1. HARP Chronic Disease Management Program

2. Where We Have Come From? Didn’t do it alone Formed a consortium to plan then implement Program evolved over the three years Nine Pilot Projects COPD, CHF, Falls Prevention, Diabetic Foot, Ed Care, COACH, ARION, Stroke, Integrated Disease Management Stroke was not mainstreamed ARION funded within Mental Health

3. Mainstreamed Services July 2005 DHS Funded State wide HARP Chronic Disease Program DHS HARP Chronic Disease Guidelines July – December Consultation with Staff and Internal External key Stakeholders Executive Endorsement of PIH HARP CDM Program Model and Structure

4. PIH HARP CDM Governance Structure

5. BUDGET 2006 – 2007 $4250,000 EFT 35.45 - 48 Staff

6. Client Flow

7. Central Intake HARP Chronic Disease Management Program 2007 Falls Prevention Diabetes Diabetes Co-management in General Practice Diabetic Foot Service Chronic Respiratory Disease Melbourne Easy Breathers Asthma Service Respiratory Outreach Medication Management Chronic Cardiovascular Disease Chronic Heart Failure Heartwise Cardiac Coach Intensive Service Coordination Case Management Psychosocial support Psychology Integrated Service across acute – community continuum

8. HARP CDM Service Components

9. Chronic Respiratory Stream A comprehensive, multi disciplinary pulmonary rehabilitation program. Asthma Service

10. Melbourne Easy Breathers’ Outcomes Evaluation of Easy Breather clients: 65% achieved improved physical function 69% achieved reduced breathlessness Clients reported Improved self management Coping better Reduced anxiety and depression Reduced fatigue Improved confidence

11. Chronic Cardiovascular Disease Multidisciplinary community care for people with Chronic Heart Failure COACH – Coaching cardiovascular risk factors people post cardiac surgery

12. CHF Outcomes

14. Diabetes Service Component Endocrinology, Vascular, Podiatry, Specialist Nurse Wound Consultant and Allied Diabetic Foot Service Diabetes Co-Management Service – Specialist Nurses and General Practitioner Diabetes Risk Management.

15. Outcomes – Acute DFU Before the DFU existed, audit of all RMH patients admitted with diabetic foot conditions showed that of these patients: 20% had a minor amputation 10% had a major amputation Since the DFU was established, of a similar group of patients (Jan-Dec 2005): 8.8% had a minor amputation 2.2% had a major amputation = 50% reduction in amputations

16. Medication Management Outreach pharmacy support for HARP CDM eligible clients.

17. Outcomes – Community January – December 2005 Amputations 22% all patients had a history of amputation pre-HARP 1% of patients have required a minor amputation post-HARP Ulcerations 83% of patients had a history of ulceration pre-HARP 69% maintained ulcer free since HARP 50% with an ulcer healed ED presentations Reduced by 4% post HARP Inpatient admissions Reduced 12% post HARP

18. Local outcomes Chronic Disease Management 1,768 patients 2002-05 COPD or CHS and/or chronic and complex conditions Comparison of actual use 6 months pre- & post-enrolment: 42% reductions in ED presentations 19% reduction in admissions 43% reduction in mean LOS (by 2.5 days) 32% reduction in median LOS (3 days) Equivalent to 2,730 bed-days over 6 months

19. Falls Prevention Service Multidisciplinary community nursing and allied health Falls prevention service

20. Local outcomes: Falls Prevention 259 patients presenting to ED or admitted post fall. 75% reduction in severe falls related injuries at 12 months 53% reduction in falls risk Improved static & dynamic balance Improved Quality of Life (AQoL) Improved confidence to perform tasks without falling 46% reduction in ED presentations 67% reduction in hospital admissions 10% reduction in mean LOS (10 to 9 days)

21. Psychosocial Service Psychologist counselling and support to enrolled HARP clients Acute and community support for frequent attenders to RMH emergency department

22. Local Outcomes – Psychosocial Program 79 people with complex psycho-social problems (homelessness, mental health, D&A etc) Clients reported: High satisfaction with service Improved integration and coordination of services Reduced anxiety Coping better Hospital usage: 42% reduction in ED presentations 33% reduction in admissions Clients spent less time in ED when they did attend

23. Referral See detailed eligibility handout. E-referral via iSOFT link to www.connectingcare.com www.connectingcare.com Need help? Ring 9319 9456 & talk to intake workers Xam & Norma

24. HARP CDM Clients Seen 1 July – 31 December 2006

25. PIH HARP Key Activities January – December 2007 Integration of HARP and RMH Diabetes Services Statewide Diabetic Foot Best Practice Roll Out Review of HARP Intake location – RMH Direct Access Unit Review of HARP Psychosocial Services and development of a model of care Implementation of DHS Comprehensive Assessment Tool Inter-Rai Pilot Development and implementation of HARP CDM Client Management System Implementation of VINAH reporting Greek Speaking COACH quality Service Improvement Initiative