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A Quality Initiative and Research Project from the Chronic Care Program
Service Redesign On The Run
Katrina Scott-Charlton, Care Coordinator, Chronic Care Program, ACT Health
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Improving the management and quality of life for ACT residents with:
Chronic Obstructive Pulmonary Disease Chronic Heart Failure Parkinson’s disease
The Chronic Care Program
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The Chronic Care Program
Client Nurse Care Coordinator C
omplex?
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Respiratory specialist
podiatrist
Community nursing
Endocrine
ACAT
oxygen cylinder hire
Medication management
Mobility aids
Social worker
GP
OT
Hospital Admission
s
Cardiology
Community services
Physio
Geriatrici
an
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Provide holistic assessment, care planning, education and support
Assist clients to access health and community services
Attend appointments with clients
Provide psychosocial support and advocacy
Facilitate Advance Care Planning
Support for carers/family
Clinical Care Coordinators
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Action Research
Problem
Plan
ActObserve
Reflect
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Problem
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1) Create a safe, systematic approach for moving clients toward self-management and discharge
2) More time efficient
Plan
Literature review
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Category 1: high needs (usual input)
Category 2: Low needs (monthly phone call only)
Act
Graduation discharge to CCP
nurse support
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9 month trial Quantitative
◦ Monitoring of: Staff to client ratios Numbers of Category 1 and Category 2 clients Activity through Occasions Of Service
Qualitative◦ Client feedback via survey◦ Staff feedback via regular team meetings ◦ Staff focus group
Observe
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46.6% increase in staff to client ratio
58.4% increase in clients receiving care coordination
79% increase in Occasions of Service
Quantitative Outcomes
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Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-130
20
40
60
80
100
120
Pts
Cat2 Pts
Cat1 Pts
Project Imple-mentation ↓
Total Numbers of Clients/Category 1 and 2
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Staff Feedback:◦ Occasional home visits were needed for some
Category 2 clients
Client Survey:◦ 52% response rate!◦ 90% felt they had enough support and
information through a monthly phone call◦ 45% felt that it would be beneficial to have an
occasional home visit
Qualitative Outcomes
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Staff Focus Group Feedback:◦ Trial streamlined service, increased efficiencies but
remained flexible and client focussed
◦ Occasional home visits in addition to phone contact was important to ensure client safety and compliance
◦ Part of the success of the monthly phone call was due to relationship built during face to face contact during home visits
Qualitative Outcomes Con’t
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1) Create a safe, systematic approach for moving clients toward self-management and discharge?
2) More time efficient?
Reflect
What Next?
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Service redesign and research is possible - even on the run
Start planning earlyStay client/patient focussedMix methods
What we learnt
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The Care Coordination Clients Wendy Appleton and Toni Heazlewood, Care
Coordinators, Chronic Care Program Chronic Care Program team Jan Ironside, Manager, Chronic Care Program Associate Professor Paul Dugdale, Director,
Chronic Disease Management Dr Geetha Isaac-Toua, Deputy Director, Chronic
Disease Management Claire Pearce, Senior Project Officer, Chronic
Disease Management
Acknowledgements
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Questions ??