Electronic Tools to Assist with Discharge Planning Helen Jarvis Program Manager Central Intake and Post Acute Care 24th July 2014

BALLARAT Ballarat is one of Australias fastest growing cities with more than 2,000 people moving to Ballarat each year.

BALLARAT

Ballarat Health Services is Victorias second largest regional health service, providing a comprehensive range of general and specialist care across key medical and healthcare disciplines including acute care, sub- acute care, residential aged care services, community care, mental health, dental and rehabilitation services. In 2012/13 there were 32,355 inpatient separations and 53,308 attendances at the Emergency Department. BALLARAT

Central Intake and Post Acute Care Central Intake Central Intake is an access and referral management service providing consumers/carers/patients with a single point of entry to those programs within the scope of Community Programs as well as facilitating navigation of the broader community service system Central Intake Referral Sources Email Fax In Person Internal Mail Phone Total Community Programs 5098 1881 16 958 133 344 8430 Allied Health 654 3577 8 4291 898 36 9467 GRAND TOTAL 5752 5458 24 5249 1031 380 17897 Post Acute care The Post Acute Care (PAC) program assists patients to recuperate following an acute hospital admission, sub acute admission or an emergency presentation and to facilitate their independence or transition to continuing care.

E-Referrals What do we want in a E-Referral System? Easy access Improve efficiency of referral procedure Eliminate duplicate data entry Minim Data Set should be transferred from one system to another without the clinician keying anything in You should be able to confirm that the referral has been sent and acknowledged Rely on minimal training & expertise Provide statistical information Simplify transfer of information

Electronic Referral System Referral Information Management System (RIMS) The RIMS electronic referral system was initially trialled in the sub acute sector of Ballarat Health Services and was formally adopted mid 2005 System for collecting, sending & storing referrals electronically Primarily based on SCTT tools Supports secure email, Autofax & printing Pop-up calendar function on all date fields Auditing at the referral, provider and form level Facility to flag forms intentionally not completed Lock down facility to restrict forms to read only after sending Facility to supersede forms to generate a duplicate for editing after sending Facility to transfer form definitions between RIMS installations

RIMS Patient management System PAS Connecting Care Service Provider Pathway

Key Benefits Streamlined data entry and better data quality Linked to patient management system to provide demographic and episode data and integrated with Connecting Care. The forms required by each agency are automatically generated by the system, Referrals are stored electronically to enable analysis of referral activity; The user interface guides users to complete relevant fields based on the information needs of the receiving service provider; Forms can be emailed to agencies using Public Key Infrastructure (PKI) encryption capability through the Connecting Care system, otherwise they are able to be automatically faxed through a standalone electronic fax management system, or printed and manually faxed or mailed out.

RIMS Referrer Statistics Department Referrals Post Acute Care 1128 Social Work 876 Emergency 838 Central Intake 634 HARP 609 3 North 467 2 North 271 4 South 259 Hospital in the Home 244 ACAS 217 Inpatient Rehabilitation 186 Occupational Therapy 178 Gandarra Palliative Care 158 3 South 157 Transition Care 157 4 North 100 Geriatric Evaluation & Management 67 Rehab in the Home 67 Cognitive Dementia & Memory Service 21 Diabetes 21 Domiciliary OT 20 Jim Gay Unit 20 2 South 17 Wound Care CNC Team 16 PDPU 14 Midwifery 4 Clinical Services 3 Dialysis 3 Outpatient Department BH 3 Information Technology 2 Psychiatric Services 2 Acquired Brain Injury Clinic 1 Total 6760

Provider Referrals Ballarat District Nursing And Healthcare Inc. - Nursing 912 Ballarat Health Services - Community Programs - Central Intake 902 Ballarat Health Services Post Acute Care 694 City of Ballarat Council - Home Care 654 Ballarat Health Services - Base Hospital - Respite care - Aged Care Assessment Service 561 Ballarat Health Services - Hospital Admissions Risk Program 371 Ballarat Health Services - Continence Resource Centre 365 mecwacare 207 City of Ballarat Council - Home Maintenance 173 Ballarat Hospice Care Inc - Palliative Care 166 Ballarat Health Services Carers Choice Grampians Region 157 Homecare Plus 108 City of Ballarat - Meals on Wheels 92 East Grampians HS Post Acute Care 76 Ballarat Health Services -TCP & RC 74 Maryborough District Nursing Service 69 Moorabool Shire Council - Home Care Assistance 64 Hepburn Shire Council - Home Care (Housekeeping Assistance) 55 Maryborough Post Acute Care 54 Ballan District Health and Care - Support groups - District Nursing Services 53 Djerriwarrh Health Services District Nursing 52 Hepburn Health - Daylesford District Nursing Services 48 Ballarat Health Services - Central Intake for Community Programs - Dietetics 45 Golden Plains Shire Council - Home Care 36 East Grampians - District Nursing Service 35 Beaufort District Nursing Service 28 Ballarat Health Services - Central Highlands Coordinated Community Care Linkages 27 Stawell Regional Health - Post Acute Care 27 Stawell Regional Health - District Nursing Service 23 St John of God Hospital Ballarat - Home Nursing Service 22 UnitingCare Ballarat - Do Care 22 RIMS Provider Statistics

Issues Varied computer skills Computer access Currency of PAS information Confirmation of e-referrals Policies & Procedures in place for receiving e-referrals Cost of Discharging Problems Readmissions For the person to be referred to the right program: - Hospital admission risk program - Hospital in the home - GITH - TCP - Restorative Care - HACC services - District nursing

Easy access Improve efficiency of referral procedure Eliminate duplicate data entry Minim Data Set should be transferred from one system to another without the clinician keying anything in You should be able to confirm that the referral has been sent and acknowledged Rely on minimal training & expertise Provide statistical information Simplify transfer of information What do we want in a E-Referral System? E-Referrals

Has been in use across Victoria for over 14 years as an online Service Directory and secure referral and messaging solution. Is now using the National Health Services Directory (NHSD) as its source of agency, site and services information. The NHSD is national asset content managed by a range of organisations and is used by a wide range of applications for definitive information. Now sends to and receives secure messages from Argus using sites. Argus is a major secure messaging system used by thousands of GP, Specialist and Private Allied Health practices. Will soon be launched nationwide, allowing a much wider range of medical, primary care and community services organisations to use secure messaging to better coordinate care across the spectrum of Spectrum of Services. Has adopted the national eHealth standard called SMD (secure message delivery) to allow this messaging to and from GPs. Connecting Care

RIMS Patient management System PAS Connecting Care Service Provider National Health Services Directory (NHSD) Pathway

Referral Information Management System

Referral Information Management System

Referral Information Management System

1. Drivers for change Identified need to reduce the burden on the ward staff making referrals A review of RIMS found that over the last 3 months ward staff completed 489 referrals to PAC and Central Intake alone. This is conservatively estimated at 80 hours of data entry. Our Health Independence Programs, which include HARP, PAC, Centre and Home Based Rehabilitation programs and Specialist Clinics, need to streamline intake in preparation for Activity Based Funding and to meet the requirements of the Department of Health. Central Intake Screening Tool

2. Aims Introduce a system that: - Requires ward staff to identify patient needs rather than specific funding and program requirements - Allows the Referral Team to screen patients and complete referrals - Supports expansion to remaining Health Independence Programs. Simplify the referral process and provide additional resources to complete referrals into PAC and HARP. Reduce the number of queries about referrals made to PAC and HARP. Central Intake Screening Tool

Assess Coordinate Communicate Clarity over role All Referrals apart from District Nursing and Palliative Care Central Intake Referral Team

Screening Tool

Guidelines Documentation on the Screening Tool and Referrals will be ISBAR which is the endorsed communication tool across Ballarat Health Services I- Identify Yourself and Patient (using 3 patient identifiers). S- Situation State the immediate issue/Current situation. B- Background Relevant past history. A- Assessment Provide your assessment of the Patients current status. R- Request Be clear about what you are requesting. Responsibility for actions and clear timeframes. Central Intake Referral Team

6.2.1 The workforce has access to documented structured processes for clinical handover that include: Preparing for handover, including setting the location and time while maintaining continuity of patient care Organising relevant workforce members to participate Being aware of the clinical context and patient needs Participating in effective clinical handover resulting in transfer of responsibility and accountability National Safety and Quality Health Service Standards

Consumer Information Service Coordination Tool Templates 2012 The Service Coordination Tool Templates (SCTT) is a suite of templates developed to facilitate and support service coordination.

Consumer Consent Service Coordination Tool Templates 2012 The SCTT support the collection and recording of initial contact, initial needs identification, referral and coordinated care planning information in a standardised way.

Summary and Referral Service Coordination Tool Templates 2012 Using the SCTT can improve communication between service providers, the recording of information generated by screening and assessment processes, information sharing, and the quality of referrals and feedback between service providers. This can assist service providers to share relevant information to support better outcomes for consumers.

National Health Services Directory (NHSD) http://www.nhsd.com.au/ Connecting Care A comprehensive web-based directory providing secure messaging and e-referral https://www.connectingcare.com/ Department of Health State Government of Victoria, Primary Care Partnership, Service Coordination Tools http://www.health.vic.gov.au/pcps/sctt.htm Useful Links