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Phase Three – Solutions Design
Sydney South West Area Health ServiceCCHRONIC AND CCOMPLEX CCARE CCOLLABORATION
AND CCOORDINATION
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Scope of the Project
Patients with multiple chronic & complex conditions (identified diagnoses)
Patients who can be safely managed in the community setting.
Patients presenting to Concord and Canterbury hospitals on more than 2
occasions in a calendar year.
Patients over the age of 16 years .
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Avoidable Admissions (the defined 8 DRGs)
• Community Acquired Pneumonia (E62C).
• Chronic Obstructive Pulmonary Disease.
• (E65B) Bronchitis and Asthma (E69C).
• Deep Venous Thrombosis (F63B).
• Acute Non-Surgical Pain (musculotendinous) (I71C).
• Cellulitis (J64B).
• Urinary Tract Infections (L63C).
• Red Blood Cell Disorders and Transfusions (Q61C).
• Respiratory chronic conditions
• Cardiac chronic conditions
• Coronary artery disease.
• Hypertension.
• Diabetes
Chronic & complex condition disease groups
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Engagement of GPs
• Invitation to participate in Working Parties & interviews
• Presented the GPC Division
• Survey via GP Division
– What works well?
– Gaps?
– Would you like to be involved?
• Newsletters
Most Prominent Issues Identified by Patients and Staff
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Most Prominent Issues Identified by Patients and Staff
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Diagnostic themes identified
• Communication
• End of Life / Advance Care planning
• Discharge planning
• Self Management
• Duplication & fragmentation of coordination
• Case management
• Team work
• Lack of single point of contact
• Managing exacerbation in the community – medical governance
• Information systems & info sharing
• Referral processes
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Diagnostic Report – April 2010
Sydney South West Area Health ServiceCCHRONIC AND CCOMPLEX CCARE CCOLLABORATION AND CCOORDINATION
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Patient journey – the current journey
Hospital presentation
Discharge / Transfer of care
Community Care
Self Management
Deterioration / Acute Exacerbation
Health Review
Coordination of Care
Case ManagementHospital care
Patient journey – the desired journey
Deterioration
Hospital presentation
Discharge / Transfer of care
Community Care
Self Management
Deterioration / Acute Exacerbation
Health Review
Coordination of Care
Case ManagementHospital care
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Solutions • Expansion of CERNER to include Patient Care Plans• Flagging of C&CC patients in the EMR / CERNER• GP access to CERNER, sharing medical care & pt action plans• Single point of contact• Hospital in the Home / Ambulatory Care – rapid assessment/
community treatment• Care plans• Patient held file• Case Management of High Risk Patients• Improved discharge processes• Increased self management• Advance Care Plan• Electronic Service Directory• Discharge follow-up
What next
We
are
here
•Finalising Solution Design report•Implementation Working Parties•Recommendations•Cost Benefit Analysis
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Project Team & Contact Details
For further information or to contribute to the Solutions, please contact the Project Team:
Sue Schasser [email protected]
Debbie McNamara [email protected]
Peter Reisinger [email protected]