronic Obstructive Pulmonary Disease.
(E65B) Bronchitis and Asthma (E69C).
Deep Venous Thrombosis (F63B).
Acute Non-Surgical Pain (musculotendinous) (I71C).
Cellulitis (J64B).
Urinary Tract Infections (L63C).
Red Blood Cell Disorders and Transfusions (Q61C).

4. Chronic & complex condition disease groups
Respiratory chronic conditions
Cardiac chronic conditions
Coronary artery disease.
Hypertension.
Diabetes

5. Engagement of GPs Survey via GP Division What works well? Gaps?
Would you like to be involved?
Invitation to participate in Working Parties & interviews
Presented the GPC Division
Newsletters

6. Most Prominent Issues Identified by Patients and Staff

7. Diagnostic themes identified
Communication
End of Life / Advance Care planning
Discharge planning
Self Management
Duplication & fragmentation of coordination
Case management
Team work
Lack of single point of contact
Managing exacerbation in the community – medical governance
Information systems & info sharing
Referral processes

8. Patient journey – the current journey
Discharge / Transfer of care
Health Review
Deterioration / Acute Exacerbation
Self Management
Hospital care
Case Management
Coordination of Care
Hospital presentation
Community Care

9. Patient journey – the desired journey
Discharge / Transfer of care
Deterioration / Acute Exacerbation
Health Review
Self Management
Coordination of Care
Hospital care
Case Management
Deterioration
Hospital presentation
Community Care 9

10. Solutions Expansion of CERNER to include Patient Care Plans
Flagging of C&CC patients in the EMR / CERNER
GP access to CERNER, sharing medical care & pt action plans
Single point of contact
Hospital in the Home / Ambulatory Care – rapid assessment/ community treatment
Care plans
Patient held file
Case Management of High Risk Patients
Improved discharge processes
Increased self management
Advance Care Plan
Electronic Service Directory
Discharge follow-up

11. What next Finalising Solution Design report
Implementation Working Parties
Recommendations
Cost Benefit Analysis

12. Project Team & Contact Details
For further information or to contribute to the Solutions, please contact the Project Team:
Sue Schasser
Debbie McNamara
Peter Reisinger