IMPLEMENTING
INTEGRATED MULTIDISCIPLINARY
MODELS OF CARE.
DEBRA STARR
INTEGRATED SERVICE AND PLANNING MANAGER
INTEGRATED COORDINATED CARE
HOW WE ARE CHANGING HOW WE WORK
Aims and Objectives
 Strategy
 Past Pilots
 Results
 Overcoming barriers to implementation
 Current model of implementation
 Current Pilots
 Evaluation

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AIMS
Stream-lined, coordinated service for those entering
our system with complex and/or chronic diseases.
 Client-centred approach using self-management
models of care.
 Services focusing on not just presenting issues, but
risk prevention and holistic management of health
issues.
 Coordinated Care planning and discharge.

REACTIVE
PROACTIVE
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OBJECTIVES OF CBCHS INTEGRATED
COORDINATED CARE

Multidisciplinary Teams

Interdisciplinary Assessment

System Redesign

Consumers Active Partners

Processes/Evaluation/Quality

Training and Support
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STRATEGY
Driver
 Strategic Plan
 Operational Plan
 Team Planning
 Identification of change champions

A PRIORITY FOR ORGANISATION
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COMMUNICATION STRATEGY
Client Information
Board
Newsletter
Teams
MEC
Forum
Focus Group
Team
Leaders
Program
Managers
Client participation
Meetings
Questionnaire
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BACKGROUND
PILOTS
Pilot – PDSA Approach
Interdisciplinary Assessment
Learning's from the design and
implementation of the tool
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INTERDISCIPLINARY ASSESSMENT
Patient and Carer Issues
Physical
Psycho-social
Cognitive
Functional
Interdisciplinary Assessment
Team Based Assessment
Health Needs Identification
Planning
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Goals
Actions
PILOT 2





6 month pilot study (2012)
Investigated the implementation of how an
Integrated chronic disease model of care could be
introduced into the Primary Health Service at
CBCHS.
Involved 22 staff members.
Training provided on self-management of chronic
disease
3 multidisciplinary pilot groups
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RESULTS
Understanding and confidence
Job satisfaction
Identification of client priorities
Collaboration, coordination a
resources
Multidisciplinary Teams
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OVERCOMING BARRIERS TO
IMPLEMENTATION
Discipline Specific Verses Multidisciplinary
 Change ‘like the way things are’
 We already work in an integrated model
 Previous Pilots and getting staff on board
 Confidence
 Time, Wait Lists, Competing Priorities
 Processes/tools/TRAK

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SYSTEM RE-DESIGN
CBCHS Client Flow
Chronic/Complex Clients
IHT*
SLOW STREAM
Chronic/Complex
Low Self-Mangement skills




Health Needs Assessment
Care-Planning/Coordination
Promote and Maintain SelfManagement Skills
Referral






Health Needs Assessment
Intensive Care
Planning/Coordination
Self-Management
facilitation
Referral
Advocacy
Case-conference
MEDIUM STREAM
Chronoic/Complex
Ability to Self-Managing
FAST STREAM
Clients using 1 service




Health Needs Assessment
Less intensive intervention
Referral
Self-management as need
identified
Intake
INI
Identification of Chronic/Complex clients for IHT
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NEW PILOT
INTEGRATED HEALTH TEAM (IHT)
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EVALUATION

ACIC

PACIC

Audit

Focus Group
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FOCUS GROUP RESULTS






One holistic assessment reduced duplication/ better
understanding of clients needs
Development of Tools: case discussion, care planning,
discharge
Trust in other Services/ Job satisfaction
Collaborative care planning/joint consultations/case
conference/home visits
Primary Clinician/Learn from others/peer supervision
Client outcomes Observed: less hospitalisation, increased
confidence, independently attending appointments
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VIGNETTE
Before
Frequent nonattender
 Doctor Shop
 Not taking
Medications
 Lack of social support
 Mistrust in health
system
 Reduced ability to
manage conditions

After
Attending Appointments
 Taking Medications
 Has formulated Goals
 Walking with an aid
 Wearing shoes
 Has council services
 Has trust in health system
 Increased Confidence
 Improvement in health
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status

LEARNING'S



Model of implementation takes time
Variable evidence suggests that some Health
Professionals are on board and some are not.
Model and process have been implemented in a
pilot with positive results
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FUTURE DEVELOPMENTS


The challenge ahead to further implement an
Integrated coordinated system across all sites.
All Health professionals completing a
interdisciplinary assessment on all clients
entering our services.
Debra Starr
dstarr@cbchs.org.au
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