Aged Care Service

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Aged Care Service Integration ProjectGreater
Newcastle Cluster
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Ageing Population
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Community Aged Care Services

• CNCstaff consultancy education research
  planning clinical support CDNs CQI projects
• CDNs Assessment, cognitive screening
• ACCR completion
• Episodic case management
• Carer support
• Incidental counselling, education and information
  to PWD carers
• Support Geriatric medicine clinics
• Support GP practice nurse with diagnosis
  management
• LWMLP carer support group
• Advance Care Planning

• Comprehensive assessment
• ACAT ACCR completion
• ACAT Delegation
• ACAP MDS Reporting
• Compliance with Commonwealth guidelines
• Clinical support to staff
• Monthly reporting

• Project plan development and implementation
• Monthly reporting
• Education

• Assessment, care planning, and management of the
  older persons presenting to E.Dept
• Discharge Planning
• Comprehensive Assessment
• ACAT Completion ACCR
• Monthly reports

• Comprehensive Assessment
• Completion of ACCR
• Delegation
• ACAP MDS reporting
• Compliance with commonwealth guidelines
• Community and Private Hospitals
• Advance Care Planning
• Guardianship
• Elder Abuse

• Clinical support
• Chair Nurse Peer Review Meetings
• Education and Research
• Policy development and review
• CQI
• Project management
• Competency development and review

• Cognitive testing
• Neuropsychology testing of referrals from
  Geriatricians, neurologists, psychiatrist.
• Research
• Education
• Support to CDNs re cognitive testing

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High Demand for serviceRural
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High demand for serviceHunter


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Aged Care Assessment Teams
Aged Care Service

• Hunter Team
• Rural Team servicing the rural regions
• Staffing
• Clinical24 FTEs Admin71 FTEs
• Allied Health and Nursing
• Geriatricians6 FTEs

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Integration Project Implementation

• Involved
• Phased in approach
• Change management
• Staff participation
• Team divided into geographical areas/teams
• Re-Location to 7 Community Health Centres
• Adoption of new IT systemCHIME program
• Standardisation of work practices
• Central Intake Service
• Staff education
• Additional equipment

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Aged Care Service model within Community Health
Services
Aged Care Service
The ideal service model aligns services to
patient needs and provides timely support across
the continuum of care.
GPs
Day Centres
COPs
Home Mods
Nursing
CAPAC
Physio
ACAT
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Aged Care Service
to a patient-centred model that integrates
health care services
Acute Setting

• New model
• Better alignment of services to patient needs.
• Continuity of care, Seamless integration.
• Location of services closer to the patient
• Link with HAHS Dementia plan to better meet the
  needs of people with Dementia
• Increase resources Dementia Nurses to meet
  demands for case management/Care Coordination of
  people with Dementia
• Flexible delivery modes

Greater Newcastle Cluster
Community Health Services
Transitional Care Residential Care
Specialists Teams
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Aged Care Service

• Multidisciplinary Teams maintained within each
  Community Health Centre and consist of
• Registered Nurse
• Community Dementia Nurse
• Occupational Therapist
• Social Workers/Welfare Worker
• Geriatrician
• Administration staff

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Community Dementia Nurses

• Role
• Comprehensive Assessment
• Cognitive screening
• Carer education and support
• Counselling
• Episodic case management
• Assess for suitable and appropriate care options
• Support Geriatrician Clinics

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Clinical Coordinator Role

• Response to Priority One referrals
• Allocation of referrals to ACAT and CDN
  clinicians
• Delegation and response to priority assessments
• Advise to service providers/health professionals
• Assessment of and Problem solving of complex
  cases
• Advice/Information regarding ACAP guidelines
• Positions staffed from within team

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Clerical support provided at each Community
Health Centre for the Aged Care Service
Clerical Support

• Clearly defined roles
• ACCR processing
• Customer service
• Integration of medical records
• Scanning of assessments and ACCRs into CHIME
• Maintenance of resource information

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Referrals and enquiries to be managed by the
Referral and Information Centre
Access
Referral Information CentreRIC
Client Carer GP Hospital
Community Service Directory

• Providing accurate and comprehensive information
  and assistance about community based services

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Referral and Information Centre
Access
GP Client Carer Hosp

• ACAT RN seconded to the referral and Information
  centre
• CHIME Program enabling electronic referral
  allocation to ACAT
• CHIME business rules developed
• ACAT referral acceptance criteria developed
• Involved in the development of Aged Care intake
  templates
• Staff receive referrals electronically
• Staff have more available time for assessments
• Referrers have improved access
• Education provided to RIC staff and ongoing

Enquiry
Screening / assessment
Referral
Information provided
Service request
Other assistance
Protocol / template
Liaison with other services
Allocate to service
Allocate to clinician
Service delivery
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Referrers
Access
Referrers have different needs
Source of Referrals to ACAT
Source (1) CHIME, for 12 month period
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Standard Referral Management Process
Community Aged Care Service
Referral Information Centre
Intake managed by experienced clinicians with
knowledge of community services and problem
solving skills.
Phone[phone]
Aged Care Assessment Teams Community Dementia
Nurses Neuro-psychology
Service specific intake templates, supported by
information systems which enable
managers/clinicians to prioritise patient needs
without needing to call them for further
information.
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Central Office maintained for .
Central Office Role

• ACCR processing
• Maintain RACF Provider information
• Management of waitlists
• Management of enquiries for complex cases
• Management of priority one referrals
• Daily communication with RIC staff
• Service to acute care hospitals

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CHIMEThe solutions supported by changes to
information technology.
Information Technology
Community Health Information Management
Enterprise (CHIME)

• Adoption of the CHIME program improved
  integration with CH IT systems
• All staff trained in the use of CHIME
• Geriatricians trained to provide access to
  patient information
• Geriatrician reports accessible on CHIME
• Reports developedCommonwealth reporting,Activity,
  home visit and waitlist management
• Clinical documentationIntake templates,GP
  Feedback letters,assessments and reporting
• Access available to Acute Care Hospitals

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Wait times
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Wait times have been sustained
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Average Wait Times
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Benefits of Integration

• Reduction in wait times
• Efficiencies in travel times
• Located closer to the population we serve
• Improved collaboration with key health providers
• Developed relationships with other service
  providers who share clients
• Heighten awareness of ACAT assessments and role
• Reduction in inappropriate referrals
• Facilitated client discussion and information
  sharing
• Common information/communication system promoting
  seamless information
• Access to single electronic medical record
  (CHIME)
• Opportunities for case conferencing
• High staff satisfaction

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• THANK YOU