Comprehensive Assessment
Implementation of the Active Service Model
St. Vincent’s At Home (SVAH) and
Domiciliary Therapy Team (Dom)
Louise Hogan
Acting Manager
St. Vincent’s At Home-Fitzroy
– District nursing service established in 1959
– LGAs covered include Boroondara, Darebin, Melbourne,
Moonee Valley, Moreland and Yarra
– Provides nursing services under three programs:
– Home and Community care (HACC)
– Hospital in the Home (HITH)
– Post Acute Care (PAC)
Domiciliary Therapy Team-Kew
– HACC funded allied health service established in 1992
– Provides low intensity interventions to clients living at home
including:
– Physiotherapy
– Occupational Therapy
– Speech Pathology
– Podiatry and
– Dietetics
– LGAs covered include Boroondara, Yarra and the southern
part of Darebin.
What is the Active Service Model (ASM)?
If ageing is to be a positive experience,
longer life must be accompanied by
continuing opportunities for health,
participation and security. Active ageing
makes the most of these opportunities
in order to enhance quality of life.
(Ref: WHO Active Ageing: A Policy Framework)
Key Principles of the Active Service Model
– Promoting a ‘wellness’ or ‘active ageing’ approach
– Acknowledging the importance of social connections to
maintain wellness
– Holistic and family-centred approach to care
– Actively involving clients in setting goals and making decisions
about their care
– Providing timely, flexible and targeted services
Key Principles of the Active Service Model
– People want to remain autonomous
– People have the potential to improve their capacity
– People’s needs should be viewed in an holistic way
– Services organised around the person
– Collaborative working relationships
Where did we start?
– HACC funded agencies required to develop an ASM initial
implementation plan for 2010-2011
– ASM PREPARE tool used to:
– assess strengths and weaknesses
– explore opportunities for improvement
– develop key priorities and strategies for action
Key Areas Identified
Strengths:
– Both teams have processes and practices that are already
closely aligned with the ASM
Areas for improvement:
– Education and training of staff to ensure a cultural shift towards
the ASM model across all staff in both teams
– Review assessment framework to improve the focus on client
goals rather than nurse/therapist goals
What did we do?
– Initial education to staff regarding the ASM principles and
implementation strategies
– Staff workshop to review Client Assessment Tool-revised to
include more specific goal setting focusing on client’s strengths
and capacities
– Revised Assessment Tool implemented for trial February 2011
– ASM is now a standing agenda item on monthly unit meetings
– ASM approaches discussed at monthly team/case conferencing
meetings
Review of Assessment Framework
Pre ASM:
– Issues/problems identified by Client/carer and ability to
manage
– Goals to be achieved by Client/Carer
ASM Approach:
– Client Goals & Aspirations (short/long term)
– Client Identified Issues (Health/ADLs/Social/Cultural)
– Carer (Issues/Goals/Support Required)
– Achievable steps towards goal
– Strengths/Issues/Actions
Challenges
– Continue to develop the capacity of the team to ensure a
cultural shift towards the ASM model across all staff
– Evaluate the revised HACC Client Assessment Tool-ensure
ongoing effectiveness
– Improve engagement between staff and client-clients
encouraged to suggest personal goals and what would
motivate them
Successes: Case Studies
SVAH
– Elderly gentleman referred to SVAH for wound management to leg
ulcers. Lives with supportive wife and both client and wife independent
with ADLs and home duties. Wife had expressed interest in assisting
provide wound care to her husband.
– SVAH commenced 2nd daily visits for wound management with the aim
of educating wife to perform wound care and reducing visits over a 6
week period. After a 6 week period client’s wife was attending wound
care independently and the SVAH nurses reduced their visits to
weekly to continue to monitor.
– The nurse provided education to client and wife regarding ongoing
prevention of leg ulcers. The wife and client both provided positive
feedback and were very pleased with the flexible service provided and
their increased knowledge about managing and preventing leg ulcers.
Successes: Case Studies
Dom Team
– Socially isolated elderly woman with osteoarthritis of hips, had lost
confidence walking in the community. The local council volunteer dog
walkers referred to Dom Team Physiotherapy to improve mobility and
confidence in walking outdoors with an aid.
– Dom Team Physiotherapist commenced weekly visits to implement
an exercise program and supervised a progressive outdoor walking
program over an 8 week period.
– After the 8 week period client was able to accompany the volunteer
dog walker for part of the distance as well as regularly walking to the
local shops with a mobility aid.
– The physiotherapist referred client to a local social support group
which she continues to attend weekly. The volunteer coordinator
provided positive feedback and stated that the client continues to
attend social group and often stays for lunch.
Opportunities
– Within STV - HIP (Health Independence Program) services
have a similar philosophy
– Collaboration with City of Yarra
– Partner with existing referral agencies and explore new links
– Marketing of services to ensure considered for all suitable
clients
– More proactive discharge planning and referral beyond the
standard health care providers
– Client Satisfaction Survey
Acknowledgments
Gen Cooper Manager SVAH & Dom Team
Kirsten Rodger Group Manager Integrated Care
Staff of SVAH and Dom Teams
Emily Hooke and organising committee