Cardinia-Casey
Community Health Service (CCCHS)
Partnership Development with
Casey Hospital
Michael Jaurigue
Senior Clinician
Physiotherapist
Belinda Ogden
Senior Clinician
Occupational Therapist
Cardinia-Casey
Community Health Service (CCCHS)
Partnership Development with
Casey Hospital
Why?
What?
Who?
How?
When?
We Got Thinking
What would a ‘good’ client journey through our health service
look like?
Let’s look at someone discharged from Emergency or an Acute
Medical Ward
Clinician (usually
PT or OT) refers
client for follow-up
in CHS
Access and Intake
process referral
and arrange an
appointment in a
timely manner
Client and
clinician discuss
and establish a
Care Plan
Client and
clinician act on
Care Plan
What does it actually look like?
Clinician (usually
PT or OT) refers
client for follow-up
in CHS
Acute clinicians may
not be fully aware of
what services we
offer
Access and Intake
process referral
and arrange an
appointment in a
timely manner
Often a delay in
processing referrals at
Access and Intake
P1 appointments may
not be available for 46 weeks
Waitlist for routine
referrals may be up to
3 months
Client and
clinician discuss
and establish a
Care Plan
Something we could
do more consistently
across clinicians and
services
We are mandated to
complete Care Plans
for each client
Client and
clinician act on
Care Plan
Something we do
quite well
We have programmes
in place to support a
journey towards ‘SelfManagement’
What do we do?
• Employ more clinicians?
• Expand Access and Intake?
• What if we targeted this specific population?
• What if we re-think our current processes?
– WHY?
• Southern Health Key Priorities
• The Low Back Pain Project
• Opportunity to raise the profile off CCCHS
• Opportunity to review our clinical staff profile
Southern Health Key Priorities
•Patient Centred Care means that we put the patient at the centre of
absolutely everything that we do
•Introduced by the Federal Government in 2012
•By ensuring our systems and process and our general way of working is
focused
our patients
•By December 2012, within 4 hours of someone
arrive on
arriving
at our we will directly improve healthcare outcomes.
Emergency Departments 72 per cent of people will be admitted, treated,
referred elsewhere for treatment, or discharged to recover at home
•By the end of 2015 this target increases to 90 per cent
•National Emergency Access Target (NEAT)
•This is not only a mandatory target it is also the right thing to do for our
patients
•As
an organisation, we have to work in a sustainable
waytotothe
ensure
we for Healthcare Improvement, the overall vision
According
Institute
use our resources wisely and effectively
for all healthcare services is to have:
•We will improve the patient experience and outcomes by providing timely
access
topriority
care. of Living Within Our Means ensures
•The key
we asses
our
•No needless
deaths
resource use and actively look for ways to reduce
•Nounnecessary
needless painspending
or suffering
•No helplessness in those served or serving
•No unwanted waiting
•No waste
•No one left out
The Low Back Pain Project
• Conducted in 2009
• To determine the effectiveness of a CCCHS physiotherapist
working with allied health at Casey Hospital ED
• 3 month duration
• Findings:
– Average 6.4 day gap from referral to initial assessment
– 95% attendance rate at LBP clinic
– 7% re-presented to ED
An Opportunity for Community Health
• To raise our profile in a large organisation
• To review the clinical profile in community health
• To improve relationship between Community Health and
Acute sector
• To improve communication flow between sectors
Project Brief
CCCHS Partnership Development with Casey Hospital
Key points:
• Refer to success of LBP Project
• Emphasise potential for an improved client journey
• Highlight need for experienced clinicians in the roles
• Acknowledge need to involve key stakeholders in development
• Outline potential of maximising resources
– Reduce likelihood of re-admissions
– Reduce reliance on brokered services
Project Brief
Objectives
• To develop a care pathway from the Emergency Department
and General Medicine Wards at Casey Hospital to Community
Health Services which facilitates the uptake of early
intervention strategies and service provision
• To reduce the number of times a client has to go through
screening and assessment processes
Project Brief
The role of the Senior Clinicians would include:
• Establishing a partnership between Casey Hospital Allied
Health and CCCHS Allied Health
• Providing a seamless transition of clients from Casey Hospital
to CCCHS
• Providing a new service that provides clients/patients with
ongoing management in the community that ensures their
needs are being met through an integrated care plan
• Identifying client goals and facilitating interventions in order
to achieve these goals
The Building Blocks
What have we done so far?
•Appoint Senior Clinicians
•Promote the service
•Meet with stakeholders
•Assessment tools
•Come up with a name!
•Data collection and
•Establish eligibility criteria
methodology
•Establish referral process
Senior Clinicians
• Intimate knowledge of
Community Health
Belinda Ogden -OT
8 years experience
3 years in Community Health
Michael Jaurigue - PT
11 years experience
8 years in Community Health
• Advocates of Social Model of
Health
• Experience in implementing
Active Service Model
• Experience in partnership
development and interagency care coordination
Stakeholders
• Casey Hospital Allied Health
Met with AH Manager and Senior Clinicians
Presented at Allied Health meeting
• Mobile Access Services Team
• Post Acute Care
• Care in Context
• Clients
What do we call ourselves?
Community Health Emergency Response Service
Acute Community Health
Acute Response Community Health
Community Health Acute Response Team
C H A R T
Getting clients
Eligibility criteria
Referral process
Promote the service
Assessment Tools
• The EQ-5D for all clients
• SCTT templates
– Including Single page screener of health and social needs
• Plus more specific measures as determined by the treating
clinician
Data Collection
Key points:
•
•
•
•
•
•
Time from referral to initial contact
EQ-5D results at initial Ax, d/c from CHART, at 6 months
Number of CHART sessions
Whether they were added to the PT/OT wait-list
Re-admitted to Casey Hospital?
Client satisfaction survey
To infinity and beyond
• Review at 3/6/12 months
• Troubleshoot as we go along
• Maintain relationship with Casey Hospital
Questions?