1. Service Coordination projects 2012- 2013 Rochester & Elmore District Health Service

2.  REDHS received funding for service coordination project in both 2012 & 2013  Both projects undertaken by Leanne Rankin  Diabetes Educator and community health nurse at REDHS  Previous experience as ICDM worker for Campaspe PCP.

3. Issues addressed  Central intake  All primary care referrals to central intake  Including using Connecting care for all internal and external referrals.  Referral acknowledgement processes  GP Communication  Processes when clinicians should communicate to GP  Following initial assessment  Any time during episode of care as required  On discharge  Templates for all letters

4.  Central intake  Referral acknowledgement practices both CCC and Fax  Use of CCC for all internal referrals within REDHS  Use of CCC by REDHS for referrals out  Local agreements with GP  Development of local agreements around referrals, communication and acceptance of Team Care Arrangements

5.  Connecting care usage

6.  Staff change over within Primary Care  Ongoing education for all staff re Connecting care usage  Policies development & implementation

7. Issues addressed  Review of last years project areas  Care planning  As extension of HACC ASM work to all primary care services  Assessments  Review by clinicians and format for client records  Central client record  Primary care client record amalgamated into hospital client record and stored in medical records department.

8.  Medical records  standardised UR  All records common file and stored in medical records  Service coordination online education package part of PC staff orientation.  Care planning  service specific  REDHS shared support plan  Assessments.

9.  Issues with HSD and connecting care change over  Ongoing staff changes  Ongoing staff education

10.  Fortnightly staff meetings  Small team  New younger clinicians

11.  Thanks to PCP for the funding for the project.  Advantages to having a worker at a local level to initiate activities specific to the needs of our own organisation  Networks within service coordination steering committee.

12. Leanne Rankin Rochester &Elmore District Health Service 5484 4481 lrankin@redhs.com.au