“EVERYTHING YOU EVER WANTED TO KNOW

ABOUT SERVICE COORDINATION”

 WORKSHOP

Jean Crewe & Sharyn Rognrust

PURPOSE OF THE WORKSHOP

Provide overview of Service Coordination principles

Share available resources to support Service Coordination

Explore ways of embedding Service Coordination in your agency

OUTCOME

At the end of today’s session you will be able to:

Identify key Service Coordination principles

Identify available resources to support Service Coordination implementation in your agency

WHY DO WE NEED SERVICE COORDINATION?

Leanne’s StoryLeanne is a 59 year old woman who was diagnosed with schizophrenia in her early 20s. Leanne has been prescribed clozapine for a number of years by a psychiatrist at the local mental health clinic. She also sees a case manager at the same clinic. Leanne is unemployed and smokes around 20 cigarettes a day. She has indicated little desire to cease smoking although admits it causes a strain on her finances. Leanne describes a sedentary lifestyle and has recently been diagnosed with Type 2 diabetes. This diagnosis has caused Leanne to suffer from increased anxiety. She has a supportive family but they live across the other side of town. Leanne has a GP that she sees periodically.

WHY DO WE NEED SERVICE COORDINATION?

Consumers and workers experience:

A lack of information about service system

A lack of clear and transparent referral pathways

Inconsistent practice across agencies

A lack of coordination between agencies

Inconsistent quality in providing services

Poor information sharing and feedback

WHAT IS SERVICE COORDINATION?

Service Coordination = Better Access to Services

SC places consumers at the centre of service delivery to ensure that they have:•access to the services they need•opportunities for early intervention•improved outcomes

SC ACROSS GOVERNMENT ORGANISATIONS

The Victorian Health Policy and Funding Guidelines 2012–13

Under Section 1.4 health funded organisations are expected to:

•provide quality service coordination and use the Service Coordination Tool Templates (where relevant) to make referrals and share consumer information

•participate actively in Primary Care Partnerships, and encourage staff to participate in Primary Care Partnership activities where appropriate.

WHAT ARE THE BENEFITS OF SC?

From your perspective:•improved networks •common practice standards •reduced duplication •improved waiting list management•Service Coordination aligns with accreditation standards of providing quality services

WHAT ARE THE BENEFITS OF SC?

From a consumer perspective:•up-to-date information about services•timely response•the same standards of service from each agency •supported access to the most appropriate service •clear entry points and referral pathways •support to be actively engaged in the planning and delivery of services

SERVICE COORDINATION – 13 YEARS ON

2000   2013

Varying levels of partnership

Increasing integration

 

Established cross government funded partnerships of health and human services

Some locally agreed practiceAgreed practice

 

Statewide agreement for service coordination practice

350+ tools for screening, referral, care planning

Standardised information

 

A single suite of tools (SCTT, GPR) and associated resources

Limited use of technology

No secure electronic referrals

Increased use of technology

 

SCTT/GPR in 30+ applications

Growing secure e-referrals

HL7 capacity

National Health Services Directory

SERVICE COORDINATION PRINCIPLES

SERVICE COORDINATION PRINCIPLES

1. A central focus on consumers2. Partnerships and collaboration3. The social model of health4. Consistency in practice standards5. A duty of care6. Competent staff7. Engagement of other sectors8. Protection of consumer information

CENTRAL FOCUS ON CONSUMERS

PARTNERSHIPS AND COLLABORATION

WHAT IS NORTH EAST PRIMARY CARE PARTNERSHIP?

Primary Care Partnershipsare established networksof local health and humanservice organisationsworking together to findsmarter ways of makingthe health system workbetter, so that the healthof their communities isimproved.

WHERE ARE WE?The NEPCP covers the local government areas of Banyule, Darebin and Nillumbik NILLUMBIK

BANYULE

DAREBIN

WHO ARE OUR MEMBERS?

Austin Health Banksia Palliative CareBanyule City CouncilBanyule Community HealthDassiDarebin City CouncilDarebin Community HealthMindNeamiNillumbik HealthNillumbik Shire CouncilNorth East Valley Division of GPNorth Western Mental HealthNorthern HealthRDNSSpectrum Migrant Resource CentreWomen’s Health in the North

HOW CAN YOU BE INVOLVED?

NEPCP website www.nepcp.org.au

Snippets eBulletin: fortnightly, latest news and updates

Working Groups: Integrated Chronic Disease Collaborative Integrated Health Promotion Network Problem Gambling Steering Committee Closing the Health Gap

SOCIAL MODEL OF HEALTH

EXAMPLEGary 34 yo, is depressed and drinking too much after the breakdown of his marriage. He is in financial difficulty after losing his job and money through gambling. He has several issues and a shared care plan is being developed. One of his goals is to gain shared custody of his two children.

CONSISTENCY IN PRACTICE STANDARDS

SERVICE COORDINATION OPERATIONAL ELEMENTS –ESTABLISHING COMMON

LANGUAGE

ESTABLISHING COMMON LANGUAGE

QUIZ

How well do you know the Service Coordination Tool

Templates (SCTT)?

The SCTT is used only for the purpose of making referrals

False It is appropriate for a consumer to be offered a copy of their

SCTT

True When using the SCTT for referral purposes you are required to

complete all the SCTT profiles

False GPs use the SCTT

True The SCTT is only available in paper format

False The SCTT can be used to develop a consumer care plan

True

True OR False

Facilitates Service Coordination

Supports the collection and recording of Initial Contact, Initial Needs Identification, Referral and Shared Care/Case Planning information in a standardised way.

SCTT

Service Providers:Know what forms are required to make referralCan record information in consistent wayCan inform consumers about privacy of informationCan deliver consumer-centered careCan share information electronically

Benefits of SCTT tools

Consumers:Screening health and social needsReducing the need to repeat the informationAssisting more timely access to servicesReducing duplication of assessments

Benefits of SCTT tools

SCTT 2012 REVISION WHAT'S NEW?

SCTT 2012 REVISION WHAT'S NEW? (CONT)

HOW DOES SCTT FIT IN SERVICE COORDINATION?

Process

Using the right tool for the jobT

he r

ight

too

l for

the

job

Process Tools

Initial Contact Consumer Information templateService directories e.g. HSD

Initial Needs Identification

Profile: Single page screener for health and social needsProfile: Accommodation and safety arrangementsProfile: Need for Assistance with daily livingProfile: Health and chronic conditionsProfile: Alcohol, smoking and substance involvement screeningProfile: Social and emotional wellbeingProfile: Care relationship, family and social networkSummary and Referral Information

Assessment Specific agency or program tools

Care Planning Shared support plan

Referral Confidential Referral Cover SheetConsumer InformationSummary and Referral InformationConsumer Consent to Share Information

•For referral to Palliative Care use the above plus Palliative Care Supplementary information•Service providers who conduct assessments also send Functional Assessment Summary•GPs only-use GP Referral form

SCTT 2012 online training module available by June 2013

SCTT 2012 embedded in electronic consumer data management systems by the end of 2013

DH Timelines

A DUTY OF CARE

COMPETENT STAFF

SERVICE COORDINATION ON-LINE LEARNING MODULE

Available at: http://elearning.health.vic.gov.au/scol/

ENGAGEMENT OF OTHER SECTORS

• Service Coordination embraces the broadest range of partnerships across organisation types (small to large, non-government to government etc) and across disciplines.

• Partnership or inter-agency agreements are documents that record the agreed terms and conditions of collaboration between separate agencies and/or sectors.

• Resource http://www.communitydoor.org.au/node/139

HSD aims to provide Practitioners and Service Providers with access to accurate and up-to-date information about health, social & disability services in Victoria.

http://humanservicesdirectory.vic.gov.au

Human Services Directory

Can people find your service? Is your information current and correct? Is there an assigned position in your agency to

update HSD?

Your Agency Information on HSD

PROTECTION OF CONSUMER INFORMATION

PRIVACY AND CONSENT The privacy resources provided here are

designed to assist practitioners in their discussions with consumers regarding how their information will be dealt with and have been developed in line with commonwealth and state privacy legislation. http://www.health.vic.gov.au/pcps/coordination/privacy.htm

SUPPORTING PUBLICATIONS

VICTORIAN SERVICE COORDINATION PRACTICE

MANUAL 2012Provides a vision for Victoria’s Service Coordination and Practice

A Reference GuideConsumer Outcomes & Good Practice IndicatorsConsumer PathwaysTools & Resources

Covers

Initial ContactInitial Needs IdentificationAssessmentCare Planning Referral

Available online at: http://www.health.vic.gov.au/pcps/downloads/sc_pracmanual2.pdf

VICTORIAN SERVICE COORDINATION PRACTICE

STANDARDSAn example of the standards for care planning

Source: http://www.health.vic.gov.au/pcps/downloads/sc_pracmanual2.pdf

GOOD PRACTICE GUIDE 2012

Available online at

http://www.health.vic.gov.au/pcps/downloads/good_practice.pdf

CONTINUOUS IMPROVEMENT FRAMEWORK 2012

Supports organisations to monitor and improve service coordination implementation and practice

Based on PDSA (Plan, Do, Study, Act) cycles of improvement

Available online http://www.health.vic.gov.au/pcps/downloads/continuous.pdf

SERVICE COORDINATION TOOL TEMPLATES 2012

USER GUIDESuite of referral templates

Standardised format for collection and sharing of consumer information

Supports service coordination practice

Formalised documentation of consumer consent

Available online:http://docs.health.vic.gov.au/docs/doc/0043138AFA564E4FCA257A5B0019239A/$FILE/1206018_SCTT_jun12_12.pdf

SERVICE COORDINATION SURVEY

PCP’s annual reporting requirement to the Department of Health.

Component of the Continuous Improvement Framework that supports the Victorian Service Coordination Practice Manual

PURPOSE OF THE SC SURVEY

to identify areas that require greater focus

to inform areas of future work

2012 Survey results:http://www.nepcp.org.au/resources/north-east-primary-care-partnership-service-coordination-survey-2012#attachments

BENEFITS FOR YOUR AGENCY

Reviewing your current practices & systems

Acknowledging areas of good performance

Identifying opportunities for improvement in Service Coordination

BENEFITS FOR YOUR AGENCY

Improving understanding of the practice of Service Coordination across programs & services

Benchmarking current practice against previous results

Producing evidence for existing quality assurance systems & accreditation processes within the agencies

LOCAL PRACTICE EXAMPLE

LOCAL PRACTICE EXAMPLE

1. A central focus on consumers2. Partnerships and collaboration3. The social model of health4. Consistency in practice standards5. A duty of care6. Competent staff7. Engagement of other sectors8. Protection of consumer information

WHERE TO FROM HERE?

•Action plan•Future workshops•Service Coordination Champions•Evaluation survey

Jean CreweProject Officer-

Service Coordination & IntegrationPhone: 9450 2678

Email: jean.crewe@bchs.org.au

Contact and support