Improving Community Care in GSAHS
planning changes in Community and Allied Health.
This will provide GSAHS with an enhanced mechanism to monitor service delivery activity and outcomes and for an Area Team to provide ongoing support to local operational managers. As part of the review of models of care, it is proposed that the Child Infant and Family Tertiary Service (CIFTS) will continue to provide an assessment service as part of Early Intervention. GSAHS will continue to work and consult with the CIFTS clinicians to enhance the integration of their services with local community health, with a view to enhancing access to assessment services to all GSAHS communities.
GSAHS acknowledges that Mental Health/ Drug and Alcohol streams are important services provided by GSAHS in a community health setting however these streams are not included in this review process.
1. Outline of Consultation Process
This consultation and discussion process will occur at two levels:
1.1 An Area Direction and Review Team
• Director of Population Health Planning Performance and Research and Director Clinical Operations
• Director Allied Health and Chronic Care
• Palliative Care Program Development Coordinator
• Health Development Manager
• Early Intervention Manager
• Workforce Directorate Representative
• Service Planning Representative
• Community Representative
• Division of General Practice Representative
Aims and purpose:
• To lead the process for “Improving Community Care” and provide a governance framework;
• To gain acceptance of the “Improving Community Care” framework
• To liaise with and support the Sector Consultation and Implementation teams;
• To accept and consider feedback to incorporate into the “Improving Community Care” framework; and
• To lead implementation of the agreed service model across GSAHS.
1. 2. Sector Consultation and Implementation Team
• Sector General Manager (GM)
• Sector Coordinator Allied Health and Chronic Care*
• Sector Director Of Nursing (DON)
• Division of General Practice Representative
• Staff members X 4 (by EOI)
• Community members X 2
* Sector Chair
• To lead the “Improving Community Care” consultation process at the sector level, under the direction of and in consultation with the Area team;
• To collect and collate feedback from sector consultation processes; and
• To provide support and direction to the sector Community and Allied Health service providers in implementing the agreed service model.
2. What is the consultation process to achieve?
A framework discussion document, “Improving Community Care”, has been developed. This framework document will provide the basis for consultation and discussion to refine and develop agreement on the model of care which is the best fit for our communities.
2.1 The purpose of the consultation process is:
• To review the framework document, “Improving Community Care” and put forward recommendations to the Sector Consultation and Implementation Teams and then to the Area Direction and Review
Team;
• To consider and recommend options for the development of Key Performance Indicators (KPI’S) for Community and Allied Health services;
• To assist in the development of prioritisation of services;
• On completion of the review and acceptance of a final model, to provide support for the implementation of the new models of care in each community.
Greater Southern Area Health Service
‘Improving Community Care’
Framework Discussion Document
1. Background
In the preliminary review process, Greater Southern Area Health Service (GSAHS) has taken into account a number of factors impacting on current Community and Allied Health service provision. These include:
a. Activity Data - GSAHS has reviewed current data on activity related to non-admitted occasions of service (DOHRS) in the acknowledgement that this data only allows broad level analysis and gives indicative information only.
b. Staffing - GSAHS has reviewed the full time equivalent (FTE) of community nursing and allied health staff currently employed in each community health service. The FTE has been reviewed taking into consideration the population size, health status and general socioeconomic status of the communities.
c. Services - An overview of present services being delivered by Community and Allied Health employees at service sites in GSAHS has identified that increased expectations and a lack of identified service priorities has
created variances in service provision and community expectation across the Area.
d. Strategic Directions - GSAHS has completed this review in the light of NSW State Health Plan, NSW Community Health Review and related priorities, the NSW Health Service Agreement with GSAHS and recent
recommendations in “Caring Together”. An important additional consideration is the COAG subacute care directions and associated KPIs, which provide additional support and direction for GSAHS proposal. Analysis of this information and data has formed the basis for identifying issues and developing a revised model of care for Community and Allied Health services.
2. Key Supportive Principles
a. GSAHS will improve equity and access to services to communities, large and small, taking into account communities which have lower socioeconomic status and those communities with high Aboriginal population.
b. Enhanced and innovative recruitment and retention strategies and a formal workforce plan will be developed for both nursing and allied health services. This will include the planned development of an assistant
workforce as well as enhancement of a specialist role in allied health and nursing.
c. Services provided in GSAHS Community services will be provided within a consistent framework of service delivery.
d. Service delivery will be seamless between acute facilities / discharge planning and community health services
e. Service stream networks will be developed to provide clinical specialist support for generalist clinicians in nursing and allied health to ensure evidence based care for best health outcomes. Appropriate access to
medical specialist advice/consultation will be developed through these service stream networks.
f. GSAHS will continue to investigate and enhance the use of telehealth and videoconferencing facilities to improve access to services to more remote communities.
g. Improved collaboration and working partnerships with General Practitioners and the Division of General Practice especially for those clients with chronic and complex conditions will be enhanced to ensure client care is provided in a holistic manner and with a client centred focus. The Health One model will continue to be promoted.
h. Enhanced access in all communities to services in early childhood, with formal discussions and Memorandum of Understandings developed with other providers of Early intervention services including Department of Ageing, Disability and Home Care (DADHC) and NSW Spastic Centre as well as a variety of other Non-Government Organisations (NGO’s) and children’s services
i. Formal discussions and strategic planning with Home and Community Care (HACC) services will be strengthened to improve equity and appropriate services delivery for shared services.
j. Accountability for Community and Allied Health services will be enhanced with the development of appropriate Key Performance Indicators for both process and health outcome measures.
k. Key Population Health services, including Health Development and Aboriginal Health services will be integrated with the core business in Community and Allied Health service provision.
l. Effective and dynamic leadership will be achieved by reviewing the current community health management structure.
3. PROPOSED Model of Care
In addition to the issues identified above, the proposed new model for Community and Allied Health makes reference to:
• The need to better align Community and Allied Health services with other clinical services within the Area.
• The need to increase the equity of service provision across the area to better reflect the need for services as opposed to historical patterns of delivery.
• The need to adjust the balance between management and clinical services by reducing overall levels of management
• The need to ensure the model is sustainable and affordable over the long term, without compromising quality or safety.
• The need to adjust portfolios of responsibility, overall workloads and lines of accountability for a number of key positions.
The change is also reinforced by NSW Health’s Integrated Primary and Community Health Policy (NSW Policy PD 2006_106) in which Priority Area 3 identifies the need for Primary and Community Health (PaCH) services to
have improved models of care, highlighting the need for evidenced based practice.
In response, the model proposed by GSAHS recommends two priority
streams of service:
1. Chronic Care.
2. Early Intervention.
These service streams are in line with NSW Health future directions for community care and acknowledge the identified issues and growing community needs in terms of:
• The ageing population;
• The growing incidence of chronic disease, as identified by the recommendation in Caring Together to extend the NSW Health Severe Chronic Disease Management Program to include high risk patients over the age of 18.
• The need to continue to ensure early intervention strategies to the community.
The proposed model addresses identified issues within Community and Allied
Health from two perspectives:
• The clinical function within the models of priority care delivered in the
stream areas; and
• The organisational structure of GSAHS Community and Allied Health
services.
By making changes both in the structure and the function of community health services, GSAHS can identify significant areas of enhancement to service delivery for the communities we serve. This will result in GSAHS being able to set a framework of community service provision to take us forward, taking into
account future increasing demands for service.
GSAHS acknowledges that elements of this proposed model of care are already in existence in some Community Health services and that there has been considerable work initiated in some Community Health services in line
with these directions.
4. Model of Care: Structural Approach
a. An Area Strategic Team:
This team will work collaboratively to ensure that operational managers in the
three sectors of GSAHS are provided with support in the implementation of a
consistent and networked approach to the new model for Community and
Allied Health services and in the longer term, will provide a direction and
governance framework.
b. Sector Community Care within a Hub and Spoke Model:
The Hub and Spoke model is proposed to improve sustainability and appropriate access to GSAHS Community and Allied Health services in all communities. Clinicians within each hub/spoke will work collaboratively across communities to enhance the sharing of resources and to improve professional support. The Hub and Spoke model will address issues of varying demand and additionally during periods of clinical staff absence or when there is a vacancy; clinicians can be deployed by their clinical stream managers to service priority clients
within the hub area. Consequently, this model will assist in reducing gaps in service provision and workforce supply.
c. Chronic Care and Early Intervention Clinicians:
Nursing and allied health clinicians will identify themselves as working in chronic care and/or early intervention. This will assist in developing an enhanced client-centred focus and increasing the ideal of interdisciplinary
work as opposed to identification to their discipline only. For example, a clinician may be a chronic care nurse, early intervention physiotherapist. In rural areas with limitations to both nursing and allied health disciplines
particularly, some clinicians will work across streams but their work will be
clearly identified into specific streams.
d. Acute / Community Service Integration:
In larger hub sites GSAHS currently has Integrated Service Managers who are responsible for the management of both inpatient and non admitted services. In many communities, allied health staff is employed from a
community base and in-reach into the acute facilities. This will become consistent in all communities. This will enhance efficiency in the distribution of allied health services as well as increasing the emphasis on the role of the community based services to enhance discharge planning. In the longer term, the nursing service will be encouraged to work within a similar philosophy with nurses being able to work across both acute and community settings.
e. Workforce Planning and Skill Mix:
In recommendation 1.123 of the final report on the Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals1, Commissioner Garling recommended reform to workforce practices by nominating guiding principles including:
• The clinical workforce should be prepared to work in a multidisciplinary environment and to participate in an interdisciplinary team responsible for the delivery of patient centred care. GSAHS has a two pronged approach: to develop expertise at higher levels whilst at the same time acknowledging the need for new workforce roles
which will support the professional roles and enhance access to services in our rural communities.
• Specialties roles within a hub and spoke model: GSAHS model of care is a primary health care model with rural clinicians often providing care over a number of care categories ideally in a interdisciplanary approach
of sharing professional expertise.
• GSAHS acknowledges the need for clinical leaders in specialist area to act as consultants in specific service areas.
• The recent Health Professional Award allows the development of appropriate allied health professional specialist clinicians at level 3 and 4 to provide this consultant input.
• GSAHS is also in the process of reviewing the role of Clinical Nurse Consultants (CNC) and Clinical Nurse Specialist (CNS) to enhance a consultative role for community nursing
• Assistants in nursing and assistants in allied health: GSAHS is committed to the use of innovative models of workforce with the use of trained assistants. Assistants can work with the professional workforce in carrying out more routine tasks in monitoring and supporting clients in their care plan. This concept is well accepted by GSAHS allied health professionals where the use of assistants enables an increased role for the allied health professionals in higher level tasks. The long term result will be significant streamlining and availability of care in all communities.
• GSAHS has a partnership with Riverina TAFE to provide certificate 4 training in allied health assistants in a traineeship model suitable to rural communities.
f. Development of Key Performance Indicators for GSAHS Community Care &
Development of Prioritisation of Services and related KPI’s for each service:
(Discussion paper to be developed for discussion with Sector Implementation
Team currently under construction)
In this Inquiry, Commissioner Garling reviewed community health practices as an extension of the continuum of care of acute care services in NSW Public Hospitals. In acknowledgment of lack of visibility of both outcomes and throughput in community health services, GSAHS will develop KPIs in all of the identified priority service areas within the clinical stream areas. The KPIs will include throughput but also commencement of health outcome measures; the KPI’s will assist GSAHS into the future to measure and enable workforce planning and resource distribution.
5. Model of Care: Clinical Approach to service provision
The proposed model of care will be provided following a set of principles and the philosophy of self management by the client (and their carer).
A: Principles of care
All care will be delivered using the following principles:
• Interdisciplinary teams within both streams
• Holistic assessment procedures are evidenced.
• Care plans are developed and are “client goal” focused with outcomes evaluated and time limited
• A self management philosophy of care utilised by all clinicians.
• Care is delivered in partnership with other providers
• Services are timed to enable admission/ assessment/ care planning/evaluation and referral within a six week timeframe.
• Discharge and referral to primary and other service providers is evident.
• Services are provided as “in reach” to hospital inpatients with transition to outreach OR as outreach services.
B: A Self Management Approach
This philosophy of care provision is aimed at empowering clients (and their carers) to take as much ownership as possible for their own health status.
This is achieved by:
• Providing clients with appropriate information and knowledge of the disease;
• Supporting clients for a time limited period to develop healthy lifestyle choices and behaviours by way of client centred care plan;
• Increasing client’s awareness of symptoms and signs to allow them to act early to minimise acute episodes;
• Providing short term discipline interventions during more acute episodes.
6. The model proposed by GSAHS recommends two priority streams of service:
• Chronic Care.
• Early Intervention.
Clinical Service Stream: Chronic Care Stream
The chronic care stream will encompass categories of
1 Subacute care
• Rehabilitation- including discipline specific services
• Geriatric Evaluation and Management
• Palliative Care
2. Maintenance Care- Including HACC services
3. Aged Care Assessment Team (ACAT) services
Prioritisation:
Clients with the highest function limitation which is affecting the ability for them to be maintained at home including clients with chronic conditions of Chronic Obstructive Pulmonary Disease (COPD), Heart Failure and Diabetes, will be prioritised for service delivery.
Clinical Service Stream: Early Intervention Stream
The early intervention stream will encompass categories of
• NSW Kids Services*
• Aboriginal Health Services
• Physical Abuse and Neglect of Children (PANOC).
• Sexual assault and sexual health
• Women’s health and Breast care
• Falls prevention.
• Healthy weight
• Tobacco control
• Immunisation
• TB services
Early intervention services are provided according to the availability of
funding, and generally are identified as service priority areas by NSW Health.
(*NSW Kids will include Maternal and Child Health including Universal Home
Visiting, State wide Infant Screening- Hearing (Swish) & Sight (StEPS) Child
Health Network, targeted therapy services – including Child, Infant and
Tertiary Services (CIFTS),Audiology and Genetic Counselling )
References:
Final Report of the Special Commission of Inquiry – Acute Care Services in
NSW Public Hospitals, November 2008
Caring Together, The Health Action Plan for NSW.
NSW Health State Health Plan
NSW Health:
PD 2006_106: Integrated Primary and Community Health Policy 2007-2012.
GL2007_019: Integrated Primary and Community Health Policy
Implementation Plan 2007-2012.
PD2008_025 SNAP Data Collection- Australian National Sub acute and Non
acute Patient (AN-SNAP) classification.
PD2008_063 Episode funding policy 2008/ 2009 NSW
To provide feedback or for further information, please email the GSAHS corporate email address: corporate@gsahs.health.nsw.gov.au