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A Framework for
Planned Activity Groups
Alpine & Indigo Partnering for
Healthy Ageing in Planned Activity Groups
HEALTHY AGEING
DEMONSTRATION
PROJECT 2012
1
Acknowledgements
This document has been developed with the input of the current Planned Activity Group Staff from across Alpine and Indigo Shire areas and written by Jane
Darvall, who has been employed as a project person to work on this Healthy Ageing Demonstration Project (HADP) one day a week for a 12 month period.
Firstly thank goes to all of the staff from the Planned Activity Groups who are listed below. They have been very generous with their time, open with their
thoughts, reflective of their current work practices, willing to contribute to and be challenged by discussions and enthusiastic in generating new ideas and
solutions. Thanks you to you all.
Thanks also goes to the Management of these services that have been supportive of the HADP project by willingly allowing staff the time and opportunities to
contribute, have provided guidance to the project and provided input into the development of the Framework. Thanks to Craig Cross and Trevor Marshall from
Alpine@home, Shane Kirk at Indigo North Health and David Kidd and Cameron Butler at Beechworth Health Service.
A special thankyou also goes to the Hume Region, Department of Health for their support and input into the project. Thank you to Janet Chapman, Manager
Population Health & Service Planning: Neil Duggan and Joan Slater from HACC Services; Calvin Graham, Heather Russell and Kath Paine from the Aged Care
Branch.
Kerry Chapman Alpine@home Jenny Tully Beechworth Club Connect
Angela McCormack Myrtleford Leisure Group Jennifer Plate Beechworth Club Connect
Jayne Dunell Myrtleford Leisure Group Jo Matthews Beechworth Club Connect
Sandy Southern Alpine Leisure Group Jenny Dale Yackandandah Club Connect
Mandy Morrison Alpine Leisure Group Ann Monshing Yackandandah Club Connect
Leigh Laing Alpine Leisure Group Julie Walker Yackandandah Club Connect
Clare Southern Alpine Leisure Group Marianne Thompson Tangambalanga Club Connect
Carolyn Martin Alpine Leisure Group Raelene Ghiggioli Tangambalanga Club Connect
Jane Dwyer Alpine Leisure Group Jo Kelly INH Leisure Club
Mirella Glogglia Alpine Leisure Group Ken Grace Bright Leisure Group
Tracy Preston Mt Beauty Leisure Club Helen Braidwood Bright Leisure Group
Lyn Edyvean Mt Beauty Leisure Club Karen Briggs Bright Leisure Group
2
INTRODUCTION
As part of the Healthy Ageing Demonstration initiative Alpine@home, Beechworth Health and Indigo North Health have partnered on a project
throughout 2012 with the aim to develop a Practice Framework for Planned Activity Groups from the ground up. This has been done through the
engagement of current Planned Activity Group participants and staff, the sharing of best practise ideas, fostering innovative and new ideas and
drawing on external resources.
This Framework is primarily developed by and for the Planned Activity Group staff to support the good work they are currently doing and to guide
new initiatives and development for the future.
The drivers for this project are ensuring that Planned Activity Groups:
Are meeting the needs of the current frail aged and disable populations in their communities
Are ready for the growing future demand as the aging population is set to grow dramatically over the next 2 decades
Are able to meet the needs of the future consumers that will have more information about their health status and social support needs, and
higher expectations of what services can provide for them
Are actively involved in the service planning and coordination across the health care and social support services working together to support
clients and that the PAG role and function is understood
Are maximising the opportunity for partnerships with other local community groups
Are adequately skilled and supported to provide a range of activities that maximise the individuals functioning and opportunities for social
connection
The purpose of this framework is to
Clarify purpose and function of Planned Activity Groups across Indigo & Alpine Shires
Value the role & contribution Planned Activity Group makes to the coordination of care across the health and social support services
Share experience & knowledge
To support and promote future service development of Planned Activity Group
Target audience
Planned Activity Group staff of Alpine@Home, Beechworth Health Service and Indigo North Health.
All staff and Management of Alpine@Home, Beechworth Health Service, Indigo North Health, Alpine Shire and Indigo Shire.
Department of Health & interested staff from services providing health and social support services across the Hume Region.
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CONTENTS Section Page
Background 4
1.0 Accessibility 9
2.0 Client journey 12
3.0 Designing programs 16
4.0 Partnering with the local community 22
5.0 Staff development and training 25
6.0 Opportunities across Planned Activity Group’s 28
Conclusion 30
Appendix 1 Person Centred Care 32
Appendix 2 Active Service Model 33
Appendix 3 Victorian Service Coordination Manual 2012 34
Appendix 4 Healthy Ageing Demonstration Project 36
Appendix 5 Special Interest Check list 38
Appendix 6 Time table for Planned Activity Groups across Alpine & Indigo Shires 43
Appendix 7 Contact information for Planned Activity Group’s across Alpine & Indigo 44
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BACKGROUND
Planned Activity Groups (PAG) provide community based group programs as a component of the Victorian Home and Community Care (HACC)
service and is funded jointly by the Commonwealth and State Governments. HACC services are ‘targeted to frail older people, people with
disabilities, and their carers, providing basic support and maintenance to people living at home whose capacity for living independently is at risk, or
who are at risk of premature or inappropriate admission to long term residential care’1.
Planned Activity Group services ‘maintain an individual’s ability to live at home and in the community, by providing a planned program of activities
directed at enhancing the skills required for daily living and providing physical, intellectual, emotional and social stimulation. They also provide
opportunities for social interaction as well as respite and support for carers’. 2
Most of the Planned Activity Groups across Indigo and Alpine Shires have evolved from pre-existing groups with differing purposes and functions; such
as day hospitals with a focus on rehabilitation or day care centres with a focus on respite for carers.
The Victorian Home & Community Care (HACC) Program Manual 2003 is still the primary guide used for the implementation of HACC services,
including PAG’s, across Victoria. However this document is currently being redrafted and should be available in 2013.
Planned Activity Group (PAG) by definition is as the name states a group program planned to meet the needs of the target population of frail aged
and / or people with disability in the community.
However the introduction of ‘Active Service model 2010’ and ‘Person Centred Care 2008’ has seen the broadening of the nature & intention of
Planned Activity Groups with a focus now on ‘how can we work with you rather than do for you’. (See Appendix 1and Appendix 2).
For Planned Activity Groups that have traditionally focused on providing group programs these new models now refocus the role and function of
Planned Activity Group’s by putting the client, and their carers, in the centre with the focus on ‘planning with’ rather than ‘doing for’. The aims of the
programs provided by Planned Activity Group are ensuring social well-being, maintenance of functioning and active living. This broadening of focus
has provided an exciting opportunity for Planned Activity Group’s to work in more individualised, creative and meaningful ways.
1 Victorian Home & Community Care (HACC) Program Manual 2003
2 (Victorian Home & Community Care (HACC) Program Manual 2003)
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The Planned Activity Group’s across Alpine & Indigo have all changed their names to better reflect this change in philosophy; Alpine@home groups
are all called ‘Alpine@Home Activity Groups’; Beechworth Health Service are all called ‘Club Connection’; and Indigo North Health is called ‘Leisure
and Lifestyle Program.’
With the trend over the last decade of people living at home longer with in home support services rather than moving into low care residential
facilities Planned Activity Group groups have seen a change in the population they provide services to. Many participants are now frailer and or
experience dementia, and as a result require higher levels of emotional and physical support, such as assisted toileting, mobility and transportation.
Planned Activity Groups are a vital component of the health and community services that work together with the person to maintain living at home
for longer. Planned Activity Group supports people to maintain social connections and functioning and are likely to be the service that sees the
person for the most hours each week, as most participants attend at least 2 days a week. This makes the Planned Activity Group staff an essential
component in the coordination of care processes that are outlined in The Victorian Service Coordination Practice Manual 2012. (See Appendix 2:
Relevant Models)
One of the challenges for Planned Activity Group in small rural communities is the community perception of the role and function, as many people
view joining the PAG as the last step before entering permanent residential aged care. Although this may be the natural pathway of care for many
people most participants once they are engaged with Planned Activity Groups and attending regularly will see an improvement in functioning and
emotional wellbeing and report enjoying being a part of the Planned Activity Group environment.
In 2011 the Department of Health and the Hume Integrated Aged Care Planning Collaborative (HIACP) contracted the lime Management Group to
conduct a project on An Approach for Improving Social Connectedness of Older People, December 2011. The identified vision is ‘The Hume Region
has abundant opportunities for older adults to enjoy social activities and events within the community that provide meaningful and purposeful
connections with other people’.3 The overarching goal for the Hume Region on social connectedness is ‘Improving the social connectedness of
older people in a way that is person centred, sustainable and maximises reach and effectiveness.’4 The vision and overarching goal both support
and provide direction for this Planned Activity Group Framework in the area of social wellbeing one of the key objectives for Planned Activity Group.
3 An Approach for Improving Social Connectedness of Older People, lime Management Group, December 2011. 4 An Approach for Improving Social Connectedness of Older People, lime Management Group, December 2011.
6
In the table below outlined are the four guidelines and five enablers, identified by the Lime report, for improving the social connectedness of older
people across the Hume region. The table below also shows where these guidelines and enablers inform this Framework for Planned Activity Group.
Lime Report Framework for PAG The four guidelines are
1) Providing accessible services
Section 1: Accessibility
2) Providing meaningful activities
Section 3: Designing Programs
Section 4: Partnering with the Community
3) Providing inclusive activities and outreach
Section 1: Accessibility
Section 2: The client journey
Section 3: Designing Programs
4) Providing a skilled workforce
Section 5: Staff development and training
Section 6: Opportunities across PAG
The five enablers
1) Service Coordination
Section 2: The client journey
Section 4: Partnerships with the Community
2) Transitional Support
Section 2: The Client Journey
Section 3: Designing Programs
3) Capacity building
Section 3: Designing Programs
Section 4: Partnerships with the Community
Section 6: Opportunities for PAG
4) Innovation
The Development of this Framework for PAG is an innovation project
aiming to further implement the ASM; increase service flexibility and
development; responding to the changing needs of people
5) Workforce development
Section 5: Staff Development and Training
Section 6: Opportunities across PAG
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Development of this Framework
As part of the Healthy Ageing Demonstration initiative Alpine@Home, Beechworth Health and Indigo North Health have partnered on a project
throughout 2012 with the aim to develop a Practice Framework for Planned Activity Groups from the ground up. The Planned Activity Group staff
have worked together, with the facilitation of the Project Person Jane Darvall, to articulate their current practises and challenges which has resulted
in the development of this framework. (see appendix 2 for detail on the project process)
The first phase involved the scoping of current Planned Activity Group groups by meeting with participants, carers and staff during March and April
2012. The information gathered was then analysed by Planned Activity Group staff and service management to identify key areas for service
development, taking the project into phase 2.
The six key areas identified are:
1. Criteria for attending:
Packaged care clients &, Residential care clients
Relationship to residential aged care activity programs
2. The client journey:
PAG as a component of care
Assessment & referral processes
Information gathered on clients & review processes
3. Group activities & Planning:
Purpose & function of activities eg. Socialisation, mental stimulation, retention of skills, physical mobility
Planning and review of programs
4. Relationship to other local community groups:
Opportunities for partnerships in delivering programs
Combatting stigma of PAG and fostering pathways
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5. Staff Training & Development:
What areas of training required
Creating opportunities
Service partnership opportunities
6. Across PAG service developments:
Coordination, review & planning of activities
Innovation eg. client engagement
This framework has been developed from the ground up, meaning that the Planned Activity Group staff have been the primary informants for the
Framework. This started with a full day workshop on July 27th 2012, attended by 15 current Planned Activity Group staff and held in Yackandandah.
Each Planned Activity Group then nominated one of the topics above to work on in more detail to be included in the framework.
Framework was launched to the Planned Activity Group staff and management of Friday 7th December 2012 with a workshop to develop
individualised action plans for each local area Planned Activity Group.
The framework will now address each of the six key areas identified in more detail.
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1.0 ACCESSABILITY
The Victorian Home & Community Care (HACC) Program Manual 2003 clearly states that the target group for Planned Activity Group’s are frail older
people, people with disabilities, and their carers. All of the Planned Activity Groups across Indigo and Alpine predominantly have participants that
are frail older people with the majority over the age of 80. Bright and Myrtleford both have a group of younger participants that have significant
mental health and/or intellectual disability.
1.1 Transition from PAG to Permanent Residential Aged Care
In line with the HACC Program Manual if a person is moved from home into residential aged care they are no longer permitted to attend the Planned
Activity Group program. However with the introduction of person centred care in 2009 it is now viewed that once a person moves permanently into
residential Aged Care services maintaining the familiar contact with PAG can support the person at a time of significant life change. Continuing to
attend the Planned Activity Group program for a period of time can be of benefit in assisting the transition from home to care by maintain social
contact & links with social networks. Where this is already happening the Planned Activity Group staff report that after 3 to 6 months most people
stop wanting to attend Planned Activity Group as they have integrated into their new environment.
Process for transition:
To be decide on a person by person basis
Informed by the persons wishes, carers, the Planned Activity Group staff and Residential Care staff
A time period is set for 3-6 months & then reviewed. If it is appropriate for the person to continue attending after the initial 3-6 months then
ongoing attendance is to be reviewed 6 monthly
The person may not attend Planned Activity Group as frequently as before moving to residential care
The person cannot be recorded as attending programs in residential aged care and Planned Activity Group at the same time
1.2 People moving into temporary Respite care
When a Planned Activity Group participant moves into short term temporary respite care they are still able to attend their usual Planned Activity
Group days if it is practical for them to do so. Arrangements for attending Planned Activity Group whilst in respite care must be made between the
Planned Activity Group staff and the respite care staff prior to the person moving into respite care. This must be made based on the clients and
carers wishes, the practicality of the location of the respite care and through discussions with the Planned Activity Group staff.
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1.3 Aged Care Packages
Some people attending the Planned Activity Group programs are on Aged Care Packages. Across Indigo and Alpine people on Aged care
Packages pay the same daily rate to attend as anyone else attending from the community. These clients are also counted on the statistics.
1.4 Integrated residential aged care and Planned Activity Group activity programs
Indigo North Health has implemented an innovative approach to coordinating the group programs across the residential aged care and Planned
Activity Group programs. This allows for increased flexibility in the small rural community context and broadens the focus of services as providing
support to attend a range of leisure and lifestyle activities in the community. It also allows for individually tailoring the program to peoples areas of
interest and need for support. It is important that services are mindful that Planned Activity Groups are funded via a different stream than Residential
Aged Care; therefore the staffing resources and client contacts need to be clearly attributed to the two areas. As Planned Activity Group are
funded to support people living in the community it is essential that no community residents are prevented from attending the Planned Activity Group
because there is insufficient space due to the presence of residential aged care participants (except where someone is transitioning into residential
aged care).
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1.0 Accessibility to Planned Activity Programs Overall goal: To ensure that frail aged and disabled people in the community remain socially connected, particularly when their living
circumstance change, through access to Planned Activity Programs in their local communities.
AIM ACTIONS
1.1 Transition from home to
permanent Residential
Aged Care
Residential Aged Care and Planned Activity Group to
work in partnership to ensure that the transition from
home to residential aged care is supported by
maintaining social connections with the PAG.
All PAG’s to have a formal arrangement /policy with the
Residential Aged Care Services outlining the process for
continued attendance at PAG for a fixed period of time.
1.2 Temporary respite care
A persons social connection with PAG are maintained
whilst in respite care to support maintenance of social
skills and connection to social networks.
All PAG’s to have a formal arrangement / policy with the
respite services outlining the process for attending PAG
whilst in respite care.
1.3 Aged Care Packages
Access to PAG’s is equitable for all people in the
community requiring PAG.
Currently in place.
1.4 Integrated residential
aged care and PAG
activity programs
To ensure that a broad range of activities is available
and flexibility in attendance allows for the individual
needs of participants to be met.
Alpine@Home and Beechworth Health Service to consider
this model as an alternative model in the small rural
context to provide flexible and responsive group programs
that are client centred.
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2.0 THE CLIENT JOURNEY
The Planned Activity Group services of Indigo and Alpine shires are a component of small rural health services that provide a diverse range of services
aiming to maintain independent living in the home environment. The Planned Activity Group staff are likely to be the service having the most
contact with a person on a weekly basis as participants may attend anywhere from 1 to 4 days a week for up to 6 hours each day.
This means that the Planned Activity Group staff are a vital component in the coordination of care with clients and must be a part of care planning,
implementation and review processes as outlined in the Victorian Service Coordination Manual 2012. This manual states under ‘Partnerships and
collaboration that service providers work together and take responsibility for the interests of consumers, not only within their own service but across
the service system as a whole.’5 (see appendix 3: Victorian Service Coordination Manual 2012)
The Active Service Model also supports this with ‘Principle 5: A person’s needs are best met where there are strong partnerships and collaborative
working relationships between the person, their carers and family, support workers and between service providers.’ 6 (see appendix 2: Active Service
Model)
2.1 Informal functional observation –‘Valuing the role of the Planned Activity Group staff’
The Planned Activity Group staff are spending between 6 to 20 hours a week with the clients that attend the program. They are observing clients
over time and in different environments and situations.
The Planned Activity Group staff are continually making informal functional observations of the clients to ensure:
Client’s needs are met
Appropriate support and assistance with mobility, toileting, dementia/memory loss etc
Safety of the individuals and group as a whole
Choice of activities and programs are appropriate
The Planned Activity Group staff will often be the first people to observe temporary or permanent changes in a client’s physical, cognitive, emotional
or social functioning. These informal functional observations can assist the coordination of care for a timely and / or early intervention for the client,
which can prevent further functional deterioration. If there are any client unmet needs identified that are outside the Planned Activity Group role,
the responsibility of the Planned Activity Group coordinator is to refer out to the local HACC Assessment Service for a Living At Home Assessment, or
the GP or case manager.
5 Victorian Service Coordination Manual 2012 6 Strengthening assessment and care planning. A Guide for HACC assessment services in Victoria 2011
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2.2 Intake & Assessment
For new clients coming into the Planned Activity Group program the intake, initial needs assessment and eligibility for HACC service are all completed
by the service wide intake component of each health service, ie Alpine@home, Beechworth Health Service, Indigo North Health. All of these services
use the Service Coordination Tool Templates (SCTT tools) for intake.
The intake service will then provide a copy of the SCTT Service Coordination Tool to the Planned Activity Group staff and a time for the new client to
attend and trial Planned Activity Group will occur.
The Planned Activity Group staff report that this initial engagement with clients in very important. It may take three or four visits to build rapport so
that the person feels comfortable enough to join the group program. Some Planned Activity Group staff report that for socially isolated clients it can
be useful to visit in their home initially to build the rapport before they are willing to attend. This is supported by the Lime report ‘there is an increasing
body of evidence about the direct link between social connectedness and health in older people and the more socially isolated an older person is,
the more likely they are to be at risk of poor emotional and physical health which compromises healthy ageing.’7
Although there is no service specific assessment tools or specialist assessment tools for Planned Activity Group all clients are assessed by the Planned
Activity Group staff in order to develop the service specific care plan. Several of the groups use an Interest Checklist as a way to find out more about
client’s leisure and lifestyle interests and report that it assists with building rapport when engaging a person new to Planned Activity Group. (see
appendix 7: Special Interest Checklist)
2.3 Coordinated Care Planning & Review
As Planned Activity Group staff spend high amounts of contact hours with clients each week and over a long period of time it is essential that they
are part of the coordinated care planning and the routine review of clients in line with Active Service Model and the Victorian Service Coordination
Manual 2012.
The Planned Activity Group is to develop a care plan for each client to describe how the Planned Activity Group service will be provided, how the
service will handle the toileting, mobility issues, dementia/memory loss issues and review dates for when the person is at the Planned Activity Group.
Where possible, people should have only one agency Care Coordination Plan that each component of the service adds their information to,
including Planned Activity Group. Where it is not possible for Planned Activity Group staff to attend meetings then feedback could be provided in
writing or via an earlier meeting with the case manager or key worker.
7 An Approach for Improving Social Connectedness of Older People, lime Management Group, December 2011.
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2.4 Access to files & note writing
Planned Activity Group staff are required to make a file entry on all participants at a minimum of once a year or ‘by exception’. The annual update
must reflect on the Leisure and Lifestyle goals in the Care Coordination Plan and any other significant events of the year. ‘By exception’ means that
a file note must be made for any event, change or incident that occurs outside of the usual daily routine or not covered by the Leisure and Lifestyle
goals recorded in the Care Coordination Plan. Planned Activity Group staff, like all employees of the Health Service, are governed by, and must
comply with, the privacy legislation and use and access to files policies.
2.5 Communications
As part of a participants care coordination team Planned Activity Group staff are to communicate with other components of the health and social
support team with the participants consent and or when they are concerned about the health or functional status of the participant.
Notifications across the care coordination team must also be made when there is an unexpected or planned change in the participant’s location.
eg. If someone is admitted to hospital or spending time in respite care all components of the service are to be notified to avoid unnecessary concern
when a service attends the home to provide home care or collect the person for Leisure and Lifestyle activities.
2.6 Information for outing & off site
A contact list is required for taking participants on outings in case of an emergency. This list must contain the minimum of information and include
next of kin, GP and other service provider information. In the case of a medical emergency contact to the Health Service or GP clinic must be made
for the most up to date medical and medication information.
This list must be kept in a locked filing cabinet or destroyed on return from outings.
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2.0 The Client journey Overall goal: People engaged with more than one health and community service will have well-coordinated care through involvement
in a coordinated care planning process that respects the wishes of the person, their cares and is informed by the key staff. AIM ACTIONS
2.1 Informal functional
observation
PAG staff have knowledge and understanding of
informal functional assessment and play a key role in the
care coordination team for a person
There must be clear and accessible pathways for PAG
staff to communicate informal observations of client
changes in functioning. Eg. If concerned re client’s
physical health do they contact the client GP or case
manager or district nurse, HAS, allied health, other
HACC services?
PAG staff to receive training in informal functional
assessment
2.2 Intake and assessment
All people joining a PAG will have an intake and initial
needs identification conducted by the service wide
intake system and their specific leisure and lifestyle
needs will be identified by the use of an interest checklist
as part of initial engagement with PAG.
Implementation of an Interest Checklist
Develop a process for engagement of people who are
identified as isolated.
2.3 Coordinated Care and
review
PAG staff must be an engaged part of the care
coordination plan and review processors of participants
who attend PAG regularly.
Systems for Care Planning and Review must support the
involvement of the PAG staff
Where possible each person should have only one
Care Coordination Plan
2.4 Access to files
PAG staff have access to client files for the purpose of
fulfilling their role under the privacy legislation.
Annual and ‘by exception’ note writing is the minimum
requirement for PAG participants. Ie. client ill or
changes in functioning, eg changes in concentration
or memory PAG staff must have education and training of Privacy
Legislation & File Management
2.5 Communications
PAG staff are a respected part of participants care
coordination and will be notified of significant changes
in a participants health status and living environment.
A communication system that complies with privacy
legislation must be implemented for notification
between services when there is a change in health or
living status of a participant
2.6 Information for outings
When offsite the PAG staff have necessary information at
hand to respond in the event of an emergency
An emergency contact list is kept updated for outings
and stored in accordance with privacy legislation.
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3.0 DESIGNING PROGRAMS
3.1Aims & objectives of Programs
The Planned Activity Groups aim to enhance the skills required for daily living and provide physical, intellectual, emotional and social stimulation. As
Beechworth Health Service has stated in its Resource File the Planned Activity Group activities must be stimulating and challenging; provide variety;
be fun and entertaining; promote independence; and be adapted to meet individual abilities to create a sense of achievement.
Aims Types of activities
Physical Wellbeing
To maintain and improve physical function, balance and endurance
through physical activity and healthy eating.
Exercise groups
Pole walking
Outings
Games – crocket, bowls etc
Cooking
Healthy meals
Intellectual Wellbeing
To maintain intellectual function through activities requiring memory,
concentration, general knowledge, problem solving and critical thinking.
Quizzes
Board games
Education sessions
Guest speakers
Emotional Wellbeing
To monitor and support emotional wellbeing through creating a safe and
inclusive environment, that respects individual difference, listens and
responds to individuals needs and supports people in times of transition,
lose and grief.
Safe, inclusive & supportive
environment
Engaging activities
Education sessions on self-care and
emotional well being
Social wellbeing
To maintain meaningful roles and a community identity, promote
communication skills and orientation to time and place by supporting
social interactions and networks.
Interactive group activities
Shared meals & Theme days
Outings
Activities that involve family & friends
Supported access to other leisure
activities in the community
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3.2 Managing Group dynamics
As Planned Activity Groups are predominantly group based there is a need for the staff to be constantly aware of and managing group dynamics.
This is a complex area that requires group leadership and communication skills. The group dynamic can be intensified in small rural communities as
most of the participants will have prior knowledge of one another and historic or current relationships that exist outside of the Planned Activity Group
environment.
3.3 Programs targeting specific groups
The participants of a Planned Activity Group will have varying interests, levels of functioning and needs for support. In order to meet the need of all
participants and to pitch programs so that they are not too boring for some or to challenging for others is a constant challenge for Planned Activity
Group staff.
The Planned Activity Groups have addressed this by segmenting programs over different days to meet the differing needs of participants. For
example some groups have high and low need care days, or target specific cultural groups such as the Italian Group at Myrtleford.
Indigo North Health has a flexible system of segmenting programs across the day. Eg. Some people may attend an exercise program in the morning
and join the larger group for lunch while a small group of women might attend a craft activity group at the Senior citizens with the support of a
volunteer.
3.4 ‘Must have’ programs
Exercise groups certified by physiotherapists or run by physiotherapist are a very successful component of most Planned Activity Group programs as
they are well attended and often have good outcomes for people recovering from injuries or illnesses. Physiotherapists from local hospitals will often
refer people to these exercise programs as part of their rehabilitation after a hospital admission. These programs must be certified by physiotherapists
and provide programs that continue to challenge peoples physical strength, endurance and balance.
All Planned Activity Group’s need to provide a component of the program that attracts higher functioning participants in order to meet the needs of
people who require some support to achieve leisure and lifestyle goals however are mostly still independent. Activities that work well for attracting
these people are; a weekly swimming group to a heated pool in Wangaratta; a monthly active and social big bus outings for up to 50 people; pole
walking and other exercise programs.
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3.5 Education Programs
Providing education via an external provider through the Planned Activity Group program can be a great way to bring carers, friends and volunteers
into the Planned Activity Group environment and support people to increase health literacy, improve understanding of services available and gain
skills in managing their health and wellbeing. An example of this is Indigo North Health had a person from the aged persons mental health program
deliver the 6 week ‘Well for Life Program’ which focuses on health, wellbeing and financial management in retirement. The program was attended
by some Planned Activity Group participants, carers and volunteers.
3.6 Other community based Leisure and Lifestyle Programs
It is a valid role for Planned Activity Group staff to support participants to access and attend other Leisure and Lifestyle programs in the community.
This may occur on an individual basis or in a small group. The support offered from the Planned Activity Group staff may be to find out when and
where activities are held, to assist with transportation to the activity or to attend with the participant/s. Volunteers can be a great way to support this
attendance as long as the support needs of the participant are manageable for a volunteer. An example of this is where 3 or 4 women who attend
Planned Activity Group access a weekly sewing group at the local Senior Citizens group with the support of a volunteer.
Planned Activity Groups can access a range of community recreational facilities to support a diverse range of activities that suit the Planned Activity
Group participants. Most of the Planned Activity Groups are already doing this with examples being use of the local bowling & crocket clubs or a
social game of pool at the pub.
An area of expansion for Planned Activity Group is to consider a role of supporting people to remain engaged with leisure and lifestyle activities they
already attend but are starting to find difficult to attend due to a change in level of functioning (eg unable to walk to activities any longer) or lifestyle
change (eg person who used to drive them can no longer do so.)
3.7 Supporting people to attend community health appointments
Planned Activity Group staff can support the overall care coordination of a participant by assisting access to individual community and health
appointments such as GP, physiotherapy & podiatrist on days that the person is already attending the Planned Activity Group program. This is
particularly beneficial if appointments can be coordinated for people who live alone in remote areas. This may also include supporting people to
maintain relationships with family and friends.
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3.8 Client driven programs
The Planned Activity Group program activities are planned on a monthly basis and all of the Planned Activity Groups do this with the participants at a
monthly meeting. The meeting generates ideas for centre based activities, outings, theme days and attendance at other local community activities
eg fashion shows at the local bowling club or the local high school yearly production. The program is then written up into a timetable and given to
all the participants.
3.9 Annual review of program
Time must be allocated for the Planned Activity Group staff to conduct an annual (or six monthly) review of their programs and planning for the next
year. This review must include:
Review of
1. Attendance at the programs; how many new participants and has attendance declined and why?
2. The service aims and objectives to identify if they are still relevant and to ensure the participants needs are being met under the four areas of
Physical, intellectual, emotional and social needs
3. Activities to identify if they are still meeting the participants needs as indicated by attendance and feedback from participants
4. Current community partnerships for effectiveness of supporting the Planned Activity Group participants Leisure and Lifestyle goals
5. Innovations of other Planned Activity Group or Leisure and Lifestyle programs
Outcomes
1. To modify the aims and objectives of the Planned Activity Group to ensure they are meeting the leisure and lifestyle needs of current & future
participants
2. To identify the activities in the program that will remain in the program for the next 12months
3. To identify new activities for introduction and trial in the next 12 m
4. To identify 3 to 5 areas for service development or innovation for the next 12 months and develop an action plan to address these with realistic
time frames.
3.10 Monthly newsletter
A monthly newsletter is a great way to communicate with and engage the current participants and carers and can also be used to attract new
participants. It is also an engaging and fun way to let other parts of the local health service and community know what Planned Activity Group is up
to. Including the monthly program for the next month also advertises the program. The Bright Newsletter is a stand out example with interesting
photos and stories of the month’s goings on.
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3.0 Designing Programs
Overall goal: To ensure that Planned Activity Groups are providing access to a range of leisure and lifestyle activities that are supporting
the physical, intellectual, emotional and social needs of current participants and attractive to potential and new participants. AIM ACTIONS
3.1 Aims and objectives of
Programs
PAG is to have clearly understood aims and objectives
that guide the selection of activities to meet the needs
of participants.
All PAG’s must have clearly stated aims and objectives
for their program as outlined in 3.1 above. These must
be accessible to and understood by PAG staff
3.2 Managing group
Dynamics
Group dynamics are understood and managed to
ensure that participants feel safe and included in the
group and that the full potential of the group is reached
through productive interaction of members.
All PAG staff must receive guidance and training on
managing group dynamics. Eg. Skils in defusing,
reframing and negotiating.
Resources must be available to staff to assist them in
managing group dynamics.
3.3 Programs targeting
specific groups
PAGs are flexible in segmenting programs so that
individual and small group needs can be met.
PAGs to identify where and how segmentation of their
program can better support them to meet a range of
client needs.
3.4 Must have groups PAG’s must ensure that participants have access to
exercise programs and that needs of potential and
newer members to PAG are met with at least one higher
functioning activity weekly.
All PAGs to identify if they are currently meeting the
needs for exercise and higher functioning activities and
if not to develop an action plan to address this in the
next 6 to 12 months
3.5 Education Programs Education programs are delivered through the PAG
program to promote wellbeing for participants, carers
and volunteers.
All PAGs to identify if there is currently a need to
provide education programs and if so are they meeting
the need?
3.6 Other Leisure& Lifestyle
programs in the
community
PAG staff will support the attendance at other activities
in the community that meet the leisure and lifestyle
needs of PAG participants
PAG’s to consider this as an alternative to delivering all
of the programs within the PAG structure.
To consider a new role for PAG, with the broadening of
the function to being Supporting Leisure and Lifestyle
goals, in supporting people to continue attending
current attendance at activities when it is becoming
difficult for them to do so.
Develop and support the use of volunteers in this area.
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3.7 Supporting people to
attend other community
and health appointments
For clients that are isolated and live in remote areas PAG
staff will support attendance at other community or
health appointments on days that they participate in
PAG.
PAG’s role in this is to be identified by the care planning
process.
3.8 Client driven programs PAG provided programs are driven by the leisure and
lifestyle needs of the participants
To continue monthly planning meetings with
participants
To identify new and creative way to gain participant
input into the program design. Eg surveys / feedback /
giving satisfaction rating of activities
To identify ways to get input and feedback from future
PAG participants
3.9 Annual Review of
Programs
PAG programs are reviewed annually to ensure that the
aims and objectives of the programs are meeting the
needs of current and future participants and carers.
Each PAG to have a 6 monthly or annual allocation of
time to review and plan the program under the
headings outlined in section 3.9 above
3.10 Monthly newsletter PAGs will provide information about the program to
participants, carers and other service providers in an
engaging and timely manner.
Consideration of a format version of a newsletter that
allows for quick addition and alteration on a monthly
basis
Potential for an email/ mailing list for circulation of
newsletter to carers and other service providers
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4.0 PARTNERING WITH THE LOCAL COMMUNITY
As stated in the Lime report ‘organisational partnerships are beneficial for achieving social mobilisation of older adults. It is also optimal to use and
develop existing service networks and platforms to include older people at risk of isolation, rather than establish new and stand-alone programs. This
integrated approach assists in smoothing transitions for older people as their interests and support needs change.’8
The Planned Activity Group staff have also identified that partnering with other community services creates opportunities for intergeneration activities,
can reduce community stigma of Planned Activity Group groups and can foster pathways for people as their support needs and interest in leisure
and lifestyle activities change.
4.1 Building & Maintaining relationships with other community groups
Each of the communities that Planned Activity Groups operate in will have a different selection of services that are the predominant leaders for
leisure and lifestyle in that community. The Planned Activity Groups need to be aware of who the significant partners are for them in relation to
delivering a program for their participants and must establish service relationship links to these services. This may be via planning and delivering
services jointly with other community groups; attending community forums; being on mailing lists for alerts of upcoming events; establishing a regular
email or face to face communication with other community providers; attending meetings of other clubs; and inviting other groups to visit Planned
Activity Group. These relationships will promote the role of Planned Activity Group as a vital and flexible component of local community leisure and
lifestyle activities.
Bright, Mt Beauty and Yackandandah all have access to a great community resource of a local radio station. They have all created a link to the
stations that will play the requested songs of participants. This is a fun and engaging way for participants to interact with the broader community.
8 An Approach for Improving Social Connectedness of Older People, lime Management Group, December 2011.
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4.2 Active Retirees
Active retirees have many leisure and lifestyle pursuits in small rural communities, many of which they actively govern and run themselves. Some of
these groups are Senior Citizens, Probus, Lions Club, Rotary Club, Country Women’s association, Hospital Axillary, Men’s Shed, bowling club, crochet
club, cycling groups, Neighbourhood centres, volunteer networks and U3A. As active retirees need for support increases with ageing there may be a
role for Planned Activity Group.
‘Volunteering has a positive impact on the older person who volunteers and the older person or people assisted by volunteering. Volunteering builds
the social capital of the communities where it operates.’9 Volunteers are a valuable component in the Planned Activity Group program and can
provide necessary support roles to assisting people to access individual health and community appointments and providing support to an individual
or small group of participants to access other leisure and lifestyle activities.
4.3 Bridging the age gap
Intergenerational relationships between older people and younger members of the community can be mutually beneficial. For example older
people can assist with reading programs at schools, improving self-esteem through being valued contributor in the community. Teenagers from local
high schools have developed skills and understanding in providing community support through teaching older people to use computers and Skype
so they can contact families’ members who live away.
There are many ways that these partnerships can occur such as attending school performances, visiting kindergartens to work on craft or reading,
and high school pupils attending Planned Activity Group for a semester as part of school curriculum.
4.4 Use of community venues
Planned Activity Groups can promote the normalisation of leisure and lifestyle activities through the use of other community venues where
appropriate.
9 An Approach for Improving Social Connectedness of Older People, lime Management Group, December 2011.
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4.0 Partnering with the local community
Overall goal: To ensure that partnerships are formed with key leisure and lifestyle services in the community so that a diverse and exciting
range of activities are available to frail aged and disabled people in the community, promoting social connectedness.
AIM ACTIONS
4.1 Relationships with other
community groups
To promote partnership work across leisure and lifestyle
programs within the community
PAG’s to identify at least 4 key community services to
establish an ongoing partnership.
PAG to identify services they should receive updates
and news letters from and services that they should
send their newsletter to.
4.2 Active Retirees To identify and partner with key services providing leisure
and lifestyle activities to retirees.
3 of the 4 key services to establish a service relationship
with must be in the active retiree category
4.3 Bridging the age gap To identify and partner with childcare centres,
kindergartens and schools on intergenerational activities
that are mutually beneficial.
1 of the key services to establish a service relationship
with must be in the active retiree category
4.4 Use of community venues To normalise activities by providing them in appropriate
community venues
When planning activities consideration is to be given to
alternative community venues.
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5.0 STAFF TRAINING & DEVELOPMENT
Staff attracted to working in Planned Activity Groups come from a range of backgrounds. Most come from a nursing or personal care background
with years of experience in other health and community programs. There are particular demands in the Planned Activity Group environment that
require targeted training such as managing engagement of isolated people, group dynamics, conducting outings, managing dementia and difficult
behaviours in an open environment and community engagement. This section will consider the minimum requirement of training for Planned Activity
Group staff and areas for targeted development specific to the Planned Activity Group environment.
5.1 Qualifications for PAG Staff
The HACC program has a minimum requirement for staff qualifications which is the Certificate 3 in Home Care. For existing staff with a Certificate 3 in
Home Care they are not required to upgrade. However as part of this Framework development Alpine@home, Beechworth health Service and
Indigo North Health have committed to all staff providing Planned Activity Group programs being trained in a certificate 4 in Leisure & Lifestyle. If this
Certificate has not been obtained prior to employment then staff are supported to commence this within 12months of starting work.
5.2 Ongoing training opportunities
All Planned Activity Group staff have access to the standard mandatory training of the health services, which includes orientation, manual handling,
emergency procedures and infection control.
Planned Activity Group staff have identified some other areas of training that would be of benefit, including - dementia management, behavioural
management, group dynamics and program skills, mental health, health coaching, client centred practises, community engagement, bus driving
and use of bus hoists, ramps and lifts. Self-care and managing stress and burn out is another area for training as Planned Activity Group is an area for
potential burn out as there is high levels of face to face contact hours.
The Planned Activity Group staff at Beechworth Health Service have been part of establishing a Planned Activity Group network for training across
the Hume region to address identified training needs specific to Planned Activity Group. This is a great forum that is well attended and must be
supported to continue.
5.3 Annual PAG Conference
As an outcome from this healthy ageing demonstration project Planned Activity Group staff have identified that it would be useful to have an annual
conference across Indigo & Alpine to share ideas, continue service development planning and conduct identified training.
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5.4 Staff exchange
Many of the Planned Activity Group staff are keen to trial an exchange to another Planned Activity Group as a way of sharing practise ideas. This
can occur where 2 staff are happy to swap work sites for a day. It is important that the learning and ideas are feedback and shared across the
Planned Activity Group staff.
5.5 Bank staff across Alpine & Indigo
As a way to better manage back fill to staff when they are sick or on leave a bank of Planned Activity Group staff is to be established across Indigo
and Alpine services. Existing staff can nominate other services they would be happy to travel to for backfill purposes. This would involve staff having to
be signed up as casual staff with other health services.
5.6 Volunteers as part of Planned Activity Group Programs
Volunteers provide a great opportunity to enhancing the programs provided by Planned Activity Groups and are currently involved in a variety of
ways across the groups of Alpine and Indigo Shires. It is essential that volunteer recruitment and training is actively addressed to support their
involvement in the groups.
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5.0 Staff Training & Development
Overall goal: To ensure that PAG staff are adequately trained and supported with ongoing development to provide an innovative leisure
and lifestyle programs to meet the diverse range of participants needs. AIM ACTIONS
5.1 Qualifications for PAG
staff
Ensure that PAG staff are adequately trained to perform
the tasks involved in providing a PAG.
Alpine@Home, Indigo North Health and Beechworth
Health Service must ensure that all of their existing PAG
staff are trained in a Certificate 4 Leisure and Lifestyle.
There must be a process in place for all newly
appointed PAG staff to commence the Cert 4 within
one year of commencing employment.
Position Descriptions for PAG staff must be reviewed to
ensure this qualification is included.
5.2 Ongoing training
opportunities
PAG staff are involved in identifying specific training
needs required to deliver an innovative PAG program.
At an annual conference the PAG staff will identify &
priories training needs for the following 12 months
5.3 Annual PAG
conference
To facilitate the sharing of ideas and practices an
annual conference for PAG staff across Alpine & Indigo
is to be conducted.
To identify who will be responsible for coordinating an
annual conference
5.4 Staff exchange A coordinated approach to staff exchange will support
the exchange of ideas and best practice.
Identify staff that would be interested in an exchange
to another PAG group
Coordinate and timetable exchanges over a 1 month
period
Facilitate a feedback and communication process –
potentially to feedback into the annual conference.
5.5 Bank staff across
Alpine & Indigo
To support the management of backfill and provide
opportunities for PAG staff to share ideas across services.
To identify staff than would like to work casually in other
PAGs.
To have staff signed on as casual employee’s of the
other Health Services
5.6 Volunteers as part of
PAG
To ensure individual client needs are met and to
enhance the activities provided by Planned Activity
Groups an active volunteer program must be supported
in the PAG environment
Services must have an active volunteer recruitment
and support program that encourages new volunteers
to work in the PAG environment
Volunteers must receive training in mandatory areas
and Active Service Model
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6.0 ACROSS PAG SERVICE DEVELOPMENTS
The cross fertilisation of ideas through the coming together of Planned Activity Group staff has been beneficial as part of this project and something
the staff have expressed they would like to do on a regular basis. As a group in July 2012 the PAG staff discussed possible ways to do this. Below are
some of the options to support the sharing of ideas and experiences across the Planned Activity Groups of Alpine and Indigo Shires.
6.1 Activity & Resource Network
One of the challenges for Planned Activity Group staff is to continually come up with new and exciting activities to challenge and excite their
participants. An online network for sharing resources such as activities, links to blogs, websites, books and upcoming events will allow for easy and
accessible sharing of resource information.
6.2 Email group & Annual newsletter
An email group or web based chat room is a great way for staff to contact one another to communicate ideas or make requests of one another. An
annual newsletter is also a possibility with contributions from each of the Planned Activity Groups. Groups could also circulate their service newsletter
to the other Planned Activity Group groups to keep them updated.
6.3 Hosting of Social events
In the past groups have come together for variety shows and other community activities. Staff reflect on these activities as being enjoyable and
great for getting to know each other. Another idea staff had is to each host an outing or picnic in the local community for the other Planned Activity
Groups to attend.
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6.0 Across PAG Service Development
Overall goal: To maximise the benefit of the knowledge, resources and skills of the PAG staff by ensuring the staff across Alpine and
Indigo have opportunities to communicate openly with one another and share experience, information and resources. AIM ACTIONS
6.1 Activity and Resource
Network
To establish an online connection between staff that is
easy to access and contribute to.
Consider the options for an online network and
implement the best option
Train staff so they can access and contribute to the
resources
6.2 Email group & annual
newsletter
To promote the sharing of info about current PAG
activities and programs
Design a format that allows each PAG to add
information easily to a newsletter format.
PAGs to email each other their PAG newsletters.
6.3 Hosting a social event To establish an informal and enjoyable way for PAG staff
and participants to interact
Set up a time table for 3 or 4 events to occur
annually that will be hosted by each PAG on a
rotating basis.
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CONCLUSION
The development of the Framework has provided an exciting opportunity for the staff from the Planed Activity Groups across Alpine and Indigo Shires
to come together and articulate the practises and challenges of their working context and to identify creative alternatives for future developments.
The Planned Activity Group context has changed dramatically over the past decade with people living longer, an increase in support services to
maintain people living at home and a change in the focus of health services to be person centred. The Planned Activity Group staff are also aware
that the context will continue to change as the aging population of all our communities is growing rapidly. This Framework is a first step in
empowering the services to identify areas for ongoing service development and change and to continue partnership work across the Planned
Activity Groups of Alpine and Indigo Shires.
As people age, or for people with disabilities, it can be difficult to maintain their links with social activities and to access supports in their local
community. Planned Activity Groups play a vital role in supporting people to maintain an active community life, with respect and dignity, by
maintaining physical, cognitive, emotional and social functioning.
Times of transition in a person’s life can often be stressful. For people aging this can occur when they are moving into permanent residential aged
care or into respite care. Due to funding requirements there has historically been conflict about a person continuing to attend Planned Activity
Groups once they have moved into Residential Aged Care. Section 1 of this Framework has now helped to clarify a transitional period for these
people to better support the move to residential aged care by maintaining existing friendships and relationships with the Planned Activity Group at
this stressful time of change.
The Planned Activity Group staff spend between 6 and 20 hours a week with participants and will often be the first people to identify a changing
need for a person. It is essential that there are clear processes to support the staff to be actively involved in the care co-ordination with other health
and social support services involved in someone’s life and this is explored in section 2: The Client Journey.
There are many skills required to plan, implement and evaluate a group program that is sensitive to individual needs and meets the overall group
aims. These intricacies of group program management are addressed in section 3 and section 5 addresses the skill development of the work force to
be able to deliver these group programs.
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It is essential that Planned Activity Groups have active partnerships with other social, educational, recreational and support services in their local
communities so that they can provide a range of activities to meet participants needs. It is also essential that other services in the community
understand the role and function of Planned Activity Groups so that people have access to the service in a timely manner. Section 4 considers
Partnership work with other local community groups.
It has been professionally beneficial for the Planned Activity Group staff to have time with colleagues from other services as part of developing this
framework and section 6 has identified some ways to continue this work.
It has been a great experience to develop a framework with and for the people that deliver the service. This Healthy Ageing Demonstration Project
has supported staff to clearly articulate the role and purpose of their work, to identify the key role they play within their local communities and to feel
valued across the health and social support services.
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APPENDIX 1: PERSON CENTRED CARE
Person-centred practice is a HACC assessment principle. Person-centred or family-centred practice is respect for a person’s or family’s right and
desire to make their own decisions. The approach focuses on self-determination and empowerment. For Aboriginal people, older people from CALD
backgrounds, or younger people with a disability, family members may play a pivotal role in care relationships and in making decisions.
It engages, encourages and supports the person and their family or carers, where relevant, to take an active part in assessment, goal setting, care
planning and implementation decisions and processes.
Person and family-centred practice includes:
• A commitment to seek to understand the desires and wishes of the person (and family members or carers, where relevant)
• A conscious resolve to be ‘of service’, by supporting and helping the person to identify and address their issues or concerns
• Openness to being guided by the person – to seek, engage and respect the guidance and preferences of the person
• Understanding the process as person-driven regarding decisions about support needs and service delivery
• Flexibility, creativity and openness to what might be possible, including innovation, experimentation and unconventional solutions
• A willingness to persist to achieve goals.10
Links to Person Centred Practice. Guide to implementing person-centred practice in your health service 2008 Person-centred practice: Best care for older people everywhere - The toolkit - Victorian Government Health Information, Australia
10 Strengthening assessment and care planning. A Guide for HACC assessment services in Victoria 2011
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APPENDIX 2: ACTIVE SERVICE MODEL
The Active Service Model (ASM) is a quality improvement initiative which explicitly focuses on promoting capacity building and restorative care in
service delivery. HACC ‘clients’ in this context include both service recipients and their family or carers.
The core components of the ASM are:
• Capacity building, restorative care and social inclusion to maintain or promote a person’s capacity to live as independently and autonomously as
possible
• A holistic person-centred approach to care, promoting wellness and active participation in goal setting and decisions about care
• Timely and flexible services that respond to the person’s goals and maximise their independence
• Collaborative relationships between providers, for the benefit of people using services.
In principle, this approach applies to all people accessing HACC services and to all HACC service types. The service response will differ according to
individual needs and goals. It takes as its starting point that ageing or disability is not in itself a determinant of functional, social or psychological
decline, leading to an inevitable need for service. It is important to note that capacity building in this context does not only relate to physical
function, but includes social and psychological wellbeing.
Five principles underpin an ASM approach:
Principle 1: People want to remain autonomous
Principle 2: People have potential to improve their capacity
Principle 3: People’s needs should be viewed in a holistic way
Principle 4: HACC services should be organised around the person and family or carer; the person should not be slotted into existing services
Principle 5: A person’s needs are best met where there are strong partnerships and collaborative working relationships between the person, their
carers and family, support workers and between service providers. 11
ASM PREPARE (Department of Health, 2010) is a resource tool for use by HACC-funded agencies to assist in implementation of the active service
model.
• Victorian HACC active service model discussion paper (Department of Health, 2008)
• Victorian HACC active service model implementation plan 2009-2011 (Department of Health, 2010)
http://www.health.vic.gov.au/hacc/projects/asm_project.htm
11 Strengthening assessment and care planning. A Guide for HACC assessment services in Victoria 2011
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APPENDIX 3: VICTORIAN SERVICE COORDINATION PRACTICE MANUAL 2012
A state-wide primary care partnerships initiative Service coordination places consumers at the centre of service delivery to maximise their opportunities for accessing the services they need. Service
coordination enables organisations to remain independent of each other, while working in a cohesive and coordinated way to give consumers a
seamless and integrated response.
Service coordination can offer many benefits to consumers and service providers.
Benefits for consumers:
■ Provision of up-to-date information about local service availability and support options to contact the most appropriate service
■ No wrong door – every door in the services system can be the right door for consumers to access services
■ Clear entry points, plus transparent and consistent referral pathways and processes that are easy to navigate
■ Improved and timely identification of needs through the initial needs identification process
■ Improved response times to requests for information and referral
■ Confidential transfer of information for referral purposes in a way that does not require the consumer to repeat their information
■ Improved access to assessment and coordinated shared care/case planning
■ Clarity regarding who is involved in service provision and what their responsibilities are to meet the consumer’s goals
■ Reduced duplication of assessments and services and identification of service gaps
■ Increased knowledge of the local service system and access to resources that support service coordination, such as the Human Services Directory
■ Consistent service standards from each service provider
■ A positive experience of the service system.
Benefits for service providers:
■ Practices, processes, protocols and systems that set out clear guidelines and expectations around key areas of work and inter-organisation
practice, including continuous quality improvement strategies aligned with accreditation standards
■ Documented practice standards for initial contact, initial needs identification and shared care/case planning, providing a common language
between services
■ Improved consistency and quality of consumer information through the use of common tools such as the Service Coordination Tool Templates
■ More efficient use of resources through improved information and feedback from referrals, fewer inappropriate referrals and less duplication of
services
■ Streamlined services through the provision of a consistent, agreed, standardised way for practitioners within and across organisations to identify
consumer needs, identify appropriate services, make referrals, provide feedback, communicate and coordinate care, leading to improved
operational efficiency.12 http://www.health.vic.gov.au/pcps/downloads/sc_pracmanual2.pdf
12 Victorian Service Coordination Practice Manual 2012. Published by Primary Care Partnerships, Victoria.
35
Service Coordination in Victoria
What is service coordination?
Service coordination places consumers at the centre of service delivery to maximise their opportunities for accessing the services they need. Service
coordination enables organisations to remain independent of each other, while working in a cohesive and coordinated way to give consumers a
seamless and integrated response.
Table 1: Service coordination principles
Principle Description Central focus
on consumers
Service delivery is driven by the needs of consumers and the community rather than the needs of the system, or those who practice in
it.
Partnerships and
collaboration
Service providers work together and take responsibility for the interests of
consumers, not only within their own service but across the service system as a whole.
The social model
of health and
the social model
of disability
The social model of health2 is a distinct conceptual framework for thinking about health and wellbeing. This framework is concerned
with addressing the social and environmental determinants of health and wellbeing, such as education and housing, as well as
biological and medical factors. This includes the spiritual and family connections that contribute to wellbeing.
The social model of disability3 adopts a human rights approach to disability and differentiates between physical impairment and the
disabling effects of society.
Competent staff Elements of service coordination must be undertaken by staff who are appropriately skilled, qualified, experienced, supervised and
supported.
Duty of care A duty to take reasonable care of a consumer. The duty of care extends to service coordination, where staff have a duty of care to
provide accurate and timely information, and assist consumers with referrals.
Protection of consumer
information
All confidentiality and consumer information requirements are met. The brochure Your information – It’s private4 and the SCTT Consent
to share information template are designed to improve consumer outcomes, information flow and practice.
Engagement with a broad
range of service sectors
Service coordination embraces the broadest range of partnerships across sectors including non-government, government and
private providers.
Consistency in practice
standards
Service coordination procedures and tools are developed to provide consistent, coordinated service delivery.
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APPENDIX 4: HEALTHY AGEING DEMONSTRATION PROJECT 2012
Project Background
Project Aims
Alpine@home, Beechworth Health and Indigo North Health are partnering on a Healthy Aging Demonstration Project to look at Planned Activity
Groups (PAG’s), currently provided under the HACC funding, to ensure they have integrated the ‘Active Service Model’ and are engaged positively
with the community.
Jane Darvall commenced as project person in Feb 2012
Phase 1: Scoping current PAG groups, reviewing literature & other best practise examples Mar-Apr
The first phase of this project was to scope the current PAG’s by meeting with participants, carers and staff during March and April 2012.
This includes:
Alpine Health – Myrtleford, Mt Beauty & Bright
Beechworth Health – Beechworth, Yackandandah & Tangambalanga
Indigo North health – Rutherglen & Chiltern
Phase 2: Service Development opportunities May-June
This information was then analysed by all PAG staff and service management to identify key areas for service development. Six main areas were
identified as listed below.
1. Criteria for attending:
Packaged care clients &, Residential care clients
Relationship to residential aged care activity programs
2. The client journey:
a. PAG as a component of care
b. Assessment & referral processes
c. Information gathered on clients & review processes eg. Medication, emergency response, off site outings
37
3. Group activities & Planning:
a. Set activities vs’ flexibility
b. Purpose & function of activities eg. Socialisation, mental stimulation, retention of skills, physical mobility
4. Relationship to other local community groups:
a. Opportunities for partnerships in delivering programs
b. Combatting stigma of PAG and fostering pathways
5. Staff Training & Development:
a. What areas of training required
b. Creating opportunities
c. Service partnership opportunities
6. Across PAG service developments:
a. Coordination, review & planning of activities
b. Innovation eg. client engagement
Phase 3: Implementation July – Nov
A framework has been developed from the ground up, meaning that the PAG staff have been the primary informants for the Framework. This
started with a full day workshop on July 27th 2012, attended by 15 current PAG staff and held in Yackandandah. Each PAG then nominated a
specific topic to work on in more detail with the project person Jane Darvall.
Framework was launched to all PAG staff and management of Friday 30th November 2012 with a workshop to conduct a gap analysis and develop
individualised action plans for each local area PAG.
Phase 4: Evaluation December
The effectiveness of any changes made will be evaluated with staff surveys and interviews
38
APPENDIX 5: INTEREST CHECKLIST EXAMPLE OF INH
HACC LEISURE CLUB (PAG)
Interest Checklist Clients past & present activities/interests
Activity Past (please tick)
Present (please tick)
Would you like to pursue in the
future?
Y= YES.....N= N0 Hobbies
Craft
Crocheting
Knitting
Stamp Collecting
Coin Collecting
Antique Collecting
Beading
Drawing/Sketching
Painting
Woodwork
Pottery
Sewing
Playing an Instrument
Writing songs / Music
Photography
Embroidery
Quilting
Scrapbooking
Car Racing
Vintage Cars
Shopping
Media / Literature
Films/Movies
Magazines
Newspaper
Poetry
Radio
Reading Books
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TV
Writing
Computers
Topics of Interest
Comedy
County & Western
Current Affairs
History
Murder / Mystery
Musical
Nature
Sport
War
Art
Outdoor Activities
BBQ / Picnics
Bush Walking
Camping
Gardening
Swimming
Water Skiing
Snow Skiing
Shooting / Hunting
Bird Watching
Boating
Yachting / Sailing
Four Wheel Driving
Motorcycling
Climbing
Fishing
Canoeing / Kayaking
Spiritual
Meditation
Reiki
Tai Chi
Yoga
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Religion (Please specify)
Practicing
Non practicing
Sport / Exercise
Swimming
Lawn Bowls
Carpet Bowls
Football
Soccer
Bike Riding
Golf
Pool / Billiards
Bocce
Croquet
Ten Pin Bowling
Tennis
Water Sports
Netball
Exercise Program
Weight Program
Strength Training
Horse Riding
Baseball
Basketball
Darts
Walking
Dancing
Ballroom
Old Time
Folk
Latin
Belly Dancing
County & Western
Tap
Jazz
Irish
Ballet
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Hip-Hop
Swing
Line
Social
Bus Trips
Reminiscing
Chatting
Family Outing
Dinner Party
Horse/Dog Races
Clubs
RSL
Lions
Domestic Activities
Cooking
Laundry
Cleaning
Sensory
Aromatherapy
Foot Spa
Massage – Body
Massage – Hand
Remedial Massage
Spa Bath
Grooming / Beauty
Hairdresser
Makeup
Nail Care
Games / Puzzles
Bingo
Cards
Checkers
Chess
Crosswords
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Jigsaw Puzzles
Snakes & Ladders
Hooky
Quoits
Quizzes
Scrabble
Scattergories
Board Games
Animals / Pets
Birds
Cats
Dogs
Chooks
Fish
Horses
Cows
Sheep
Pigs
Goats
Rabbits / Guinea Pigs
Ducks / Geese
Lama / Alpaca
Reptiles
Authorised by: J. Kelly Date: 15/11/2012
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APPENDIX 6: TIME TABLE FOR PAG GROUPS ACROSS ALPINE & INDIGO SHIRES
Group Monday Tuesday Wednesday Thursday Friday
Alpine
Bright
Mt Beauty
Myrtleford
+Italian
Indigo
Beechworth
1st & 3rd
Yackandandah
Tangambalanga
Rutherglen
Chiltern
Total 6 +Italian 5 4.5 5 3
+Italian – On a Monday in Myrtleford the Alpine Leisure group runs on the hospital campus and the Italian Group is run from the Community Hall
Every 1st & 3rd Wednesday in Beechworth the Club Connection is an outing group
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APPENDIX 7: CONTACT DETAILS FOR ALPINE & INDIGO SHIRE PAG STAFF
(NB: not for general circulation) Name Service Email Phone Mobile
Craig Cross Alpine@home [email protected] 0409408586
Trevor Marshall Alpine Health [email protected]
Angela
McCormack
Myrtleford Leisure
Group
0357519326
Jayne Dunell Myrtleford/Bright
Leisure Group
0357519326
Kerry Chapman Alpine@home [email protected]
Mandy Morrison Alpine Leisure
Group
Via Kerry Chapman
Leigh Laing Alpine Leisure
Group
Via Kerry Chapman 0357511870
Clare Southern Alpine Leisure
Group
Via Kerry Chapman
Carolyn Martin Alpine Leisure
Group
Via Kerry Chapman
Jane Dwyer Alpine Leisure
Group
Via Kerry Chapman
Mirella Glogglia Alpine Leisure
Group
Via Kerry Chapman
Sandy Southern Alpine Leisure
Group
Via Kerry Chapman
Tracy Preston Mt Beauty Leisure
Club
0357543526
0409519300
Lyn Edyvean Mt Beauty Leisure
Club
035750116
0429009717
Jacqui
McGregor
?Mt Beauty Leisure
Club
Ken Grace Bright Leisure Group [email protected] 0357555123
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Helen
Braidwood
Bright Leisure Group [email protected] 0357555123
Karen Briggs Bright Leisure Group [email protected] 0357555123
Jenny Tully Beechworth Club
Connect
[email protected] 0357280249
Jennifer Plate Beechworth Club
Connect
Jo Matthews Beechworth Club
Connect
[email protected] 0357280200
Jenny Dale Yackandandah
Club Connect
0260271551
Ann Monshing Yackandandah
Club Connect
Julie Walker Yackandandah
Club Connect
David Kidd BHS [email protected]
Marianne
Thompson
Tangambalanga
Club Connect
[email protected] 0260271551
Raelene
Ghiggioli
Tangambalanga
Club Connect
Jo Kelly INH Leisure Club [email protected] 0260336222
Shane Kirk INH CEO [email protected]
Peter Fursden INH Leisure Club [email protected]
